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Wednesday Sep 03, 2014

Frequently Asked Questions -- and Answers -- About Direct Primary Care

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the eighth post in an occasional series of blogs that will look at the different roles family physicians can play.

"Is that actually working for you?"

© 2014 Michael Laff/AAFP

I recently participated in a panel discussion at the AAFP's National Conference of Family Medicine Residents and Medical Students along with Abbas Hyderi, M.D., M.P.H., left, and Lilia Cardenas, M.D., center. Students and residents had a lot of questions about my direct primary care practice.

"What if a patient gets hit by a bus?"

"What about patients who are publicly insured?"

Whenever I discuss my direct primary care practice, I expect a barrage of questions. After opening my DPC practice more than two years ago, I think I've heard them all.

When I participated in a panel discussion recently at the AAFP National Conference of Family Medicine Residents and Medical Students, I was ready for all comers. The panel covered a range of family medicine topics, so I only briefly spoke to questions regarding DPC. But afterward, a sizable group of curious students and residents approached me. Several had already thoroughly researched DPC, but most had just recently been introduced to the idea.

A few themes -- and perhaps misperceptions -- emerged. I will try to address a few of them here.

Q: How do your patients get labs, meds, specialists or surgery?

A: My chief concern is my patients' care when I am sitting in the room with them. Family physicians can provide comprehensive care to 80 percent to 90 percent of people at most times in their lives. Enhancing our services should be our main focus. How can we provide the best primary care in an efficient and affordable manner? The better we do our job, the fewer hospitalizations, consults and coronary stents patients will need.

I do have a good portion of patients who have ongoing needs for chronic conditions. A membership-based direct model has allowed me to do innovative things to assist in those areas. We provide labs, meds and procedures at huge discounts. We subcontract lab services and provide members most routine labs (lipids, A1c and many more) for no charge and others with minimal fees. Selling wholesale medications directly to patients often results in hundreds of dollars in savings per month for individual patients. Most procedures are $10-$20 to cover the cost of supplies.

Q: What about insurance?

A: Direct primary care is not anti-insurance. Sometimes, although rarely, people really do get "hit by a bus." Insurance is absolutely necessary for certain types of care. Some events and conditions are inherently expensive. I encourage all my patients to have an insurance plan in case of such an event.

However, hypertension management and radiation treatment for brain cancer are radically different things. Why should we pay for them in the exact same manner? For better or worse, the move toward higher deductible insurance plans has created a demand for transparency among patients. Direct primary care can help fill that void. For many of my patients, combining a high-deductible health plan (a "bronze" level plan on insurance exchanges) with a DPC practice membership with us is a significant savings versus a Cadillac, low copay plan ("gold" or "silver").

Despite my recommendations, many of my patients are uninsured. This is not ideal, but they will
continue to get stellar, continuous care with us in the meantime.

Q: What about someone who cannot afford the DPC membership?

A: The main reason many people cannot afford health care is because it's too dang expensive. Most of my patients found us because they could not afford insurance premiums and/or out-of-pocket expenses under the current system. They could not afford to be without direct primary care.

Although "affordable" is a relative term, I recognize some people have trouble paying even modest DPC membership fees out-of-pocket. There are many ways we could assist people in obtaining care outside of the status quo.

When DPC physicians advocate that insurance be removed from the primary care picture, many people jump to the conclusion that we are therefore calling to end all public assistance. But this is not the case.

There are a variety of alternative funding mechanisms -- outside of subsidized managed care -- that could assist people in getting better primary care. Some progressive health insurance plans and DPC practices, such as Qliance (Washington) and Turntable Health (Nevada), have partnered and are available on state-based exchanges, which is allowed for in the Patient Protection and Affordable Care Act. Also, permitting a portion of public assistance funds to be controlled by patients directly -- via health spending accounts -- could help pay for DPC practice membership fees.

Q: Is DPC really a viable option for me and my patients?

A: There are a number of factors that should be considered before switching to this model of practice -- both personally and from a business standpoint. Despite some stereotypes, DPC practices are not monolithic. Many docs have succeeded with varying models and in a wide variety of communities and populations. However, growing a practice is not easy or without risk. Research and a solid business plan are required.

An increasing number of resources are available to help doctors start and manage a DPC practice. The AAFP recently created a member interest group for DPC, and the Academy also is offering a series of DPC workshops, starting in November.

Even without systemic changes, patient demand for high-quality, affordable primary care will grow. I hope more family physicians will join in meeting that demand.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.


In your first question you mention specialist care and surgery but I don't see a clear answer in your explanation. What do your patients do when needing input from specialists who require insurance? Or for surgery, both elective and non-elective? Is a high deductible plan plus monthly membership still saving the patient money? Is obstetrical care an option with this model? Thank you.

Posted by Matthew on September 03, 2014 at 07:45 PM CDT #

Thanks for the questions Matthew. They limited me to 700 words so I couldn't fit in quite everything in one post. Obviously every patients situation and needs can vary a lot and can be unpredictable - including the same person in different years! So speculating which patient may "come out ahead" in a given system cannot be universally better with any system. That is the inherent nature of "insurance". Re: Specialists. The vast majority of patients will not require specialists help in a given year. Or at least should not if family docs were practicing at their highest scope of training in the right environment. The few that do need specialist consultations do not typically need ongoing frequent visits - again much improved if coordination of care by primary is better. My patients either on high deductible or uninsured haven't had a big issue getting appointments with any type of specialists. However it can be a decent out-of-pocket expense paying for those visits. for uninsured patients we have created a small network of "cash friendly "doctors (cardio, pulm, derm) that have very reasonable upfront fees - often much less than insurance based prices. Also, I have found many specialist who are very happy to give me advice about a patient over the phone pro bono. Re: surgery. The range of expenses associated with procedures and surgeries can vary drastically. Unfortunately most types of major surgery run thousands of dollars but there are a few places that have cash friendly prices and save people lots of money money on elective surgeries. Ultimately this would be an area where insurance is a really advisable thing to have. However I don't think it necessarily make sense to pay 500 extra dollars per month in insurance for a family just so that major surgery (1:100 chance or less in a given year) will cost a few thousand dollars less to meet the deductible. Re: OB. Many of my patients have standard insurance coverage and do their OB care through the local hospital. However, many of my patients also decide to do midwives and home births or freestanding "birthcenter" - or both philosophical and financial reasons. In Kansas it is fairly easy for a pregnant woman to gain coverage for OB care under Medicaid. So if they are uninsured and prefer a hospital delivery many go that route.

Posted by Ryan on September 03, 2014 at 10:09 PM CDT #


Posted by Matthew on September 03, 2014 at 10:54 PM CDT #

I am a family doctor that does OB and that is a particularly wonderful part of my job. Is is possible to do DPC and provide OB care? Do you know of any FPOBs that are doing direct primary care?

Posted by Sandy on March 12, 2015 at 05:12 PM CDT #

Hi Sandy! I am not aware of any docs doing OB care in a DPC model. The biggest expense of OB care is the facility fee for delivery, by far, so think financially that would be a big consideration by patients. Also, with bundled insurance payments for OB care, I'm not sure how that would work. However, I think it would be possible given the right setting and partnerships. Obviously lots of nurse midwives make it work doing home deliveries or birthing centers.

Posted by Ryan on March 18, 2015 at 10:44 AM CDT #

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