US doctors try to cut out insurers and government with 'direct primary care'

  1. Direct primary care means you pay the doctor directly, insurance isn't part of equation
  2. Supporters say it allows doctors to focus on patients, not money
  3. Chronically ill patients need to have good insurance coverage

Dr. Michael Ciampi never felt alone with his patients. Every appointment seemed to be adjudicated by “big” government or insurance companies, two things he resents in respective order. All decisions and payment went through these third-parties. So, five years ago he cut out the middlemen. Now his patients pay his office directly for treatment. 

Once Ciampi converted his Maine-based practice to a “direct primary care” (DPC) model and stopped accepting insurance of any kind, he lost hundreds of patients.

His practice is smaller these days, but he says he doesn’t regret his decision. His patients pay a $60 monthly subscription fee, similar to a gym membership, for unlimited primary care visits. He says he’s never been happier.

“This movement began because physicians were feeling burnt out … now we feel like we’re giving higher quality and affordable care, and people are satisfied,” Ciampi told WikiTribune.

As the cost of health care rises in the United States, physicians who operate outside of insurance networks believe their model could offer insight into improving the national system. Once third parties are removed from the healthcare equation, they believe doctors are incentivized to think about the long-term health and finances of their patients.

Whether or not this assessment is correct, it gets to the heart of the argument often voiced in conservative circles that the key to reforming healthcare is to treat it as a product and treat patients as consumers.

Transparent pricing

To Ciampi, the cost of treatment was “a mystery” before he eliminated third-party payers.

“I had no idea what I was charging patients … now all of our prices are on our website,” he says.

Price transparency is a fundamental economic principle that Ciampi sees as key to reducing healthcare costs. For $60 a month, his patients have 24/7 access to Ciampi, including video conference calls and email, which doctors who take insurance are often prohibited from using with patients (U.S. News).

When it passed, the Affordable Care Act, commonly known as Obamacare, promised free preventive medical treatment, including annual primary doctor visits. But the Los Angeles Times found that patients can be billed hundreds of dollars for routine checkups thought to be free if a doctor maneuvers outside of rigid requirements.

Dr. Michael Ciampi shares his direct primary care practice on Varney & Company. (Screenshot from maciampi youtube channel).

The hidden cost of these doctor visits come from lab work and other tests that Direct Primary Care practices often include as part of subscriptions, or offer at reduced rates.

“When no one looks at the bill, they will inflate it,” says Ciampi, referring to hospitals in the United States.

Less paperwork, more focus on health

Before laying the groundwork to open a direct primary care practice, Dr. Brett Levine saw roughly 25 patients a day. Like most Americans, each patient was lucky to see him for more than 15 minutes (Business Insider). Once he opens his practice in St. Petersburg, Florida, in April, Levine expects to cut his daily workload in half.

While many DPC advocacy groups are seen as politically conservative, Levine considers himself liberal. Similar to his colleagues who are unsatisfied with government mandates, he made the move to spend more time with patients.

Dr. Brett Levine, direct primary care physician in St. Petersburg Florida. Photo courtesy of Brett Levine

“It’s become a volume game,” Levine said about when insurance-based care, “You spend most of your days doing things that aren’t in line with why you started medicine in the first place,” says Levine.

With roughly 90 percent of Americans covered by a government program or private insurance, cutting out healthcare intermediaries comes with the risk of losing customers who can’t afford a supplemental health plan (Kaiser Family Foundation).

Direct Primary Care doesn’t cover expenses outside a doctor’s office, such as hospitalization. So, even strident DPC advocates recommend their patients enroll in some sort of health insurance policy to cover treatment beyond the scope of a general practitioner.

Dr. Brett Levine’s rates for direct primary care. These rates do not represent other practices. Screenshot from levmedhealth.com

 

Levine expects business to be slow at first. But he’s confident he can keep costs low until he gets enough subscriptions to sustain a larger operation.

The concept of a lean office budget is unthinkable in traditional clinics, where close to 70 percent of budgeted funds go to overhead expenses. That includes the complicated process of billing insurers (WP Healthcare News). By avoiding third-party payment, DPC practices can save up to 40 percent in administrative costs, according to the Journal of the American Board of Family Medicine.

“Before, I was signing so many documents I didn’t even know what I was signing … there’s a void for quality of care that I think DPC can fill,” says Levine.

Can direct primary care fix healthcare?  

DPC physicians are part of a wave of critics of the fee-for-service model of U.S healthcare, which is seen as rewarding medical providers for the volume of patients they see, rather than those patients’ long-term health (Wall Street Journal).

There’s no evidence of doctors purposefully keep patients ill. But few clinics actually measure the long-term health outcomes of treatment. The prestigious Mayo Clinic began paying doctors salaries in 2009 rather than per-visit payments to end the perverse incentive of fee-for-service medicine (New York Times).

In addition to boosting the quality of life of physicians, relatively low monthly-rates of DPC practices show that they might be better at containing certain costs.

Yevgeniy Feyman, a senior research assistant at Harvard T.H. Chan School of Public Health, says patients at DPC practices can leave at any time, forcing doctors to keep prices competitive.

“In a traditional physician’s office, they don’t have as much incentive to get their price as low as possible. Their incentive is to get the price low enough just to be included in the insurance network,” Feyman told WikiTribune.

DPC’s ability to fix healthcare is ultimately limited. The business model simply can’t be applied the same way in other areas of medicine. People are far less likely to keep a specialist on retainer, and if specialists band together across fields, they could resemble the insurance companies they are trying to avoid.

And in a healthcare system that already struggles to fund treatment for those with chronic conditions, direct payments to a doctor provides little reprieve (NPR).

The three practicing Direct Primary Care physicians who spoke with WikiTribune each said they treat patients with serious medical needs, such as diabetes, and have yet to turn someone away. But these tend to be outliers. The steep cost of many “pre-existing conditions” often place specialist and hospital visits as the most critical services, none of which are covered by direct primary care.

“Chronically ill patients need to have the good insurance coverage,” says Feyman.

Insurance is for emergencies

In lieu of generous coverage, which is typically obtained through an employer, good insurance in today’s marketplace is expensive. Affordable plans tend to cover nothing, until you’ve reached your “deductible.” Deductibles are the payments a patients must make before the insurance covers anything.

Dr. John Bender, a physician in Colorado Springs, Colorado, began a Direct Primary Care practice after he saw an increase in high-deductible health plans (Media Health Leaders).

Rise in employers offering high-deductible plans, ($2,000 or more). Graph from Boston College’s Squared Away blog.

For a Colorado resident earning $40,000 a year in 2018, a common Bronze insurance plan costs $238 a month, with a $6,650 deductible – meaning the patient would need to pay $6,650, not including the monthly payments, before the insurance kicks in (Bright Health Plan). 

Bender’s practice charges $49 a month and has garnered close to 1,000 patients. He’s careful to not send them to a specialist or hospital unless absolutely necessary. For him, insurance is for emergencies.

“I tell people, treat your health insurance like fire insurance, use it once every seven years, maybe the year you have a baby … The other years you don’t touch it,” Bender told WikiTribune.

Some deductibles increased after President Donald J. Trump stripped out a key federal subsidy in 2017, adding to the cost of insurance.

While intensive procedures are beyond his office’s scope, Bender disagrees that Direct Primary Care has no value for people with chronic diseases. Patients with diabetes and obesity are often best treated at the primary level, according to Bender.

“We have this tyranny of the urgent,” he says. “And then we wonder why don’t have the same outcomes as the socialized nations around the world.”

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