All of the arguments for direct primary care (DPC) from a provider perspective are valid. As a psychotherapist and psychoanalyst, I have essentially run a direct care practice for the last 15 years. I don’t accept insurance and see patients as often and for as long as therapeutically necessary. So when DPC practices started rising in popularity, I was excited to try it. Unfortunately, as a patient who is medically complex and often needs referrals for tests and specialists, this model has fallen short for me, often spectacularly so. This post outlines some of my experiences.
Many of the doctors who go into DPC do so because they are burned out from working for hospital systems. They talk about this in podcasts and right here on KevinMD. They are tired of layers of red tape and limited time with patients. They don’t want to deal with insurance preauthorizations or interact with insurance in any way. I understand all of that from their perspectives. And as a patient, it is very appealing to have access to your primary care doctor on their cell phones, via text or video appointments, and the convenience of same or next-day appointments that are unhurried.
The hidden burden of insurance authorization
But here’s what isn’t mentioned: The DPC doctors who are burned out by insurance generally don’t want to authorize the tests that they order, like MRIs. Read: dealing with insurance. One doctor I saw would fax all of her notes to the imaging center and ask them to authorize it. When her notes were incomplete, they would call me, the patient, and ask me to ask my doctor for clarification so they could more effectively communicate with my insurance company. Then I would have to call her, and a telephone tag would ensue, with me as middleman. It was complicated and delayed the process of authorization significantly, thus delaying my care.
The financial reality of high utilizers
DPC practices typically have low membership fees (usually ranging from $125-$250 per month). For an average patient, who may see their physician a few times a year and have a couple of questions here and there, it’s a clear win for the physician. They can respond relatively quickly and the patient generally feels well cared for. However, if a patient is a high utilizer of services, the DPC practice actually loses money. If I need to see my DPC doctor three times in one month, the doctor is not making enough to cover those visits. It has led to palpable resentment on the part of my DPC doctors. One DPC physician angrily told me that she couldn’t spend time faxing her notes to an imaging center because she didn’t have office staff.
She also did not have an EKG machine, explaining that it was too expensive for her to purchase with the low membership fees charged. She wanted to send me to a cardiologist for a routine EKG. The cardiologist had a six-month waiting list and there was no medical reason I needed to see a cardiologist. The referral was made simply because the DPC doctor couldn’t afford the machine. The DPC model can inappropriately use health care resources by referring to specialists just because the membership fees aren’t high enough to cover basic supplies.
The cost of low overhead
Many DPC proponents tout how inexpensive it is to start a practice. That is correct, but when a doctor doesn’t have any support staff and/or works out of their home because it is the most cost-effective way to start their DPC journey, patients can suffer. There are no assistants to fax notes, and no office to fully and professionally examine patients. Another physician would advertise that she was a house call doctor. What that meant was that she would see you twice per year at your home for the low membership fee, or see you online, but anything beyond two in-person visits was billed at $300 per appointment. Again, as a medically complex patient, two visits per year are unrealistic for me. Primary care often does not lend itself to an online format except for simple issues and questions. The additional per-visit fee made my monthly fees extremely high for a doctor with no medical equipment other than what she could carry in her bag and without an office.
A call for critical thinking
While the DPC movement has noble intentions, I encourage both doctors and patients to think more critically about what is reasonably sustainable for both parties. A low membership fee and unlimited access is only helpful if that’s what it truly is. Perhaps a fee-for-service practice, as we do in my chosen field, would be more sustainable for all. It doesn’t provide a steady monthly income, but it does guarantee that doctors are paid for their time and patients can receive the care they need when they need it. And it is less likely that DPC doctors will feel resentful of the high-needs patient.
Zoe M. Crawford is a social worker.
