It’s The Chicken Or The Egg Again. Will Direct Care Expand Proportionately To Demand For Preventative Care?

The president’s signature legislation aims to provide every American with affordable health insurance options, but there’s been an increase in doctors becoming direct pay or cash-only practices recently.

“There’s no doubt that one of the driving forces behind direct-pay practices is frustration and anger with health care among physicians,” says Michael Smith, medical director and chief medical editor at WebMD. “More and more doctors feel they are ready to quit the system and start practicing off the grid.”

But what about patient demand for preventative care? Something that fee-for-service medicine DOES NOT ENCOURAGE — and that Direct Care thrives on.

We wouldn’t call it “off the grid” but we understand the sentiment. We still use our iPads to jot down patient notes, and restock generic drugs for future dispensing. And we started so patients and doctors can find each other, and start building direct care practices.

According to a 2012 compensation report by medical resource company Medscape, 6% of family doctors, 4% of internists and 2% of pediatricians said they were in concierge or cash-only practices. In its 2013 compensation report, all the numbers increased: now, 7% of family doctors, 7% of internists and 4% of pediatricians are cash-only practices.

Dr Neuhofel (or @DrNeu as we know him on Tiwtter) is a family doctor in Lawrence, Kan.. He launched his direct-pay practice, NeuCare Family Medicine, in December 2011. He says his payment decision was based on his dissatisfaction with the health-care system and the interactions he witnessed between patient and doctors.

Individual patients pay $30 to $40 a month while families pay $100 a month. That fee gets them unlimited visits without a co-pay, free routine lab work and testing. He also saves patients money on medications by offering them at wholesale prices. “Medicine at wholesale is 70% to 90% cheaper than at a pharmacy. A lot of patients save $100, $200 or $300 a month on medication alone.”

Wait times are rate at NeuCare, and patients can get same-day appointments that are normally 30 minutes to an hour long. The practice has 700 patients, which Neuhofel says is significantly less than the standard patient load of 2,500-4,000 most practices have, which makes lengthy appointments hard.

Neuhofel doesn’t take any insurance and keeps overhead low by employing just one nurse.

While doctors offering direct-pay care don’t accept insurance, many of the patients that are opting for this type of health care do have coverage. Those without insurance are betting it’s cheaper to use a direct-pay doctor and pay the fine under the Affordable Care Act.

However, Smith at WebMD, advises doing the math carefully. “Even though the ACA fine is $95 for an adult (or 1% of your salary) in 2014, that jumps quickly over the next two years to $695 (or 2.5% of your family income),” says Smith. “By the time you pay the fine and the direct-pay membership fee, you’re likely better off financially just buying insurance.”

With a direct-pay model, doctors are able to see fewer patients and still make the same– if not more money, according to experts.

We can see less than 10 patients in a week, and we provide better care and greater accessibility without worrying about losing money. At a certain point, the quality starts to be affected by the number of patients you have to see. So, yes, Smith is potentially “correct” about just buying insurance. But what are you buying? The opportunity to pay money, to see a doctor in 20 days when you need to see someone now?

Older patients are charged more because they typically have more illnesses or issues that require additional time.

And here’s the secret about insurance-based medicine: It DOES NOT pay for prevention. If you are on the border of having high blood pressure we don’t get paid by insurance to talk about preventing it–only to treat it. In a membership model, you can do everything and there’s an incentive to keep the patient healthy.”

According to Smith of WebMD, the direct-pay model make the most sense for people with multiple medical problems and need more than 15 minutes with their doctor per visit. It’s also attractive to those who like the unfettered access to their doctor since many of the physicians in these types of practices are available 24-7 either via phone, email or text.

And to some people’s chagrin, we’ve delighted young and healthy patients, too, with our model.

It’s about an attitude shift. We’re trained to think disaster will strike at any moment. But look at the math — heart disease is one of the leading causes of death in this country. A cheeseburger doesn’t jump out and strangle you. It’s effects are felt because we as humans like to spend decades focusing on different ambitions, instead of exercising routinely, and ordering smaller portions at the drive-thru window.

However, kids are wiseningup, and recognizing that having access to an expert, who is affordable, can actually save them money in the long run, and save their lives, too.

Dr. Smith needs to consider this path that healthcare can take — assuming we give the market power to demand new, more innovative services.

The real misfortune will be — in spite of all its good intent — seeing the ACA lead to more people choosing insurance out of fear of fines, instead of in pursuit of longevity.