What is DPC, and is it right for me?

Following my recent post “Happy Doctor, Happy Patient,” also known amongst friends as “Doc’s Manifesto” on Facebook, I’ve had many inquiries by patients and friends about Direct Primary Care. These same people also know that I cannot give a short answer to any question so my most common answer has been to wait for the next post. Nonetheless, here it is.

Direct Primary Care, or DPC, is a grass roots, patient and doctor driven answer to the current crises within primary care. As I explained in my manifesto, the current crisis has presented a moral injury for the doctors that work within it because they have sworn an oath to put the patient first. There are so many stakeholders within patient care; the insurance companies, the large health systems, the government, the electronic medical records system (EMR), and most importantly time itself. The amount of patients a doctor must see to stay profitable has decreased time with patients to a mere seven minutes per encounter. The doctor cannot make good on his or her honored oath and yet must still find peace to sleep at night. As much as the doctors have suffered from the current arrangement of the third party (insurance-based) medical system, I believe that patients have suffered more in this overpriced and money driven situation.

Now before you say that I am working on Christmas Eve, I will let you know that I am sitting here typing this to my 186th run of “A Christmas Story” and have found that I can type and still say every line in this movie. What’s more, typing this blog post actually helps me sleep at night; that is after Santa comes of course.

Back to the issue at hand. I have commonly referred to DPC as a self-subsidized healthcare, and that at first glance, the patient is subsidizing a large portion of their care up front. This is in the form of a membership to a medical practice but comes with innumerable benefit. I am going to walk through these benefits both medical and financial in this post.

Non-financial Benefits

Taking insurance out of the primary care equation removes the largest impact to delivery of care. Most of my time in my previous fee-for-service practice was encumbered by the “insurance” problem. This was in the form of dealing with the insurance companies directly to get medication, referrals, and treatments approved; and all the while seeing more and more patients in a shorter time to make sure that reimbursements for my services covered my overhead. They did not through my last several years of practice and I generally ran into the negative. Mine and my nurse practitioner Casey Meadows' patient panel has ranged from 2500-3000 patients in any one of the last 4 years.

I required more staff to deal with more patient needs as a patient panel of that size would most definitely require, and required billers in addition to other staff just to handle insurance correspondence. This fact made the possibility of meeting overhead a laughable joke.

A typical DPC practice has an average of 500 patients per provider and takes dealing with insurance companies off of the table. Members pay an up front monthly fee (much like a gym membership) which covers the overhead of a minimal staff, as a large staff is not required.

I know I said that I was going to cover non-financial benefits however this benefit is truly non-financial as it equates to better and more personalized care for the patient. All of a sudden the doctor is not concerned with seeing as many patients as possible but fulfilling the needs of his or her patients within the limited patient panel. DPC clinics are able to offer an average 30-60 minute appointment and are in most cases available to their patients after hours and on the weekends.

Many patients are turning to the DPC model for the non-financial benefits of better access to care, increased time with their provider, on-call access, same day appointments with a very rare wait time, and most importantly, because they want the attention that their provider should provide. Patients need to be listened to and heard. This just takes time.

Financial Benefits

The commercial insurance products available to non-Medicare, non-Medicaid, or “commercial” patients have become overpriced and the benefits anemic. Most of my “commercial” patients fall into this category. When discussing this problem with patients, I often find that they are paying an average of $1000 per family in monthly premiums (and as much as $2300) and have the common $6000 deductible. This is for the common BCBS, Aetna, Cigna, and UnitedHealthCare plans that are offered through employers. What this equates to is that the family must first spend $18,000 (or more) annually before seeing the benefit of the plan. This is much like turning to your credit card for a mortgage loan. The common service utilized for this age group is within the primary care wheelhouse so often these patients (or families) never meet their deductible.

Please do not misunderstand. I do feel that every patient does need some form of insurance to cover catastrophic scenarios but the common plan is not the answer in most cases. I often recommend that patients at least consider the cheapest plan offered by his or her employer and enroll only that family member only if the employer is covering the bulk of the premium. For family members who do not work for an employer that is doing this, they might consider a Christian Co-op health plan with a cheaper premium and high deductible or another catastrophic health insurance plan. There will be much more on this later. In most cases, for ‘commercial’ patients, this equates to a savings of several hundreds of dollars per month when considering the cost of the entire family.

A typical patient membership with a DPC practice ranges from $80-100 a month with family rates from $150-200 a month. I often recommend that patient’s then open a bank account that they then call their HSA to place the money saved in health insurance premiums and build up that account to cover the high deductible on a truly catastrophic plan. Mine is $10k.

I hope this helps to explain primary care’s response to the current healthcare crisis. Basically, patients pay what equates to a gym membership that covers the overhead of the doctors office. This allows the doctor to limit his or her patient panel to about 1/4th of what is seen in the traditional insurance-based practice. This allows patients to have, for the most part, unlimited access to care when needed and benefit from a provider that is not constrained by time limitations in patient encounters as is seen in traditional practices. The doctor not being overworked and overwhelmed then allows for more after hours availability. It is almost like the business of medicine should have been from the start.

On a very serious note. I appreciate all of the positive responses to my last post. They have been enormously encouraging and because of the sheer number of comments I have been unable to answer them individually as I am still a doctor in a traditional practice. There is definitely a need out there because I am hearing from patients and colleagues alike. My goal start date for Enso Direct Care is 4/1/2021 and I will have a website up soon and will post when it is available. These posts will then continue on that website in the form of a blog as there is so much more to write about.

Have a Merry Christmas and here's to a better next year!!!

Brad D. Faglie, MD (Doc)