Direct Primary Care (DPC) is a relatively new model of delivering health care to address some of the broken aspects of our current traditional health fee for service (FFS) insurance driven model. The typical DPC practice does not bill insurance, rather directly contracts with the patient who pays a monthly membership fee. In exchange, the patient receives high quality and highly accessible health care from typically one provider.
In a normal FFS health system, a patient will have to wait several day to weeks, sometimes months, to get in with his or her preferred health care provider. Once that visit is made, the patient has to run a gauntlet of checking in the front staff, waiting, being brought back by clinical staff, waiting, waiting and waiting some more, for the provider (depending on the time of day the appointment was made). Then the doctor/nurse practitioner/physician assistant will come in, typically spend 5-10 minutes in the room taking a history, performing a physical and making a diagnosis and discussing the plan. Then the provider will spend another 5 minutes outside the room documenting the visit…then moving onto the next visit. For a 15 minute visit, the patient may get ½ of the allotted time in order for the provider to see the next 15 minute patient. That does not always happen however. If a particular patient scheduled for a 15 minute slot has a long list of problems, the visit lasts longer in order to accommodate those complaints. This pushes provider a bit later and later, cascading down the subsequent patients the provider is seeing that day. Multiply that by 5 or 10 or 15 patients having more complaints than can be adequately addressed, then it’s easy to see that if the provider wants to stay on time with his or her patients, then something must give. The choices are 1) to have longer visits in the first place. This would equate to seeing fewer patients per day, and not being able to accommodate large numbers of patients. With fairly low insurance reimbursements to medical practices, this doesn’t pay the bills. Choice 2) is to postpone the documentation at the time of the visit and use the entire 15 minute time slot with the patient. This is a common practice, but not ideal. A lot of details of the visit can be forgotten if the documentation is completed even at the end of the day. But this is what happens a lot in health care. We prefer to give the entire time to the patient (particularly in primary care) and document later on our own time. But again this is not ideal since documentation suffers. Choice number 2 is part of the cause of burnout in many health care providers. There are a lot of requirements and check boxes that have to be met due to insurance companies (particularly Medicare) wanting to make sure their clients are receiving care the insurance company deems appropriate. This begs the question…why are insurance companies the ones that are deciding what is appropriate care? Is this not something that the health care provider has spent years to decades studying and doing already? The vast majority of check boxes in documentation have absolutely no bearing on health outcomes. Yet these documentation requirements are the thing that is driving spending more time on computers for providers rather than spending more time with patients. Ultimately this drives down quality of care. Counterintuitively this increases risks that we are missing something in our interactions with patients because we are actually spending more time making sure the check boxes are being met rather than actually talk with our patients sitting in the exam room in front of us. This is the reason for many doctors choosing nonclinical work—there is less and less satisfaction because we feel we are now simply those who input data rather than actually taking care of the person sitting in front of us.
The 1st choice is actually a much better choice—increasing the amount of time each person gets. Going from a 15 minute visit to a 60 minute visit or more allows us to address the majority of concerns a patient has. As above, in the current commercial FFS world, this doesn’t work well because with the payment structure, low reimbursements don’t allow clinics to be financially solvent with fewer patients. This is in part because the insurance company takes a significant portion of the payments to the clinic or doctor.
This is where DPC comes into play. Essentially this cuts out the insurance middlemen and allows payments go directly from the patient to doctor without the insurance taking a cut. DPC doctors work directly for the patients and do not need to spend the unnecessary time to meet the insurance documentation requirements. Thus, spending more time with the patients, which leads to a more satisfying visit for both patient and doctor.
In the next post I will describe DPC in more detail.
Thanks for reading!!