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The direct primary care revolution

The complexity, red tape, and high costs throughout the health care system are leaving clinicians and patients dissatisfied. A small but growing group of primary care doctors are saying, “no more” to EHR requirements, useless quality measures, and indecipherable bills.

These doctors have adopted a model of “direct primary care,” (DPC) in which their patients pay a flat, affordable membership fee every month instead of paying fee-for-service through insurance companies. Adopters of DPC say that this model allows them to focus on relationships with patients without administrative hurdles.

We spoke with Dr. Ryan Neuhofel, President of the Direct Primary Care Alliance, about how he got involved with the movement, and some of the benefits and challenges of growing the direct primary care movement.

Lown Institute: How did you first get involved with direct primary care?

Dr. Ryan Neuhofel: I was an early adopter of the DPC model. As early as the end of medical school, I recognized that the health care system was really screwed up, both for clinicians and patients. I knew I wanted to practice primary care at an independent, community-based clinic with a broad group of patients, but I didn’t see a primary care model that would allow me to do that.

I had read about a couple of doctors who had created their own direct primary care practices so I decided to just go for it. Back in 2011, there wasn’t a blueprint to follow for a DPC practice so I was somewhat starting from scratch, and making it up as I went along. All of us early adopters had a similar philosophy that we wanted to focus more on relationships rather than transactions, so charging a monthly fee instead of fee-for-service just made sense.

Lown: What makes DPC different from other models of care?

Dr. Neuhofel: DPC is transparent in every way. Patients know exactly what they’re paying, and what they’re getting. And as a doctor, I feel like I’m working directly for my patients. I can refocus on the person sitting in front of me.

The magic of DPC is time. We set aside 30-60 minutes for every appointment, and we can give every patient same-day or next-day appointments. People think this is too good to be true, which is kind of sad. But there’s only so much you can do in 10-15 minutes with the patient. If they don’t have the time to sit down and talk with the patient, you’re going to have to refer them, get tests, etc. If you really believe in the power of relationship with the patient, I don’t see how that’s possible in 10-15 minutes.

I think so many patients have felt disenfranchised and let down by the medical system. Too often, they have been screwed over financially, and not heard. If you can sit down for 30-45 minutes, it makes a huge difference. The patient feels listened to, empowered.

Lown: How do you coordinate care without using the standard electronic medical records (EMRs)?

Dr. Neuhofel: I find that records in our practice are actually more clinically relevant – they’re clean and compact, and use real language instead of just billing language. Patients can understand the notes because they’re written in a narrative. And we don’t have to worry about checking all the boxes on the EMR because we’re not billing an insurer for anything.

The flexibility of the DPC model also allows for innovative forms of communication. About half of my care is done remotely, through text messages, phone calls, and emails, because often patients just need to get an answer to a question. We can be there for the patients whenever they need us. Some may call this “telemedicine,” but in DPC it’s just part of how we communicate with our patients.

Lown: How is this practice sustainable when the cost of health care is so high? How can a small monthly fee cover it?

Dr. Neuhofel: It’s actually quite easy because we don’t live in that world of price inflation. If anything, we’ve seen prices go down. A lot of price inflation is from administrative costs and we don’t have that bloat. We also do wholesale, generic prices for medications, which are ridiculously cheap. Same with radiology services, which are actually affordable when you get the service directly instead of going through middlemen.

Not contracting with insurance companies can allow us to serve people who are uninsured or underinsured. For example, sometimes we give people “hardship credits,” or let them pay us later if we know they’re going through a rough patch financially. If you accept Medicare patients, you aren’t allowed to charge anyone less than Medicare, so we would not be able to do that.

Lown: There’s been a lot of news about “concierge medicine,” which also charges patients a flat fee for service. What’s the difference between DPC and concierge?

Dr. Neuhofel: DPC and concierge medicine are often conflated but they’re very different in many respects. Both models are attempting to offer their patients excellent service— good access, longer visit times, remote communications, house calls, etc.— but differ in how we achieve that level of care.

Other than price variation, they are fundamentally different business models. Most often, concierge doctors charge an expensive annual retainer fee in addition to billing patients’ insurance plans in a customary fashion; patients being responsible for copays and deductibles just the same. With DPC model, our lower monthly fees, $40-100/month on average, are covering actual medical services such as office visits, many ancillary tests, and procedures without any additional fees or billing— similar to a gym membership or Netflix. 

From a clinical perspective, the difference I see is that DPC tends to be a more slow, conservative approach to medicine, rather than trying to upsell people on extra tests and “executive” level services.

In the trenches, I also see that concierge practices are usually serving a different patient population that most DPC practices. My patients are far from a wealthy, country club crowd associated with concierge. Most of them are low to moderate incomes, and uninsured or with high deductibles; often people who are falling through the cracks of our broken system. I joke that I run a “concierge safety-net” clinic! I think this is true of most DPC practices.  

Lown: What is the Direct Primary Care Alliance and what are you working on right now?

Dr. Neuhofel: The DPCA is a grassroots group of doctors who are using the DPC model and trying to help others who are just getting started with DPC. Most of us are full-time physicians with really small practices. We’re trying to help other doctors learn what we do and do it right. We provide resources, education, and some advocacy.

The DPCA is non-partisan and many of us share differing political views. Most people are just trying to grow their practice, not do advocacy work. But in many ways, starting a DPC practice is an act of activism. The DPC model shines a light on everything that’s not flattering about the health care system – administrative red tape, markups on drugs and radiology, etc. We’re just as fed up with all of the crap as anyone else.

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