Those who know me know that I was once in private practice. I owned my own small practice for eleven years, then I sold it to the local hospital. After that, things got complicated. I, quite of my own accord, got in on the founding of two Federally Qualified Health Centers in 2001 while still employed at my hospital-owned practice. At one point in that first year of the FQHC’s I worked at three offices and admitted patients to two hospitals, a lifestyle I don’t recommend. Still, I don’t regret a moment of it. The FQHC’s have thrived, and with them we have established an expectation in our part of northern Indiana that no one should be without a primary care provider. If I retired tomorrow, I would feel that not only had I treated a lot of patients, but also that I had made a positive change in our medical community.
I am now leaving my FQHC and going back into private practice, because there is a need for another change, for me and for my profession. I am starting a direct primary care practice.
Direct primary care (DPC) is an idea whose time has come. It is a model where a doctor contracts directly with his patients for services in exchange for a monthly subscription fee. There is typically little or no charge for individual care episodes. Most importantly, the doctor does not bill insurance for payment. His payment comes entirely from the patients. This allows the doctor to have very low overhead, because a large part of a primary care doctor’s overhead stems from his billing department. A doctor has to have at least one billing clerk working for him if he is going to bill insurance, and that clerk needs a place to work, so the office has to be big enough to fit in the extra staff. In order to pay for the billing clerk and the extra office space, the doctor needs to see more patients, which requires more examining rooms and medical assistants, which have to be paid for by seeing more patients, and when the spiral is done a primary care doctor is typically seeing over twenty patients a day, with two-thirds of the gross proceeds going to overhead.
In contrast, a DPC practice has no billing clerks, so that expense is forgone, and the spiral runs backwards: less office space, fewer supporting staff members, until the practice has five to twelve unhurried visits a day in a small office running perhaps 35% overhead. The doctor can make a living with 300-1,000 patients he knows really well, instead of the typical patient panel of 2,500 patients.
In addition, a subscription model of payment allows for different, often better patient interactions than are allowed by the insurance companies. The reason your doctor won’t talk to you on the phone is that nobody is paying him to do it: the insurance companies don’t consider it a billable service, and most doctors don’t bill for things not on the insurance menu. You can’t interact with your doctor by Skype, or e-mail, or Twitter (or the similar platforms that offer medical-grade security) because he would have to do this for free. On the other hand, if these services are offered as part of a subscription contract with no insurer interference, then you and he can take advantage of these modern conveniences.
The rise of DPC practices has been encouraged by significant changes in the health insurance business, which I will cover in a later post. For now, I will just say that I am looking forward to practicing medicine at a quiet, thoughtful pace for patients who value my services.