12 ms·

Direct Primary Care

53 points by Mz 10y ago

ljoshua 10y ago
So I'm a little confused, because it states that you can combine DPC care with an HDHP to satisfy basic coverage and skip the penalty, but wouldn't the HDHP plan satisfy that? Or is the simple possession of an HSA combined with DPC good enough? (The second case would seem weird, since there's no "insurance" for high risk situations; it's just a savings account. And in most cases you wouldn't have an HSA unless you already were on an HDHP.) Nothing against DPC, I'm just unclear how this works in with the individual mandate.
- jschwartzi 10y ago
  IANAL, but the HDHP would be your ACA plan and the DPC would eliminate a lot of the expense of the HDHP for routine visits.
  - rootusrootus 10y ago
    I can appreciate the appeal of DPC, but in my experience routine visits (at least anything that qualifies as preventative) are generally 100% covered by the high deductible plans. Maybe that's a requirement from ACA? Maybe the DPC cost savings is in the non-preventative minor occurrences which are almost routine. Like a kid's broken bone for example, things you don't expect to happen but aren't exactly a surprise either, and not catastrophic.
    - secabeen 10y ago
      Right, the HDHPs have to cover preventative care for in-network doctors. However, you still have to be careful. I have seen doctors bill for a non-preventative visit if you ask any questions at all about specific ailments during a preventative care visit.
- uiri 10y ago
  I believe that you must have HDHP in order to contribute to a HSA. HDHP satisfies the penalty. DPC helps save costs on routine care.
tptacek 10y ago
What happens when your appendix bursts?
- FLGMwt 10y ago
  I think the premise is that the cost savings for maintenance and low complexity care make the risk of paying for emergency care worth it? Which I'd love to see numbers on. I imagine any chronic condition would almost certainly rule this out as presented.
  - PaulHoule 10y ago
    Models where a provider network gets $X a year to handle a chronic condition patient are one of the few bright spots in recent health care policies. Ten years back we may be looking at high deductable plans as a disaster -- if you have the money to fill an HSA they are great, but for most people in the U.S. an HDCP means that diabetics will not take metformin or insulin but instead they will get their feet amputated at much greater cost. One clear example is asthma. Steroid inhalers can often enable an asthma patient to breathe freely and avoid hospital admissions for about $200 a month. That looks like a crazy high price, but a hospital admission is going to cost $8000 or more. In the fee-for-service model the hospital profits from amputations, asthma exacerbations, etc. In a flat fee model they make a profit from practing good medicine.
- mrfusion 10y ago
  According to tfa you're still supposed to have high deductible insurance (thus defeating the purpose?)
  - jerf 10y ago
    It depends on what your purpose is. It is at least debatable that one of the major problems with our current system rarely addressed by anyone on any side is that it conflates a health care plan with a health insurance plan. The two things may with some justification be the same thing inside of your head, but in monetary terms, they have radically different statistical distributions of monetary payouts required, one being a fairly reliable steady drip of relatively small amounts of funds, one being a highly irregular payout of large amounts of funds. Only the latter is something that "insurance" is a solution to; if you're getting a steady drip of low-payout events the only thing insurance can do for you is add a middleman and raise net prices as a result. (Some individuals may win and some may lose, but it has to come out net more expensive for the system.) Trying to bind the two together into one thing may be part of, though probably not the entire, problem.
mrfusion 10y ago
I don't think this is a loop hole. Can anyone point me to a reference? Source: I just spent months trying to figure out how to buy truly catastrophic insurance and avoid the aca penalty with no luck.
- cjy 10y ago
  I checked and it appears there isn't really a loophole. Direct primary care providers are able to combine their offering with insurance and offer it on the ACA exchange, but they are subject to the same requirements of any other insurer. And none seem to be doing this yet: From http://www.dpcare.org/specialties http://www.dpcare.org/specialties: "H.R. 3590 recognizes DPC and allows DPC Medical Homes to offer coverage in health insurance exchanges in combination with a wraparound insurance policy provided by a qualified health plan (QHP). Working together, the two must satisfy all other essential health benefits requirements under H.R.3590. DPC practices provide all primary care in a monthly fee arrangement. The QHP is used for hospitalization, specialty care and other more costly services. The first DPC offering paired with a QHP in the healthcare marketplace went live in the Washington state exchange in January 2015. There are no DPC practices operating in the federally facilitated exchanges yet."
- vyrotek 10y ago
  Many are combining Direct Health Care with a Healthcare Share. It's a co-op model that's not really "insurance" and is meant to be drawn from for only serious issues. So kind of what you'd expect to cover with a high-deductible plan. It works more like a community who reviews and decides whether they want to contribute to your bills. One of the biggest advantages of these healthcare shares is that they're ACA exempt. Meaning, no fine. But there are other requirements to be accepted. Especially with the religious healthcare ministry ones. But they are very affordable. For example, I know people who use http://www.chministries.org http://www.chministries.org with a local (AZ in this case) DHC such as https://www.arkfamilyhealth.com https://www.arkfamilyhealth.com
  - mrfusion 10y ago
    I came across those before. If I could feel confident t they would be garunteed to cover serious issues I'd do it. But it seems like there's no garuntee so you're taking a big risk? Other issues I didn't like is that they're not eligible for an hsa? And what's the Guarantee you get the Aca exception?
DanBC 10y ago
> They see their patients more frequently This is strongly linked to several forms of harm. Over-testing, over-diagnosing, and over-treatment are dangerous. (And, in some places, expensive.) http://www.cancerresearchuk.org/about-us/cancer-news/press-release/2016-04-06-public-dont-understand-overdiagnosis http://www.cancerresearchuk.org/about-us/cancer-news/press-r...
- Mz 10y ago
  In the US, it is a huge problem that physicians spend so much time dealing with insurance, they have to churn through patients and can't establish a real relationship to them. It actively undermines the quality of care. DPC allows physicians to escape a horrifying hamster wheel of running faster to just stay in place. It allows them to take the time to get to know their patients in a way that was normal when I was growing up, but is very rare these days. It allows them to see the same patient for thirty minutes or an hour a few times a year and actually remember who they are instead of having some insanely low amount of time per patient per year, like seven or ten minutes. It has a track record in this country of stopping the insanity and improving care. http://medicaleconomics.modernmedicine.com/medical-economics/news/physicians-chart-new-path-direct-primary-care http://medicaleconomics.modernmedicine.com/medical-economics... http://aapp.org/2016/01/08/why-you-should-transition-to-direct-primary-care-and-how-you-can-make-the-process-easier/ http://aapp.org/2016/01/08/why-you-should-transition-to-dire... http://www.dpceugene.com/single-post/2016/07/06/Why-choose-the-direct-primary-care-model http://www.dpceugene.com/single-post/2016/07/06/Why-choose-t...
  - icantdrive55 10y ago
    I've been to modern doctors who spent time with me, and in all honestly--I'm getting no benefit from their "wisdom". Now the family doctor, whom retired in 2000, was time well spent. He palpated for tumors. He looked at our retinas. He listened to our hearts. He found a slight mitral valve prolapse in my mom, and myself.(Something every doctor I have seen since has completely missed, or didn't care enough to listen for?). And yes, some times the rubber glove was brought out. Since I have good insurance now, my doctors spend time with me, but I have found talking kinda useless, unless I'm in for a specific symptom. Too many they don't seem to really listen. They love to run up the bill with a depression screening. They mention fish oil. Blah--blah--blah. I sometimes think a person without good insurance might be better off. They are left alone. They aren't put on dubious anti-depressants. They arn't over treated. They won't get a testosterone patch. They won't get any edgy new treatment--that might be found to be dangerious. I will admit; I'm no fan of modern doctors, unless it's for emergency medicine. Maybe that's affecting my judgement? I don't have the respect for doctors I once had. I haven't been to a doctor recently whom I didn't walk out of thinking---He's/She's just in it for the money? I have a psychiatrist that put me on a addictive drug years ago, and has literally held me hostage with the mandatory office visits, and they are solely for money. I look back at 99% of my doctor office visits, and I can't think on any ailment they caught by spending talking time. "So give me the comprehensive blood test, and order a MRI if I"m complaining of upper right quadrant pain--please doc, and refill any addictive prescriptions for a year. I really don't want to talk to you, unless that office visit includes blood work, or something other than just yacking, and running up a bill!" I'm now fifty. If you get through your twenties-thirties without a mental malady; you succeeded. Life in America is hard on the psyche, and that can cause so many health problems--high blood pressure from self medicating? Weird pains? Most of it will be psychosomatic. In terms of health, I can offer what helped me: cut back on the alcohol, exercise a little, eat less. Get that pneumonia vaccine if you're constantly getting chest infections. It's one of the better vaccines.
padobson 10y ago
I'm curious how it would work at the hospital level, or even at the hospital network level. Pay the network a monthly fee, and then when you get sick, all of your care is already paid for. I suppose this is the idea behind HMOs, but the execution hasn't been there.
- ceejayoz 10y ago
  All the little hospitals and clinics in our area have been bought up by one of the two healthcare networks in the five-county region, and I'm fairly shocked they haven't done this. Maybe it's illegal for a hospital system to offer insurance in NY? I don't know. You'd think they'd be happy to cut out all the fuss around handling insurance approvals/rejections and pocket the 20% middleman cut.
  - whafro 10y ago
    I don't have a ton of first-hand knowledge, but I know that being licensed to provide health insurance in NY specifically is no joke. Todd Park (former US CTO, AthenaHealth founder) once told me that he didn't pay much attention to Oscar early on until he found out they had gained an NY license, at which point he dove into it. More broadly, many hospitals and hospital are getting involved in the ACO (accountable care org), which gets at some of these goals, but it's not 100% clear that an ACO model can be successful (financially or for patients), and it doesn't cut out all the relevant middle-men.
  - chimeracoder 10y ago
    > Maybe it's illegal for a hospital system to offer insurance in NY? Definitely not. A lot of hospitals are part of networks which are doing exactly this. And many of the ones that aren't are entering long-term capitated agreements with insurers, which basically means they're acting as if they were insurers but without technically being one.
  - Spooky23 10y ago
    The consolidation is happening because there's a huge surplus of hospital beds and specialists in NY.
ceejayoz 10y ago
> It achieves lower costs in large part by cutting out the middle man of health insurance for basic services. Is it actually lower cost? The cash fee for a PCP visit and what insurance actually pays are drastically different. If you're paying a membership fee just to get the same sort of rates insurance pays out at, there's no win here. > A little known provision of the ACA makes Direct Primary Care a kind of legal loophole. When combined with a high deductible health plan or health savings account, Direct Primary Care can meet the requirements for basic coverage, thus getting you out of the tax penalty for not being properly covered. That's not a loophole. That's "pay extra". You'd still need at least a Bronze plan, and any visits that bill against your DPC won't count towards your annual deductible or out-of-pocket caps.
- chimeracoder 10y ago
  > The cash fee for a PCP visit and what insurance actually pays are drastically different. If you're paying a membership fee just to get the same sort of rates insurance pays out at, there's no win here. You don't want to get the same rates that insurers pay - those are actually the inflated rates. Billing is complicated. In short, part of the problem is that doctors who take public insurance (Medicare/Medicaid) actually take a loss on those patients, because Medicare reimburses about 7% less than the direct costs of services, in the aggregate. It's one of the reasons you see very few private practices which cater solely, or even primarily, to Medicare patients. The way providers make this work, since they can't negotiate rates with Medicare, is to charge higher rates for private insurers. This ends up as an effective subsidy from private insurers to Medicare. A doctor who doesn't accept any insurance whatsoever doesn't have to manage this indirect subsidy, so the amount they charge a self-paying patient could be a lot less than what another doctor would bill a private insurer for.
  - rootusrootus 10y ago
    I would like to learn more about this. Some people here (who claim to be intimately involved with the actual financial aspects of running a clinic) say it's the opposite -- that Medicare actually pays the bills so the clinic stays open because the private insurers are so effective at getting out of paying anything. Surely there is a reliable source that can confirm one way or another how this works in practice? I get that it is probably arcane and difficult to understand, but in a country as vast as the US there is probably someone who understands it well enough to summarize for a layman.
chimeracoder 10y ago
The premise of this post is straightforward once you remember how insurance works from an economic standpoint. One thing that people often overlook when talking about health insurance is that, economically, "health insurance" is really the combination of two completely separate products, only one of which is actually insurance. Insurance is about pooling risk. It smooths risk across states of the world (e.g. the universe in which your house burned down, and the universe in which it didn't but your neighbor's house did instead). It reduces the variance between those states, and in exchange, it charges a premium for making the outcome more predictable. It is not there to save you money. The expected value of all insurance is negative, and that's intentional. By a true insurance model, routine care and elective surgery would be priced the same with insurance as it would without, because there is no risk involved. The reason it isn't it because we want to subsidize these, to enable people to obtain care they otherwise wouldn't be able to afford. We use "insurance" as a vehicle for this, but really, that's not insurance at all. It's a redistribution. So it's perfectly understandable that a primary physician who is dealing with routine care and doesn't accept insurance would be able to charge patients less (and still walk away with more money) than one who uses insurance. The reason you don't see this everywhere, though, is that policies are making it harder and harder for physicians to run private practices entirely (whether they accept insurance or not). The majority of physicians are now employed, largely by hospital networks which are required to accept insurance (in some cases legally, and in others by virtue of the fact that they need to cover their Medicare losses[0]). So, the place you are most likely to see the direct care model are with physicians who are catered to the incredibly wealthy. That's not to say that a direct care model couldn't work for people who aren't, but the way our system is set up doesn't facilitate it. [0] https://news.ycombinator.com/item?id=13356442 https://news.ycombinator.com/item?id=13356442
- pdonis 10y ago
  > The expected value of all insurance is negative Only if you ignore non-monetary costs and benefits. Risk reduction/mitigation is a benefit and has a value. If it had no value, people would not bother buying insurance. When that benefit is taken into account, the net expected value of insurance is positive for both parties: the insurer makes money (assuming it has done its actuarial statistics properly) and the insured buys risk reduction/mitigation at a cost that is less than its value. Your point about "health insurance" combining two separate products, only one of which is actually insurance, is valid, though, and very important.
dnewms 10y ago
For anecdotes: I've had a HDHP before ACA, started at about $45/mo now up to about $60/mo with an outrageously high $12.5k or so deductible. I've had two different DPC, one about $45/mo, now with one about $30/mo. Both combined are still less than I would pay in any marketplace. It's nice to be able to just see your doctor without worrying what it might cost. A large list of simple procedures are covered, and tests cost next to nothing. It's a health subscription to an actual doctor who can be just as cost-conscious as you are while still incredibly knowledgable and invested in your health.
- daxorid 10y ago
  I pay 780$/mo for a plan with a $13k max out of pocket. Where on earth are you getting 45$ ?
  - dnewms 10y ago
    UnitedHealthcare -- though my plan may have been grandfathered in to be acceptable under ACA.
    - koolba 10y ago
      What state and how old are you? That seems insanely cheap compared every plan I've seen (high deductible or otherwise).
      - dnewms 10y ago
        <30 midwest
        lotsofpulp 10y ago
        Is this health insurance purchased via your employer? If so, is your employer subsidizing it? Double digit premiums sound ridiculous, even for a male in their 20s. As a data point, I'm a <30 male, never been to a doctor with no health issues that I can tell, and my HDHP premium is $310ish, last year it was $275ish, but that's using healthcare.gov so completely unsubsidized, and I have a deductible of $1,500/$2,500 and out of pocket max of $3,600/$6,550 for their tier 1/tier 2 providers, respectively (whatever that means).
massysett 10y ago
This is not particularly novel. There are already integrated HMOs, like Kaiser Permanente and Group Health Cooperative, that function in a similar way. Kaiser is a little more complicated (there is a "Kaiser Foundation Health Plan" that acts as insurer, while physicians work for the "Permanente Medical Group") but they have integrated systems so physicians are not spending time dealing with claims--and besides, the physicians do all their work for this one health plan, so there's no web of insurance companies.
- chimeracoder 10y ago
  > This is not particularly novel. There are already integrated HMOs, like Kaiser Permanente and Group Health Cooperative, that function in a similar way Integrated practice is distinct from HMOs, though they might appear to be similar. Kaiser us an integrated practice and also provides and manages an HMO, but not all Kaiser patients belong to the HMO > they have integrated systems so physicians are not spending time dealing with claims--and besides, the physicians do all their work for this one health plan, so there's no web of insurance companies. Not exactly. Kaiser physicians still have to do all the work of coding and billing, except for them, the billing is all reconciled by a single entity and managed internally. That's different from direct care, in which the billing step literally does not happen, because the patient self-pays, usual in-person.
  - eridius 10y ago
    Kaiser does have a PPO plan, but it must not be very common because the one Kaiser doctor I mentioned this to was very surprised and had never heard of Kaiser offering a non-HMO plan before.
codingdave 10y ago
Except that if you have a HDHP, your costs towards routine care also go towards your deductible, so if you have emergency care that year, you only get hit with your max out-of-pocket for the year. Instead of paying your max for the year AND whatever your paid directly to your direct pay provider. So these types of services are a gamble - you come out ahead if you have no emergencies. And come out behind if you do. For a family with kids, I'll pass. If you are young and healthy and do not have kids, and do not do a lot of outdoor activities that risk injuries, this might make more sense.
- lotsofpulp 10y ago
  Wouldn't you hit the out of pocket max if you have an emergency? As long as you have that much cash, HDHP makes sense to me.
  - codingdave 10y ago
    Yes, but direct pay to another doctor doesn't apply towards your out of pocket max - so if you are doing a direct play place, you end up paying your max for your emergency care PLUS anything you paid directly to another provider.
  - atlasmd 10y ago
    That is a fair point - any major hospitalization and you're over your deductible anyways. But the insurance statistic is that about 87% of people with a 3k deductible will reach that in a given year and <95% of people with a 5k deductible will reach that in a given year. Which means, families are paying more than $1000/mo or 12k/year for a risk thats rarely over 5k. Which means they can decrease their insurance coverage, save $500/mo on their premiums, and save more money each year than their increased deductibles would be. Plus, our direct care models saves them on the majority of care most people need in a year. i've been a direct care doc since 9/2010 and happy to answer any questions. to (quickly) define the model: $10-100/patient/month for unlimited home/work/office/technology visits, no copays, any procedure we can do in the office is included free, and wholesale savings on medicines, labs, imaging, pathology of up to 95% (yes!) We can then take all of this value and go back to an employer and help decrease insurance costs by 30-60%.
ilaksh 10y ago
My understanding is that one of the biggest issues that we can actually improve is inflated billing. It seems that something like direct primary care could help with that issue. But maybe we could just create a law that resets things so that they cannot simply inflate the bill and then certain groups pay only a small percentage of the amount? Because it makes it so we can't tell what the real costs are at all, and then people who don't have insurance or the right insurance are screwed by these giant basically fraudulent bills. That is the really stupid part about it. Then another idea is, I think that some health care costs just really are quite high. This is because of scarcity of high-tech medical machines or doctors or specialists. Maybe the solution to that is to push for greater volume of high tech medical machinery or medicines and a greater volume of medical professionals. Maybe by supplementing with advanced AI we can relax requirements for certain types of more general physicians or nurses rather than researchers, etc. Maybe just finding ways to reduce medical education could help. Then one other idea is the realization that more and more mainstream researchers are having that A) the majority of medical problems have some significant component that is related to aging, or where aging increases risk, etc. and B) we are now in fact able to start investigating and have hope for treating the actual causes of the various system degradations referred to as aging.

53 points by Mz 10y ago

So I'm a little confused, because it states that you can combine DPC care with an HDHP to satisfy basic coverage and skip the penalty, but wouldn't the HDHP plan satisfy that? Or is the simple possession of an HSA combined with DPC good enough? (The second case would seem weird, since there's no "insurance" for high risk situations; it's just a savings account. And in most cases you wouldn't have an HSA unless you already were on an HDHP.) Nothing against DPC, I'm just unclear how this works in with the individual mandate.

jschwartzi 10y ago
IANAL, but the HDHP would be your ACA plan and the DPC would eliminate a lot of the expense of the HDHP for routine visits.
- rootusrootus 10y ago
  I can appreciate the appeal of DPC, but in my experience routine visits (at least anything that qualifies as preventative) are generally 100% covered by the high deductible plans. Maybe that's a requirement from ACA? Maybe the DPC cost savings is in the non-preventative minor occurrences which are almost routine. Like a kid's broken bone for example, things you don't expect to happen but aren't exactly a surprise either, and not catastrophic.
  - secabeen 10y ago
    Right, the HDHPs have to cover preventative care for in-network doctors. However, you still have to be careful. I have seen doctors bill for a non-preventative visit if you ask any questions at all about specific ailments during a preventative care visit.
uiri 10y ago
I believe that you must have HDHP in order to contribute to a HSA. HDHP satisfies the penalty. DPC helps save costs on routine care.

tptacek 10y ago

What happens when your appendix bursts?

FLGMwt 10y ago
I think the premise is that the cost savings for maintenance and low complexity care make the risk of paying for emergency care worth it? Which I'd love to see numbers on. I imagine any chronic condition would almost certainly rule this out as presented.
- PaulHoule 10y ago
  Models where a provider network gets $X a year to handle a chronic condition patient are one of the few bright spots in recent health care policies. Ten years back we may be looking at high deductable plans as a disaster -- if you have the money to fill an HSA they are great, but for most people in the U.S. an HDCP means that diabetics will not take metformin or insulin but instead they will get their feet amputated at much greater cost. One clear example is asthma. Steroid inhalers can often enable an asthma patient to breathe freely and avoid hospital admissions for about $200 a month. That looks like a crazy high price, but a hospital admission is going to cost $8000 or more. In the fee-for-service model the hospital profits from amputations, asthma exacerbations, etc. In a flat fee model they make a profit from practing good medicine.
mrfusion 10y ago
According to tfa you're still supposed to have high deductible insurance (thus defeating the purpose?)
- jerf 10y ago
  It depends on what your purpose is. It is at least debatable that one of the major problems with our current system rarely addressed by anyone on any side is that it conflates a health care plan with a health insurance plan. The two things may with some justification be the same thing inside of your head, but in monetary terms, they have radically different statistical distributions of monetary payouts required, one being a fairly reliable steady drip of relatively small amounts of funds, one being a highly irregular payout of large amounts of funds. Only the latter is something that "insurance" is a solution to; if you're getting a steady drip of low-payout events the only thing insurance can do for you is add a middleman and raise net prices as a result. (Some individuals may win and some may lose, but it has to come out net more expensive for the system.) Trying to bind the two together into one thing may be part of, though probably not the entire, problem.

mrfusion 10y ago

I don't think this is a loop hole. Can anyone point me to a reference? Source: I just spent months trying to figure out how to buy truly catastrophic insurance and avoid the aca penalty with no luck.

cjy 10y ago
I checked and it appears there isn't really a loophole. Direct primary care providers are able to combine their offering with insurance and offer it on the ACA exchange, but they are subject to the same requirements of any other insurer. And none seem to be doing this yet: From http://www.dpcare.org/specialties http://www.dpcare.org/specialties: "H.R. 3590 recognizes DPC and allows DPC Medical Homes to offer coverage in health insurance exchanges in combination with a wraparound insurance policy provided by a qualified health plan (QHP). Working together, the two must satisfy all other essential health benefits requirements under H.R.3590. DPC practices provide all primary care in a monthly fee arrangement. The QHP is used for hospitalization, specialty care and other more costly services. The first DPC offering paired with a QHP in the healthcare marketplace went live in the Washington state exchange in January 2015. There are no DPC practices operating in the federally facilitated exchanges yet."
vyrotek 10y ago
Many are combining Direct Health Care with a Healthcare Share. It's a co-op model that's not really "insurance" and is meant to be drawn from for only serious issues. So kind of what you'd expect to cover with a high-deductible plan. It works more like a community who reviews and decides whether they want to contribute to your bills. One of the biggest advantages of these healthcare shares is that they're ACA exempt. Meaning, no fine. But there are other requirements to be accepted. Especially with the religious healthcare ministry ones. But they are very affordable. For example, I know people who use http://www.chministries.org http://www.chministries.org with a local (AZ in this case) DHC such as https://www.arkfamilyhealth.com https://www.arkfamilyhealth.com
- mrfusion 10y ago
  I came across those before. If I could feel confident t they would be garunteed to cover serious issues I'd do it. But it seems like there's no garuntee so you're taking a big risk? Other issues I didn't like is that they're not eligible for an hsa? And what's the Guarantee you get the Aca exception?

DanBC 10y ago

> They see their patients more frequently This is strongly linked to several forms of harm. Over-testing, over-diagnosing, and over-treatment are dangerous. (And, in some places, expensive.) http://www.cancerresearchuk.org/about-us/cancer-news/press-release/2016-04-06-public-dont-understand-overdiagnosis http://www.cancerresearchuk.org/about-us/cancer-news/press-r...

Mz 10y ago
In the US, it is a huge problem that physicians spend so much time dealing with insurance, they have to churn through patients and can't establish a real relationship to them. It actively undermines the quality of care. DPC allows physicians to escape a horrifying hamster wheel of running faster to just stay in place. It allows them to take the time to get to know their patients in a way that was normal when I was growing up, but is very rare these days. It allows them to see the same patient for thirty minutes or an hour a few times a year and actually remember who they are instead of having some insanely low amount of time per patient per year, like seven or ten minutes. It has a track record in this country of stopping the insanity and improving care. http://medicaleconomics.modernmedicine.com/medical-economics/news/physicians-chart-new-path-direct-primary-care http://medicaleconomics.modernmedicine.com/medical-economics... http://aapp.org/2016/01/08/why-you-should-transition-to-direct-primary-care-and-how-you-can-make-the-process-easier/ http://aapp.org/2016/01/08/why-you-should-transition-to-dire... http://www.dpceugene.com/single-post/2016/07/06/Why-choose-the-direct-primary-care-model http://www.dpceugene.com/single-post/2016/07/06/Why-choose-t...
- icantdrive55 10y ago
  I've been to modern doctors who spent time with me, and in all honestly--I'm getting no benefit from their "wisdom". Now the family doctor, whom retired in 2000, was time well spent. He palpated for tumors. He looked at our retinas. He listened to our hearts. He found a slight mitral valve prolapse in my mom, and myself.(Something every doctor I have seen since has completely missed, or didn't care enough to listen for?). And yes, some times the rubber glove was brought out. Since I have good insurance now, my doctors spend time with me, but I have found talking kinda useless, unless I'm in for a specific symptom. Too many they don't seem to really listen. They love to run up the bill with a depression screening. They mention fish oil. Blah--blah--blah. I sometimes think a person without good insurance might be better off. They are left alone. They aren't put on dubious anti-depressants. They arn't over treated. They won't get a testosterone patch. They won't get any edgy new treatment--that might be found to be dangerious. I will admit; I'm no fan of modern doctors, unless it's for emergency medicine. Maybe that's affecting my judgement? I don't have the respect for doctors I once had. I haven't been to a doctor recently whom I didn't walk out of thinking---He's/She's just in it for the money? I have a psychiatrist that put me on a addictive drug years ago, and has literally held me hostage with the mandatory office visits, and they are solely for money. I look back at 99% of my doctor office visits, and I can't think on any ailment they caught by spending talking time. "So give me the comprehensive blood test, and order a MRI if I"m complaining of upper right quadrant pain--please doc, and refill any addictive prescriptions for a year. I really don't want to talk to you, unless that office visit includes blood work, or something other than just yacking, and running up a bill!" I'm now fifty. If you get through your twenties-thirties without a mental malady; you succeeded. Life in America is hard on the psyche, and that can cause so many health problems--high blood pressure from self medicating? Weird pains? Most of it will be psychosomatic. In terms of health, I can offer what helped me: cut back on the alcohol, exercise a little, eat less. Get that pneumonia vaccine if you're constantly getting chest infections. It's one of the better vaccines.

padobson 10y ago

I'm curious how it would work at the hospital level, or even at the hospital network level. Pay the network a monthly fee, and then when you get sick, all of your care is already paid for. I suppose this is the idea behind HMOs, but the execution hasn't been there.

ceejayoz 10y ago
All the little hospitals and clinics in our area have been bought up by one of the two healthcare networks in the five-county region, and I'm fairly shocked they haven't done this. Maybe it's illegal for a hospital system to offer insurance in NY? I don't know. You'd think they'd be happy to cut out all the fuss around handling insurance approvals/rejections and pocket the 20% middleman cut.
- whafro 10y ago
  I don't have a ton of first-hand knowledge, but I know that being licensed to provide health insurance in NY specifically is no joke. Todd Park (former US CTO, AthenaHealth founder) once told me that he didn't pay much attention to Oscar early on until he found out they had gained an NY license, at which point he dove into it. More broadly, many hospitals and hospital are getting involved in the ACO (accountable care org), which gets at some of these goals, but it's not 100% clear that an ACO model can be successful (financially or for patients), and it doesn't cut out all the relevant middle-men.
- chimeracoder 10y ago
  > Maybe it's illegal for a hospital system to offer insurance in NY? Definitely not. A lot of hospitals are part of networks which are doing exactly this. And many of the ones that aren't are entering long-term capitated agreements with insurers, which basically means they're acting as if they were insurers but without technically being one.
- Spooky23 10y ago
  The consolidation is happening because there's a huge surplus of hospital beds and specialists in NY.

ceejayoz 10y ago

> It achieves lower costs in large part by cutting out the middle man of health insurance for basic services. Is it actually lower cost? The cash fee for a PCP visit and what insurance actually pays are drastically different. If you're paying a membership fee just to get the same sort of rates insurance pays out at, there's no win here. > A little known provision of the ACA makes Direct Primary Care a kind of legal loophole. When combined with a high deductible health plan or health savings account, Direct Primary Care can meet the requirements for basic coverage, thus getting you out of the tax penalty for not being properly covered. That's not a loophole. That's "pay extra". You'd still need at least a Bronze plan, and any visits that bill against your DPC won't count towards your annual deductible or out-of-pocket caps.

chimeracoder 10y ago
> The cash fee for a PCP visit and what insurance actually pays are drastically different. If you're paying a membership fee just to get the same sort of rates insurance pays out at, there's no win here. You don't want to get the same rates that insurers pay - those are actually the inflated rates. Billing is complicated. In short, part of the problem is that doctors who take public insurance (Medicare/Medicaid) actually take a loss on those patients, because Medicare reimburses about 7% less than the direct costs of services, in the aggregate. It's one of the reasons you see very few private practices which cater solely, or even primarily, to Medicare patients. The way providers make this work, since they can't negotiate rates with Medicare, is to charge higher rates for private insurers. This ends up as an effective subsidy from private insurers to Medicare. A doctor who doesn't accept any insurance whatsoever doesn't have to manage this indirect subsidy, so the amount they charge a self-paying patient could be a lot less than what another doctor would bill a private insurer for.
- rootusrootus 10y ago
  I would like to learn more about this. Some people here (who claim to be intimately involved with the actual financial aspects of running a clinic) say it's the opposite -- that Medicare actually pays the bills so the clinic stays open because the private insurers are so effective at getting out of paying anything. Surely there is a reliable source that can confirm one way or another how this works in practice? I get that it is probably arcane and difficult to understand, but in a country as vast as the US there is probably someone who understands it well enough to summarize for a layman.

chimeracoder 10y ago

The premise of this post is straightforward once you remember how insurance works from an economic standpoint. One thing that people often overlook when talking about health insurance is that, economically, "health insurance" is really the combination of two completely separate products, only one of which is actually insurance. Insurance is about pooling risk. It smooths risk across states of the world (e.g. the universe in which your house burned down, and the universe in which it didn't but your neighbor's house did instead). It reduces the variance between those states, and in exchange, it charges a premium for making the outcome more predictable. It is not there to save you money. The expected value of all insurance is negative, and that's intentional. By a true insurance model, routine care and elective surgery would be priced the same with insurance as it would without, because there is no risk involved. The reason it isn't it because we want to subsidize these, to enable people to obtain care they otherwise wouldn't be able to afford. We use "insurance" as a vehicle for this, but really, that's not insurance at all. It's a redistribution. So it's perfectly understandable that a primary physician who is dealing with routine care and doesn't accept insurance would be able to charge patients less (and still walk away with more money) than one who uses insurance. The reason you don't see this everywhere, though, is that policies are making it harder and harder for physicians to run private practices entirely (whether they accept insurance or not). The majority of physicians are now employed, largely by hospital networks which are required to accept insurance (in some cases legally, and in others by virtue of the fact that they need to cover their Medicare losses[0]). So, the place you are most likely to see the direct care model are with physicians who are catered to the incredibly wealthy. That's not to say that a direct care model couldn't work for people who aren't, but the way our system is set up doesn't facilitate it. [0] https://news.ycombinator.com/item?id=13356442 https://news.ycombinator.com/item?id=13356442

pdonis 10y ago
> The expected value of all insurance is negative Only if you ignore non-monetary costs and benefits. Risk reduction/mitigation is a benefit and has a value. If it had no value, people would not bother buying insurance. When that benefit is taken into account, the net expected value of insurance is positive for both parties: the insurer makes money (assuming it has done its actuarial statistics properly) and the insured buys risk reduction/mitigation at a cost that is less than its value. Your point about "health insurance" combining two separate products, only one of which is actually insurance, is valid, though, and very important.

dnewms 10y ago

For anecdotes: I've had a HDHP before ACA, started at about $45/mo now up to about $60/mo with an outrageously high $12.5k or so deductible. I've had two different DPC, one about $45/mo, now with one about $30/mo. Both combined are still less than I would pay in any marketplace. It's nice to be able to just see your doctor without worrying what it might cost. A large list of simple procedures are covered, and tests cost next to nothing. It's a health subscription to an actual doctor who can be just as cost-conscious as you are while still incredibly knowledgable and invested in your health.

daxorid 10y ago
I pay 780$/mo for a plan with a $13k max out of pocket. Where on earth are you getting 45$ ?
- dnewms 10y ago
  UnitedHealthcare -- though my plan may have been grandfathered in to be acceptable under ACA.
  - koolba 10y ago
    What state and how old are you? That seems insanely cheap compared every plan I've seen (high deductible or otherwise).
    - dnewms 10y ago
      <30 midwest
      - lotsofpulp 10y ago
        Is this health insurance purchased via your employer? If so, is your employer subsidizing it? Double digit premiums sound ridiculous, even for a male in their 20s. As a data point, I'm a <30 male, never been to a doctor with no health issues that I can tell, and my HDHP premium is $310ish, last year it was $275ish, but that's using healthcare.gov so completely unsubsidized, and I have a deductible of $1,500/$2,500 and out of pocket max of $3,600/$6,550 for their tier 1/tier 2 providers, respectively (whatever that means).

massysett 10y ago

This is not particularly novel. There are already integrated HMOs, like Kaiser Permanente and Group Health Cooperative, that function in a similar way. Kaiser is a little more complicated (there is a "Kaiser Foundation Health Plan" that acts as insurer, while physicians work for the "Permanente Medical Group") but they have integrated systems so physicians are not spending time dealing with claims--and besides, the physicians do all their work for this one health plan, so there's no web of insurance companies.

chimeracoder 10y ago
> This is not particularly novel. There are already integrated HMOs, like Kaiser Permanente and Group Health Cooperative, that function in a similar way Integrated practice is distinct from HMOs, though they might appear to be similar. Kaiser us an integrated practice and also provides and manages an HMO, but not all Kaiser patients belong to the HMO > they have integrated systems so physicians are not spending time dealing with claims--and besides, the physicians do all their work for this one health plan, so there's no web of insurance companies. Not exactly. Kaiser physicians still have to do all the work of coding and billing, except for them, the billing is all reconciled by a single entity and managed internally. That's different from direct care, in which the billing step literally does not happen, because the patient self-pays, usual in-person.
- eridius 10y ago
  Kaiser does have a PPO plan, but it must not be very common because the one Kaiser doctor I mentioned this to was very surprised and had never heard of Kaiser offering a non-HMO plan before.

codingdave 10y ago

Except that if you have a HDHP, your costs towards routine care also go towards your deductible, so if you have emergency care that year, you only get hit with your max out-of-pocket for the year. Instead of paying your max for the year AND whatever your paid directly to your direct pay provider. So these types of services are a gamble - you come out ahead if you have no emergencies. And come out behind if you do. For a family with kids, I'll pass. If you are young and healthy and do not have kids, and do not do a lot of outdoor activities that risk injuries, this might make more sense.

lotsofpulp 10y ago
Wouldn't you hit the out of pocket max if you have an emergency? As long as you have that much cash, HDHP makes sense to me.
- codingdave 10y ago
  Yes, but direct pay to another doctor doesn't apply towards your out of pocket max - so if you are doing a direct play place, you end up paying your max for your emergency care PLUS anything you paid directly to another provider.
- atlasmd 10y ago
  That is a fair point - any major hospitalization and you're over your deductible anyways. But the insurance statistic is that about 87% of people with a 3k deductible will reach that in a given year and <95% of people with a 5k deductible will reach that in a given year. Which means, families are paying more than $1000/mo or 12k/year for a risk thats rarely over 5k. Which means they can decrease their insurance coverage, save $500/mo on their premiums, and save more money each year than their increased deductibles would be. Plus, our direct care models saves them on the majority of care most people need in a year. i've been a direct care doc since 9/2010 and happy to answer any questions. to (quickly) define the model: $10-100/patient/month for unlimited home/work/office/technology visits, no copays, any procedure we can do in the office is included free, and wholesale savings on medicines, labs, imaging, pathology of up to 95% (yes!) We can then take all of this value and go back to an employer and help decrease insurance costs by 30-60%.

ilaksh 10y ago

My understanding is that one of the biggest issues that we can actually improve is inflated billing. It seems that something like direct primary care could help with that issue. But maybe we could just create a law that resets things so that they cannot simply inflate the bill and then certain groups pay only a small percentage of the amount? Because it makes it so we can't tell what the real costs are at all, and then people who don't have insurance or the right insurance are screwed by these giant basically fraudulent bills. That is the really stupid part about it. Then another idea is, I think that some health care costs just really are quite high. This is because of scarcity of high-tech medical machines or doctors or specialists. Maybe the solution to that is to push for greater volume of high tech medical machinery or medicines and a greater volume of medical professionals. Maybe by supplementing with advanced AI we can relax requirements for certain types of more general physicians or nurses rather than researchers, etc. Maybe just finding ways to reduce medical education could help. Then one other idea is the realization that more and more mainstream researchers are having that A) the majority of medical problems have some significant component that is related to aging, or where aging increases risk, etc. and B) we are now in fact able to start investigating and have hope for treating the actual causes of the various system degradations referred to as aging.