Suture For A Living hosted Grand Rounds this week – be sure to stop by and check it out. One of the posts I found most interesting was from Dr. Rich of The Covert Rationing Blog, writing about direct-pay medical practices. In a nutshell, PCPs tend to get the short end of the stick when it comes to health insurance and government regulations. Many of them see themselves as being more accountable to the health insurers and government regulations than to their own patients – which runs counter to how they’d ideally like to be practicing medicine. Dr. Rich’s argument is that direct-pay medical practices – where the patients pay the doctors directly for their care, with no third party payers involved – are more ethical than what we have now, in that they allow the doctors to focus entirely on their patients, since the patients and the payers are one and the same.
Of course there is plenty of criticism of this idea, with people saying that direct-pay healthcare would only be available to the wealthy. If all PCPs were to abandon their health insurance networks and strike out on their own, it would seem that the PCP shortage would be even more pronounced for the middle class and lower income families.
But Dr. Rich makes some good points, and perhaps the idea of direct-pay medical services (and on a similar note, concierge medical services) is one that should get a second look. Several questions come to mind, however.
1. What would it cost to see a direct-pay doctor? The Epiphany Health system that Dr. Rich highlighted has a monthly fee that allows you to see the doctor. A single person would pay $83/month, and a family of four would pay $250/month. A similar sort of program here in northern Colorado has a per person fee of $600/year (that amounts to $200/month for a family of four). I am not familiar with any programs that allow patients to just pay for each visit as needed, but I’m sure that some must exist – I’m curious as to what the pricing would be if they do.
2. If things went the way Dr. Rich envisions – and all PCPs switched over to a direct-pay model, who would take care of patients who rely on subsidized or reduced-fee healthcare? Programs like CICP, CHP+ and Medicaid are safety nets for people who can’t afford healthcare by any other means. Those programs only work because doctors (including primary care physicians) are willing to accept payment from them. I’m curious as to how those people would receive treatment in a strict direct-pay system? Would physicians agree to see a certain number of patients each month at no charge, as a sort of community service?
3. Would health insurance companies begin to create policies without primary care coverage, in trade for lower premiums? If a family of four is paying $200+ each month for membership at a direct-pay clinic, they will have less money to spend on health insurance. For wealthy families, this is likely not an issue, but for families that struggle to get by, it’s highly unlikely that they would spend an additional $200/month (or more) to have access to a direct-pay clinic, as well as paying for health insurance that would cover them in the event of a hospitalization or surgery. Of course they might choose to combine a direct-pay clinic fee with a high deductible HSA qualified health insurance policy, but if direct-pay clinics became popular, it makes sense to think that health insurance carriers might start to offer policies that specifically excluded all primary care (even after the deductible is met) and had lower premiums than policies that did cover primary care.
4. Is primary care the only realistic candidate for direct-pay healthcare? Obviously direct-pay isn’t likely to become popular for very expensive care (unless you’re an extremely wealthy person, paying cash for cardiac care after a heart attack simply isn’t possible), but where do we draw the line?
5. Back to the pricing issue, how much money would doctors earn if they went the direct-pay route? Their administrative load and office overhead would no doubt be significantly smaller if they were paid directly by their patients. Would doctors price their services so that they continue to earn about the same amount they do now, or would they be willing to earn less money in trade for a better work experience? Or would they try to earn more, since many think that PCPs are underpaid? I’d be curious to hear feedback from PCPs on this one.
Those are a few of the thoughts that come to mind when I think about direct-pay medical care. I can see pros and cons to the idea, and I’m sure that there are many PCPs who would love the chance to focus more on medicine and less on administration/payer issues. But I think that most PCPs also want to make sure that everyone – regardless of financial status – has realistic access to medical care. And I’m just not sure that would be the case if more PCPs started pulling out of the health insurance networks – especially the networks that serve low income populations.