It used to be easy. You didn’t worry about your health care or how to pay for it. You had a family physician who cared for you in the office and the hospital. They coordinated every aspect of your care, including working with consultants. And after discharge, they would resume caring for you knowing what had occurred firsthand. That was then.
This is now.
Patients rarely see their primary care physician in person, if at all. The office is staffed by a number of nurse practitioners or physician assistants who assist in well-adult visits and acute care but do not assume full responsibility and are, therefore, less accountable. When a patient is admitted to the hospital, a hospital-based team takes over. If a specialist is involved, there is no longer any direct communication with the primary care. Once the patient is discharged, a summary of events is sent to the office. Those records are often never conveyed if the office is out of network or unaffiliated.
Which way is better?
It’s not surprising that when doctors worked together, the patients did better. But our system evolved into this impersonal, fragmented mess because of the administrative burdens — invented by payers and well-intentioned policy gurus — who sought to streamline an inefficient system. It became simpler and more convenient to employ those who filled out the medical records because salary incentives and penalties would ensure compliance. The practice extended beyond the hospital to physician offices, and despite Stark Laws, has led to considerable consolidation, rising prices, and limited access.
Careful of what you wish for.
With the current system owned and operated by networks and fueled by insurer-employer agreements, there is little room for disagreement. Doctors work for the system, not the patient. Spending too much time results in a penalty. Patients are kept at arm’s length. Most physicians are nothing more than pawns in a system designed to optimize revenue. The doctor can no longer see the patient if an insurance network changes. If the patient ends up in the wrong hospital, the doctor and the patient pay the price.
Despite these so-called “efficiencies,” the cost of care continues to rise while the outcomes plummet. The response? Hire more management consultants, buy more technology, and add more restrictions. They rebrand managed care as value-based care and use terms like “evidenced-based medicine” to justify denials. If only it actually worked … even an iota. Yet, as most Americans and their employers are aware, health care and health insurance costs continue to spiral out of control as more steps and “middles” are added to the process.
Throughout this transformation, many doctors stopped practicing. Some became administrators, others went to work for insurers, and others left medicine altogether.
A small group of independent doctors courageously chose to step outside the system to take care of patients for a transparent, affordable price — often less than what people pay for their cell phones or cable TV. Moving and existing outside the current system wasn’t easy, but direct primary care has allowed doctors to work only for the patient again. Patients are still able to use insurance, but with out-of-pocket costs like deductibles and copays rising every day, they can now access critical personal-based primary care at an affordable rate with guaranteed access to the doctor they choose.
Insurance can now be used for what it was actually intended for: coverage against major unexpected medical events or conditions without the fear of going broke. Ironically, people are going broke because we have become dependent on an insurance model! The DPC model has consistently outperformed every other managed care plan in quality, cost, and outcomes, not to mention patient satisfaction.
Direct-pay health care now goes beyond primary care. Advances in technology have allowed care to move away from hospitals to surgery centers, offices, and even the patient’s home. Direct access to specialists for chronic disease management and single consultations has also emerged as a convenient and cost-effective alternative to traditional referral networks, which often have limited access and long wait times. More and more employers are looking for health plans that offer a DPO (direct pay option) to eliminate surprise bills and avoid costly delays in care. Additional services, including imaging, prescriptions, labs, and surgery centers, have all embraced a direct pay model by eliminating the burden of insurance restrictions in exchange for a fair and transparent price.
Fee-for-service is often criticized as a poor model of care because it is based on volume and, therefore, can be abused. But offering a defined medical service for a defined price is the very nature of medicine. A system that receives a price per patient, regardless of services required, is never transparent, and the financial incentive to deny care is no less tempting than a fee paid for a service provided. In the age of informed consent, direct pay health care holds both parties accountable for the care, as it should be. All incentives become aligned!
The movement toward direct pay has many consequences. Prices will invariably come down as competition increases (look at LASIK eye surgery as an example). Those below the poverty line or on fixed incomes might be left behind is a straw man’s argument, as there is no reason those in need couldn’t qualify for health vouchers or federally funded HSAs.
Putting more of the dollars spent on health care back in the hands of the patients to support the social determinants of health makes the most sense. We talk about a two-tier system, but good medical care doesn’t need an elaborate and expensive bureaucracy, especially now. On the contrary, it’s a relatively simple equation based on experience, choice, and trust where the actual consumer of care makes the decisions. The DPC doctors are leading us in the right direction. It’s up to the rest of us to follow and fix this system for the people who matter most- doctors and patients. If we wait for policymakers, government, and third-party payers to fix the mess they created. God help us.
Paula Muto is a vascular surgeon. Jeffrey Gold is a family physician.
