Could Direct Primary Care Be a Key Part in Solving America’s Health Care Crisis?
“I avoid the hospital and doctor at all costs,” says Alicia Woods, who is expecting her second child. Woods, 25, is one of more than 40 percent of Americans who are dissatisfied with their health care cost, according to a recent study done by Gallup.
“I look for natural home remedies whenever I can to cure my ailments," she says. "I'm new to my current job so I don't qualify for my company's insurance plan. But what concerns me the most is if they decide to end Medicaid. That means pregnant women like myself who can't qualify for their own insurance or haven't worked at a job long enough to receive benefits will not have affordable access to health care,” she continues.
Dissatisfaction is particularly high among those with private insurance, and lack of assistance from employers is one of the key causes. Issues with health care are so significant that many have to choose between forgoing necessary surgeries versus affordable health care. And those are just the issues among those who have coverage. In much of the country, millions of people fall into what’s known as the "coverage gap”—they make too much for Medicaid assistance, and too little for affordable health insurance. People of color and the working poor are significantly more likely to be without coverage, as they are more likely to have employers that do not provide company health insurance.
Matters of health insurance are further complicated by the Trump administration's push to repeal the Affordable Care Act, or Obamacare. If they are successful, things will get worse for the majority of American citizens. Woods' pregnancy would be considered a pre-existing condition under the GOP's proposed health care bill. In addition, she lives in Texas, where many fall into the coverage gap due to the state's decision not to expand Medicaid.
Cost sharing subsidies, which help lower-income ACA customers afford private insurance, are a large cause of the repeal. Even insurance companies are speaking out. The uncertainty on the continuation of subsidies is affecting states that allow early enrollment. As a result, the insurance industry's main trade organization, America’s Health Insurance Plans, sprang into action. AHIP sent out letters to senators who were considering an ACA-destroying house bill, saying it stands to negatively affect coverage for millions.
Each year, the United States spends 3.3 trillion on health care and in 2016, a family could expect their premiums to cost around $18,142 according to the ï»¿Kaiser Family Foundation. With the rising cost of insurance, more and more people are saving visits to the doctor for emergencies only. The consequences of our state of health care uncertainty is a decrease in preventative care. Millions die from preventable diseases each year, despite the United States having one of the most expensive health care systems in the world. Both physicians and patients cite issues with the state of medical care. Patients are fed up with high insurance cost, long appointment waits, and short doctor visits. Physicians are retiring at astronomical rates due to high insurance cuts and overwhelming workloads.
A recent survey of 5,000 physicians reveals 43 percent of doctors are considering retiring in the next five years, according to the Doctors Company. Much of this is due to feeling “extremely overtaxed, overrun, and overburdened.” Thanks to third-party interference, many doctors find themselves overbooking patients to retain a profit. Forty percent of all primary care profits go to claims processing and profit insurance companies, according to the Direct Primary Care Coalition. The doctor/patient relationship began to deteriorate after the rise of insurance in the 1940s. Workloads became larger, true costs of services became hidden, and appointments became shorter.
With the nation in a period of health care transitions, a few places are trying a unique approach that might help revolutionize health care. That model is direct primary care, an approach that involves cutting third-party interactions in the doctor/patient relationship. A recent article in Business Insider provides a perfect analogy for how DPC:
“To describe how coverage functions under Direct Primary Care, doctors use the example of car insurance: You don't use your car insurance for small transactions like oil changes, but it's there for you if you get in a car accident. Likewise, health-insurance plans—especially those with high deductibles—can be there if you require health care beyond primary care.”
Dr. Phil Eskew has kept track of the history of DPC on his website, Direct Primary Care Frontier. According to Eskew, a DPC-like model started around the late ’90s to early 2000s, when three doctors decided they wanted to open a cost-sharing facility to reduce paperwork and free up time for doctors to interact with patients. DPC involves patients paying a monthly or yearly fee for access to around-the-clock doctor visits. With the decreased frustrations that come with billing insurances, DPC physicians are able to give longer and more personalized visits to patients.
Eskew believes patients play a huge part in DPC advocacy. “Keep the conversation going. DPC typically has bipartisan support. It was promoted in the Affordable Care Act, and it usually has bipartisan support in state legislative discussions too. This bipartisan support is a rare thing in today's political climate. We need more patients to ask their physician common sense questions, such as, how much does my medication cost? Why am I not able to email or text you after-hours? Why are we not able to discuss my lab results via phone rather than interrupting my workday for three hours in your waiting room?”
According to Direct Primary Care Frontier, there are three main requirements for a medical practice to qualify as a direct primary care practice: Charge a periodic fee, not bill any third parties on a fee-for-service basis, and any per visit charge must be less than the monthly equivalent of the periodic fee.
Iora Health is a DPC model that follows a heavy customer service-driven model and has opened 11 practices across the United States. To ensure providers are able to put patient needs first, they start each day with a “huddle” meeting to discuss patients’ “worry scores,” and post-visit surveys to track satisfaction. The way locations operate is left to the staff, but things like consultation room set-up, daily huddles and personalized member benefits like yoga or mindfulness classes are required by company culture.
Rushika Fernandopulle, the chief executive of Iora, believes one of the biggest issues with our health care system is that it focuses on hospital treatment—which is very expensive.
Many DPCs, like Iora, give patients electronic access to staff members around the clock and use electronic filing, which Fernandopulle believes is better suited for health care. Another unique aspect is the use of health coaches, non-medically trained professionals who deal with the customer service aspect of health care such as diet changes, helping those in need of transportation to and from visits, and finding health care items like supportive socks. DPC gives patients access to prescriptions and lab services at a wholesale cost, as opposed to copays and fees hidden by insurance companies. For this reason, it has a lot to offer to those who require long-term condition surveillance.
DPC has a significant effect on the lives of patients. "Thanks to DPC, chronic conditions are finally controlled, urgent care visits are avoided and patients feel like they have a doctor in the family. This causes patients to lose weight, feel better, and return to work when they never thought it would be possible," Eskew asserts.
“Patients with chronic conditions benefit the most from an ongoing DPC relationship, and elderly patients are more likely to suffer from chronic conditions,” Eskew continues.
Chronic diseases are the most common, most costly, and most preventable of all health issues according to the Centers for Disease Control. The prevalence of diabetes is on the rise and expected to multiply in the next couple of decades. The cost of uncontrolled diabetes is two to eight times more expensive than when the disease is managed effectively. In 2012, the total cost of diabetes was more than $245 billion, according to research by the American Diabetes Association.
But the long-term personalized care DPC can offer could make diabetes more manageable and save the nation money. Uncontrolled diabetes and short-term complications cost between $2.3 billion and $2.8 billion per year. According to this same study, 49 percent of preventable hospital admissions were Medicare or Medicaid patients.
Unfortunately, research on DPCs is scarce; however, a limited five states had enough data to measure its benefits. The study conducted by researchers in the American Journal of Managed Care compiled data from New York, Florida, Virginia, Arizona, and Nevada. The result showed $119.4 million savings in hospital use cost with over $109.2 million of that being Medicare savings in one year. It's estimated that the $2,551 annual savings per patient was greater than the cost for a yearly membership, with an average range of $1,500-$1,800.
The financial benefits weren’t the best part. Patients’ health outcomes improved as well. The patients in a 2010 study reported 56 percent fewer emergency admissions, 49 percent fewer avoidable admissions, and 63 percent fewer non-avoidable admissions than rates of the traditional model. It was also observed that members of the study “were readmitted 97 percent, 95 percent, and 91 percent less frequently for acute myocardial infarction, congestive heart failure, and pneumonia, respectively.”
Though DPCs will not solve all the issues with the United States health care system, numbers reveal we owe them a solid attempt.
“I would be happy if patients kept demanding more DPC options. If you want to have a DPC practice but there is not one listed nearby in the DPC Mapper, then they should ask their primary care physician why they have not switched to DPC. If they keep the demand for DPC high we will have wider and faster adoption of the model,” Eskew says.
With data revealing so much promise, one wonders why the DPC model isn’t more widespread. Eskew believes a large part of the reason is lack of correct information:
“Misinformation is the most important obstacle holding back wider adoption of DPC. There are too many physicians, patients, and policymakers confuse DPC with concierge. There are too many physicians that are complacent with the status quo even though it does not provide the best care to their patients, and too few patients seek out/demand better access.”
There are currently 615 practices that meet Eskew’s three-point criteria in the United States, and it seems they have a lot to offer. One of the best parts is practices don’t have to be one or the other. Many are hybrids, combining DPC principles with traditional ones. Due to unclear state and federal regulations for DPC, many physicians are hesitant to try the model. We’ve tried the traditional way, and the result is patients and physicians getting a poor deal. Perhaps it's time we do things the direct way.