Direct Primary Care: What You Need to Know

Changes in modern medicine usually bring with them a sense of leaping progress, of conquering new frontiers. But an emerging trend in physician practice, called Direct Primary Care (DPC), actually strives to improve patient care by patterning itself on a business model that dates from the last century.

You see, prior to the 1940s, most Americans paid their medical bills directly – whether to a doctor or a hospital. But as employer-based medical insurance became more common, paying those bills became much more complex: co-pays, deductibles, exclusions of service, pre-authorizations, and so on, and so on.

Today, most primary care practices (also known as “fee for service”, or FFS) spend an inordinate amount of time dealing with insurance companies. And those insurance carriers provide relatively low compensation rates to the physicians. Couple that with a practice’s ongoing office expenses and you’ll understand why doctors need to see as many patients as possible in a day.

On average, an in-office session lasts just seven minutes per patient! And those abbreviated visits inhibit doctor/patient communications – an important tool for treatment.

The Direct Primary Care model turns that concept on its head. By accepting only a limited number of patients, and no insurance payments of any kind, direct primary care doctors are free to spend more time with each patient, offer more transparency and substantially reduce office overhead.

A sports coach might call it “addition by subtraction.”

There were about 4,400 Direct Primary Care physicians nationwide in 2014, up from fewer than 150 in 2005. In the Lehigh Valley, there’s just one: Dr. Kimberly Legg Corba, D.O. owner of Green Hills Direct Family Care in Allentown (formerly Green Hills Family Health Care, which was also owned by Dr. Corba.)

“… in the DPC model you get more time with the doctor, and that means you can ask questions, discuss options and build an actual relationship.”

– Kimberly Legg Corba, D.O.

Dr. Corba helped me get a grip on some of the major similarities – and differences – between the two models.

On the surface, direct primary care practices resemble those with the traditional approach. You still make appointments, and show up at the office for typical treatments – annual wellness exams, women’s healthcare, newborn and pediatric care, wellness education, chronic disease management, and the other services that are part of family medicine.

But there are plenty of differences.

No insurance needed – or accepted

The biggest difference, of course, is the payment system. DPC practices don’t accept medical insurance; instead, their patient panel is strictly limited (more on that aspect in a bit) and each person pays a flat monthly fee that covers most routine care.

Any charges for other services, such as prescriptions, radiology and other external lab work, as well as splints, crutches and similar supplies, are discussed up front – so there are no surprises later. And if a specialist is necessary, you’re free to pick whomever you choose. Insurance companies are not involved, so there’s no such thing as “out of network.”

“And because you pay the DPC practice directly,” Corba said, “You can eliminate pre-authorizations, claim denials, or trying to decipher a long, complicated billing statement.”

(One important caution: membership in a DPC practice covers only that practice and its services. It’s always wise to have a high-deductible health insurance policy that will cover you and your family for hospital stays, major surgeries and other big-ticket items.)

Longer visits

In insurance-driven practices, face-to-face contact lasts an average of seven minutes. That’s not always long enough to fully describe your symptoms, or to review treatment options. Imagine managing several conditions – and trying to adequately discuss all of them in 420 seconds!

On the other hand, in the DPC model, “You get more time with the doctor,” Corba said, “and that means you can ask questions, discuss options and build an actual relationship. And that lets us better understand patients’ needs and concerns.”

Better efficiency

Eliminating insurance also helps a DPC office operate more efficiently. And that’s not surprising.

Many practices can spend 30% or more of their time and money just collecting insurance payments. Some of those payments have decreased in recent years – which require physicians to see even more patients to maintain income levels, which leads to higher overhead expenses.

Why does the process require so much time and effort? As an example, Corba cites her own office. Every insurer has its own reporting programs and protocols, and there’s very little overlap among them. In order to comply with those varying requirements (and thus get paid promptly), she and her staff had to develop a separate – and quite different – reporting system for every insurance carrier Green Hills accepted.

Today, those activities are gone. Green Hills operates with a very lean staff – not even an answering service – and Corba said her overhead has been reduced by about 15%.

Smaller patient base

Traditional FFS practices rely on volume to generate income; it’s one key reason that a typical doctor maintains a base of several thousand patients, and often double- and triple-books appointments (remember, it’s all based on volume).

But direct primary care offices are self-limiting; that is, each will accept just a certain number of patients. When the patient panel is filled, that’s it.

Members are assessed a monthly fee, usually in the $50 – $80 range. For that investment, members are entitled to see the doctor many times each month, without a single co-pay. (And if you’re a parent with a couple of sick kids, those individual out-of-pockets can pile up pretty quickly.)

“The doctor will see you TODAY!”

Have you ever wakened feeling like death warmed over? Only to find that your family doctor was booked solid until a week from next Tuesday?

If you had called a DPC practice, your chances of being seen the same day would have been much higher. Because of the limited patient panel, DPC doctors’ daily schedules aren’t crammed to bursting, which gives them more flexibility.

“Traditional fee-for-service practices will always try to accommodate you as quickly as possible, but the meeting the demands of a large patient panel means they can’t always squeeze you in,” Corba said.

Direct primary care practices also tend to support “technology visits” – text messaging, email, Skype, FaceTime or other remote services. It’s useful when you have a simple question or need to provide a personal update, even on weekends and holidays. And at Green Hills, all of those messages go directly to Corba; the practice has no answering service, and there’s no “on call” physician.

It’s catching on

Is direct primary care perfect for everyone? Of course not. But it does offer a practical alternative to the traditional fee-for-service medical practice, and the concept is gaining traction throughout the country.

The state of New Jersey will launch a pilot program this year, open to 800,000 state employees. The hybrid plan lets enrollees choose their preferred DPC practice for routine preventive and primary care services, with additional specialized coverage coming from within Aetna’s and Horizon’s networks.

And, according to Mark Blum, the executive director of America’s Agenda – an advocacy group that helped develop the Jersey program – that concept has sparked the interest of California, Texas, Pennsylvania
and Nebraska.

Want to learn more about direct primary care? Here are some informative websites:

Direct Primary Care
dpcare.org

Pay Flat Fees to Doctors with Direct Primary Care
kiplinger.com/article/retirement/T037-C000-S004-pay-flat-fees-to-doctors-with-direct-primary-care.html#rufQpjaTS4zo2f2w.99

The Doctor Will See You – But Not Your Insurance
aarp.org/health/health-insurance/info-08-2013/direct-primary-care.html

Green Hills Direct Family Care
greenhillsdirectfamilycare.com