One of the most profound changes to American
health care
brought about by the Affordable Care Act
is that it drove thousands of independent
doctors to throw in the towel
and join large hospital networks.
This is particularly true of primary care
doctors.
As the rules involving medical records, billing
codes, and prior authorizations
have gotten more complex,
physicians find they can’t survive without
joining large healthcare networks.
And they’re increasingly demoralized.
48% of our present family medicine, primary
care workforce
says that they're leaving within the next
three years.
Doctors feel disconnected and burnt out.
We're seeing that in medicine, it's an epidemic.
We gave away our business years ago to businessmen
and they screwed us.
So now it’s time to take it back.
Today there’s a small, but growing movement
of doctors
who are opting out of the traditional health
care system by no longer accepting insurance.
They gathered at a conference in Washington
DC earlier this year.
This new approach is is called “direct primary
care,”
but it’s essentially a throwback to an era
before insurance companies were responsible
for covering routine services
like ear infections or strep cultures.
When I started my practice in 2011, depending
on your definition,
there was maybe a dozen, or a few dozen at
most, doctors who were operating in this model.
You know the direct primary care movement
has grown,
there's now 600 to 800 practices and you know,
more doctors than that.
When companies like Aetna, Blue Cross, and
Oxford
started signing the checks for even minor
health care expenses,
it had a destructive impact on the doctor-patient
relationship.
The Direct Primary Care movement is an attempt
to reverse this damage.
Pretty much everyone except the patient controls
the money.
And that pretty much runs the show.
Dr. Ryan Neuhofel,
who’s been running his own direct primary
care practice in Lawrence, Kansas since 2011,
has a page on his website that lists the cost
of each procedure,
which the patient, not the insurance company,
actually pays.
I think what most people are accustomed to is someone managing their healthcare.
For a lot of reasons, because we've been doing
that for so long,
they just cannot imagine what it would look
like if they were just paying their doctor.
Need an x-ray?
That’s $25 to 40,
along with a monthly subscription fee that
runs from $35 for minors
to $130 for a family of four.
Because I’m membership supported I know
what my monthly revenues are going to be,
so if someone calls me, says, “hey doc,
I got this rash, can I send a picture to you”
sure, send me an email, show me the picture,
I give you advice.
If it's something I can manage,
that's medically appropriate with a text message or email or phone call I do it.
So I would say probably half of all of the
care and advice I give is just remote,
I don't have to bring people in for an office
visit
you know every time they have something minor.
Direct Primary Care doctors are able to charge
less than traditional practices
because the lack of coding and billing requires
less staff to maintain the practice.
When you're the only staff you do everything, literally!
In a fee for service world,
every moment a patient isn't walking through the door is lost money.
So most doctor's offices need to average 20-30
sometimes 40 patients a day
just to make a good business out of it.
And I don’t have to worry about that.
But fundamentally whenever you work in partnership
with your patients
without the interference of a third party
it really changes everything
for the patient and the doctor.
So we're able to be very creative in meeting
their needs,
able to give them transparency in pricing,
and just redesign the entire health care experience
around what patients really need
as opposed to us being distracted by all of
the third party coding and billing
and all those things that the normal health
care system has.
Premiums too high, deductibles too high, copayments too high-
The new Republican Trump care bill is every
bit as mean as the old one.
If we continue to let them have all the control,
there's no chance.
We can aid in that being direct primary care
and not play the game of the insurance.
But ultimately the patient controls their
own destiny,
both in their own personal health care,
as well as their health care dollar.
There are some changes to the tax code that
could speed adoption.
The IRS doesn't allow patients to use their
tax deductible health savings accounts
to pay direct primary care doctors.
In fact, just having a direct primary care
subscription
disqualifies you from contributing to an HSA
at all.
Dr. Neu and others have been meeting with
lawmakers
and proposing legislation to change this.
We are not trying to be shut out of the system,
we're not living off the reservation just
because we're cowboys.
We're doing it so we can provide good care,
but at the same time we do need to find out how
we integrate with the larger health care system.
It is so much about that relationship that
we're forming with our patients
and that's what really improves health outcomes.
Thank you for coming in doctor-
I guess before we had a name for it, before
there was direct primary care,
we couldn't really envision a way out of it.
I'm talking collectively for doctors across
the country.
But now that there's a name for it,
now that there's a clear vision of what direct
primary care is,
and what being a great doctor looks like,
more and more students and residents are aspiring
to become direct primary care docs.
Here's the thing, so you can be the doctor
you trained to be,
you can be the doctor you dreamed to be when
you were a kid,
and you have the opportunity to do it with
no bureaucratic drag.
The main reason I started my practice
and I started thinking about it in late medical
school, early in residency,
before direct primary care was even a thing,
was because I wasn't hopeful that, you know,
Washington DC or a state capitol or insurance
companies or employers or really anyone,
could or would fix primary care.
And so I can't really say that I'm super optimistic
that the politics
and the powers that be are going to understand
this or get it right,
but I think that the way that we're approaching
it with this grassroots movement
is the only way to force that change.
