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Direct primary care

I recently heard of an interesting new model for innovative primary care. While it has been dubbed "concierge primary care" in the media, I prefer the term "direct (or direct-pay) primary care" because the idea of a concierge evokes very-well-heeled clients - in fact only one of many possible customer segments for this model, which combines personalized care delivered on a membership basis with telemedicine when needed and can provide valuable benefits to, say, the single mother who can't leave work to bring her sick child to the doctor and instead emails pictures of his eye infection, or anyone who wants to spend more than 15 minutes a visit with his primary care physician.

In a November 2012 article, Businessweek asked: "Is concierge medicine the future of health care?" It provides the example of Atlas MD, a family practice based in Wichita, KS which focuses on being affordable for all and operates on a membership fee with age-based pricing:

  • Children 0-19: $10/mo with at least 1 parent membership (the practice does not handle routine vaccinations),
  • Adults 20-44: $50/mo
  • Adults 45-64: $75/mo
  • Adults 65+: $100/mo

The membership fee covers an unlimited number of visits, house calls, all in-office procedures for free, as well as wholesale discounts for medications, labs and other services. The practice does not take insurance, but 2/3 of patients are insured - they use insurance to pay for specialty care and inpatient hospital visits, for instance.

The idea behind direct primary care is not to make insurance obsolete but instead to combine direct primary care with insurance covering not-primary care events. (This is reminiscent of car insurance: motorists pay for gas, tires, inspection, and the insurance handles repairs after a deductible has been met.) The goal is thus to decrease insurance premiums, since insurance would cover a smaller subset of claims. Hopefully, the model would also reduce hospital costs by providing better primary care and treating conditions early.

Here is a video by one of Atlas MD's cofounders:

While the doctors of Atlas MD have developed an innovative model for the public good, the Businessweek article also explains that "[m]any of these rebel doctors charge high fees and target the wealthy—visiting them at their homes, accompanying them to specialist visits, and offering them what they market as physicals fit for a CEO" - in other words, primary care for the 1% with fees to match. The model was pioneered by Howard Maron in Seattle in the 1990s. Maron handpicked 50 families for his MD2 concierge practice and charged the lucky few $25,000 a year. (The article does not provide his current rates.) He compares the experience to flying by private jet.

As primary care physicians making the shift to direct-pay, personalized primary care decrease the number of patients they see, this also means that the remaining PCPs, already in shortage, have to see even more patients. This is significant because, according to the American Academy of Family Physicians (and as cited in the Businessweek article), a traditional PCP will have an average of 3,281 patients while a concierge PCP will have only 400. The remaining 2,281 return to the traditional system and increase the average of the other, remaining PCPs. This raises the question of scalability of a model that seems to otherwise have many benefits.

Also in Washington State (like MD2), Seattle-based Qliance provides personalized medicine at lower cost: $65/month for most patients. It is now available on WA's health insurance exchange under Coordinated Care and has also launched a partnership with Cigna to combine direct primary care with lower-priced insurance. In June 2011, Qliance was dubbed "concierge health care for the middle class" in yet another Businessweek article. The article explains that "the cost of collecting money from insurers... can eat up $16 of a $60 payment for an office visit, or more than a quarter of a practice’s revenue." According to the company, Qliance's patients "incur 22 percent less in medical costs annually than average." This is a far more inspiring story of innovation, which has received a total of $17m in venture capital and will hopefully help redefine the field of primary care.

For more on direct primary care, I recommend this Forbes blog post by Dave Chase: "Health Plan Rorschach Test: Direct Primary Care." He has also authored an excellent report for the California Healthcare Foundation entitled: "On Retainer: Direct Primary Care Practices Bypass Insurance." You can read it here. Finally, Qliance was the subject of the May 2010 Health Affairs article "A direct primary care medical home: the Qliance experience."

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