Direct Fee Primary Care Doctors, or the "Concierge" model.

**Update 9/21/09:  Woohoo!!  Finally found at least one website that lists participating Direct Primary Care physicians nationwide: Direct Primary Care Coalition.   My doctor isn't listed - I don't know if she's advertising yet.  I'm happy to email her contact info to anyone interested in Vancouver, however.

One fine Saturday night  recently MickeyD and I were visiting my friend E. when the corner of her evil  coffee table decided to take a nasty gash out of his eyebrow.  It could have been a lot worse.   E. was panicking a little and asked if we wanted to go to the E.R.. "No", I said - "it's not that bad and besides, he's not insured. I'll just call our doctor and have her check him out and patch him up."

What??  See a doctor without insurance?  Immediately?  Does. Not. Compute.  Because today, we equate access to health CARE with access to health INSURANCE.  But it wasn't always that way.  And doesn't have to be.

Our doc said she'd meet us at her clinic in 15 minutes. This is Saturday night. 10 p.m.  Five minutes after we arrived he was sitting calmly in her office getting dermabonded (no need for stitches), no concussion, no eye damage.  Medically approved to go to the County Fair the very next day and ride as many high velocity carnival rides as his short stature would allow.

We were home by 11 pm.   Like a modern day Marcus Welby, MD.  This, my friends is Direct Fee Primary Care. Or "Retained care".  Or "concierge" care.  Or "boutique" care.  Nobody is sure what to call it yet.  But what they see, they like.  Once reserved for the uberwealthy who could afford to keep a personal physician on staff for themselves and their family.  Now becoming widely available all across the country as a highly cost effective alternative to Health Insurance plans for the low and middle income earning masses.

This is not the nightmare so many of my fellow uninsured Americans face of not being able to get even the most basic medical care.  This is, dare I say it?  Fantastic.  How is it possible that I can get everything I'd WANT for primary care with no insurance headache and for much less than my monthly cable bill?  July 1 we enrolled MickeyD and Mr. Stang in my doctor's new Direct Contract program. For a small set up fee (like $50) and regular monthly fee (whopping $25 for Duncan, $50 for Mr. Stang) we get:

*Same Day appointments with any of the 3 doctors who practice at the clinic.
*No copays.
*No deductible.
*No paperwork.
*24/7 access to our doctor and her personal cell phone number.
*Any lab tests/treatments/procedures they can do in the clinic, at *their* cost. Including vaccines.
*No time limit on appointments. However long we need.
*Unlimited chiropractic adjustments (one of the docs is an osteopath).

All this at a fraction of the cost it would take to get them both covered on my employer's group policy.   Like 5% of the cost.  Mr. Stang is uninsurable on the individual market. We've tried.  If I were to have both him and MickeyD on my dependent plan at work, or just Mr. Stang and MickeyD on his own policy it would cost us $1200/month - plus all of the above-noted out of pocket expenses.  To go the E.R. or an Urgent Care that Saturday night it would have cost us $30 copay. $500 deductible. 20% coinsurance. All for the privelege of sitting in a waiting room for hours with the drunks, drug addicts and thugs that typically frequent an urban E.R. on a Saturday night.  And paying a small fortune for it.

Read What we don't get, After the jump:


What we don't get:
*Catastrophic, hospital care.  The way the insurance companies have been slashing coverage over the last decade I pretty much expect them to deny coverage anyway.   So I'm not convinced I'm losing much.  I've read other people are pairing up a Direct Contract with high deductible, catastrophic insurance coverage.  That's something I'm going to look into but a) I can't believe the individual market would be willing to insure Mr. Stang any more for a high deductible policy than they are willing to do at a low deductible; b) Even the premiums on our high deductible options on our group plan are outragious - and besides I'd have to wait an entire year to sign him up at open enrollment; and c) I'm still very,  very skeptical of exactly what it would take to *prove* to any such insurance company that your high deductible had been met (see previous post).  Seems like you'd just be inviting more headache.

And isn't the whole point of boosting access to primary care to drastically reduce the need for catastrophic care???.  If that's true, we're making the smarter choice by saving those premium dollars for future financial need.

*Coverage for specialists.  Interesting thing I learned when researching this. One of the biggest reasons PCPs routinely send their patients to specialists like ENT's, dermatologists or internists isn't because they don't have the training or ability to provide that kind of care. They just don't have the time. Direct contracting gives them more of that time.

*Prescription Drug coverage.   For the basics we usually need generics are available and Costco's pharmacy charges little above their cost. In the state of Washington (and Oregon, I think) you don't actually have to be a member to get yours filled. Customer service isn't fantastic (my local Safeway was actually the best), but honestly? I've had far worse from Walgreens' supposedly super cool drive through service. Every time I tried to get an Rx filled through them it was a nightmare. Interestingly enough - BECAUSE of the insurance companies getting into the middle of things. Usually because they wouldn't pay for a monthly script if I tried to get it filled one day early. Or if there was a delay or error in their data entry of our enrollment information at renewal.  I still have some of the insurance-generated headaches at Costco, but the drugs are so cheap (and my Rx copay so high) I can still afford to pay out-of-pocket for them. 

One of the models for Direct Contracting, or "Concierge" type health care is an outfit out of Seattle, called Qliance.  Here's how they did it.   And here's an excellent illustration of how it works:  How the insurance companies killed Marcus Welby. I know the chart below is pretty small- but you can just compare all the red boxes above representing how an insurance-based primary care system work with the streamlined approach of direct fee providers below and understand.

The biggest criticism of this trend in health care, however is that to make it work PCP's see fewer patients and it could contribute to the current shortage of primary care physicians. I wonder though if they're counting individual *patients* seen or number of patient *visits* when they make that critique.  Because there's certainly no benefit to a patient having to go back to a doctor for a dozen or more 15 minute appointments for the same consition, when one adequate 60 minute visit (where the doctor would have time to fully review a patient's medical history, drug regimen, and discuss treatment plans) might very well eliminate the need for repetitive visits alltogether.

Another criticism is the fact that these consumers get to "skip the line" to see a doctor - and insurance patients can't.  In my mind, the insurance companies have created that line to begin with so it's their own damned problem for not working out a way to shorten it for their consumers. The whole point of having insurance used to be it made your life easier.  That's what car insurers sell.  "You're in Good Hands",  Right?  In the case of medical insurance?  WRONG.  They've failed. Miserably.

The biggest obstacle, our doc informed us to setting up her program were legal ones.  By law, they are NOT ALLOWED to charge non-insured patients LESS than insured patients.  Even though the insured patients place a larger administrative burden on their practice.  Our doc was able to get around that requirement somehow with the help of some attorneys.  A lot of direct care providers just don't take insurance at all anymore.

Somehow, direct fee contractors end up making MORE money seeing fewer patients and providing far better primary care than they do seeing insured patients.  That alone should tell you where the system is broken. But, this model is in the gunsights of the insurance lobby, who are trying to have state insurance regulators nix the practice on the grounds that they are, in essence - providing insurance (and aren't insurance companies).  So far, state legislatures aren't buying it (at least they didn't in Washington) and have drafted special laws to clear the way for this kind of innovation.

Thankfully for us, they did.