What is Direct Primary Care (DPC)?
Hello and welcome! For this first post, I wanted to start by explaining exactly what Direct Primary Care (DPC) is. DPC is a form of primary care where the patient subscribes to a monthly membership (typically anywhere from $60-$100/mo) in exchange for access to their family doctor for all of their primary care needs. Patients who subscribe to this service have a level of access to their doctor that doesn't typically exist in the medical world today. For example, you have the ability to text, call, or email your doctor with questions or concerns. In addition, if you need to be seen in person, an appointment can be made that same day. Not only that, but these appointments aren't rushed and are typically anywhere from 30 to 60 minutes, the majority of the time without any wait. Does this sound too good to be true? Well, keep on reading to see how this is possible.
The Current Medical System: A Patient’s Perspective
To get straight to the point, the medical system in its current state is absolutely broken. It has become a place where patients hate going to see their doctor and many wonder who their actual doctor is. They try to call in to schedule an appointment to address routine health concerns only to find out that the first available appointment is weeks to months away. Because of this, a lot of patients are offered appointments to see other providers, who end up being a PA, NP, or another doctor, who they have never met before. When the appointment finally rolls around, the patient typically has a long wait in a crowded waiting room just to be pulled back to the room to continue the wait.
When the time finally comes, the provider hurries into the room. They never quite make eye contact as they frantically type away on their computer and ask what brought you in today. You begin to bring up your concerns and they abruptly cut you off and tell you to limit it to one thing and that a follow-up appointment will be needed to address your other concerns. You were likely put into a 15-minute appointment slot, which translates to a mere 5-10 minutes with your provider. Because you couldn’t get in to see your actual doctor, half of those precious few minutes are taken reviewing your medical history and medications that you already covered with your assigned Primary Care Provider (PCP) during your “establish care” appointment.
In these appointments, it’s not uncommon for the provider to notice an abnormal vital sign (like high blood pressure) which results in the entire appointment being commandeered, and you end up not being able to discuss the one concern you had to choose. To top it all off, many patients end up getting surprise bills in the mail weeks to months after the appointment, which ends up being salt in the wound. Many times it seems that navigating insurance coverage and medical bills requires specialized training to actually understand them.
The Current Medical System: A Doctor’s Perspective
For the doctor in this broken system, specifically those in Primary Care, the frustration of the patients is matched, and I’d argue it's even more frustrating due to the pressures and constraints put on them. These doctors typically went into medicine because they wanted to help and serve others. They spent over a decade of their lives going through their undergrad training (4 years), medical school (4 years), and a minimum of 3 years in residency. During this time, stress is high, sleep is limited, and the weight of a patient's life in their hands never quite lets them relax. Even after they have left work, they are often left wondering if they made the right diagnosis or started the right medication.
When these doctors finally finish their training, they enter into the workforce where they are told they need to see 18-25 patients a day with a patient empanelment of about 2,500 patients. In a typical workday, they are supposed to review the reasons why each patient is coming in, review their history and past appointments, see each patient, and then write notes, place orders for labs, medications, and imaging, and coordinate with specialists. Not only is this enough to fill more than a full day of work in and of itself, but they also need to respond to the huge list of patient messages, respond to critical labs, and submit the prior authorization for a medication for the third time because the insurance company doesn’t think Mrs. Smith needs it (where is their medical license, and where were they during the medical appointment?).
Not only does the doctor need to juggle all of these tasks, but they need to be juggled while not missing life-threatening, subtle aspects of the history or physical exam to provide the best care for the patient and avoid lawsuits. Because of these time constraints, family doctors are unable to spend time doing the things that attracted them to medicine in the first place, such as building strong, lasting relationships with their patients, managing multiple complicated comorbidities, and doing procedures. They, in turn, have to give these things up and end up referring to specialists for things that they could manage if they had the appropriate time in order to make it through each day. The clinic becomes a place of dread and burnout/physician suicide runs rampant, as many Primary Care doctors are hundreds of thousands of dollars in debt from medical school loans and are some of the lowest-paid physicians.
How DPC Fixes the System for Doctors
Here is where DPC comes in. Because of the way DPC is set up, insurance companies are completely cut out of the picture, which opens up so many opportunities for both the doctor and the patient. Insurance should be used for emergencies and things that you can’t typically pay for day-to-day. For example, let’s look at car insurance. Every time you need to change the oil in your car, change your windshield wipers, rotate the tires, wash it, fill it up with gas, etc., you pay for it up front. It just makes sense. Bringing insurance companies into the picture would just make everything worse. This is how it should be for health insurance too. Why is insurance needed to pay for an annual visit where routine lab work is ordered/reviewed and new medications are renewed? Or for reassurance when their son has a viral infection? A blood pressure check? To discuss weight loss, sleep, stress, or anxiety?
For the doctor, if insurance companies are cut out of the picture, there is no billing submitted to insurance companies, no coding, and the number of non-value-added middlemen is decreased significantly. This also results in the total overhead of the clinic being significantly reduced. This translates into less need to have so many empaneled patients (typically 500-600 compared to the 2,500), more time with each patient, better pay, and a much more simple clinic structure. For example, they would only need to see about 6-8 patients per day (30 to 60 min each patient), need only about 1 to 2 exam rooms per physician, and one or two support staff per provider. Because they have more time with each patient, they are able to get to the actual cause of the medical problem, discuss preventative medicine, perform procedures, take on multiple concerns at each visit, have time to manage some of the more complicated conditions, and actually get to know their patient and the things that are important to them. They can finally reach their full potential as a full-scope Family Medicine physician without the moral injury of the current broken medical system. Their notes transform from the traditional low-value note meant mainly to justify billing, and instead turn into a note documenting the reasoning behind medical conditions without any fluff (gasp!). They become excited to go to work because their work is fulfilling and exciting.
How DPC Benefits Patients
For the patient, there are many perks as well. Let me first pose a question. Would you go to somebody for a 5-minute haircut? No way! You want them to take time to make you look great. If this is the case with something as simple as a haircut, then why in the world would you ever think it’s okay for a tired, overworked doctor that is seeing you for the first time to treat your medical needs in this amount of time? You want them to listen to you, to know your medical history, and to be familiar with your career, family life, stressors, and medications.
You want this to be the person you can call when an urgent medical question arises instead of going to an urgent care/ER where you have to start from scratch. You want to have access to somebody that can fit you in for an appointment the same or next day when an unforeseen need arises. You want somebody that can submit a quick medication refill before you leave on vacation and reach out and make the request via a text message. You want somebody with enough training and expertise to handle 80-90% of your medical concerns and be the “one stop shop” because they have time to manage your diabetes, asthma, high blood pressure, and anxiety instead of being farmed out to a specialist for each concern. You want somebody that can function as an urgent care that can put in stitches when Johnny falls off his skateboard or when Lucy has a simple fracture. You want to know where your money is going and have no surprise bills.
With DPC, the monthly fee is not a surprise and is similar to how much you’d pay for a monthly phone bill, gym membership, or streaming subscription. Any extra costs are clearly listed on the website for labs, imaging, medications, etc. Ask yourself these questions:
How important is your health to you?
How often are you avoiding going to the doctor now because you feel like it is a waste of time and money?
Does your co-pay prevent you from seeing a doctor for questions/concerns?
How much do you have to pay into your deductible before insurance actually starts covering your care?
How much are you paying in insurance premiums for the lackluster coverage?
How much would you end up saving if you transitioned to more catastrophic insurance coverage?
When was the last time your doctor took the time with you to get to the root of the problem or to discuss things you can do today to prevent issues from getting bigger in the future?
A Final Thought
In no way am I saying that insurance is not important or necessary because you never know when a surgery will be needed, if the dreaded diagnosis of cancer will come, or if you get into a car accident and need to go to the ER and/or be hospitalized, but I am saying that it is not important or necessary for Primary Care.
Well, I need to save some things to say for future posts, so that’s it for now. Until next time!
Kaleb Roberts, DO
