Forget tech, Direct Primary Care is the new devil in healthcare.
I have always been somewhat skeptical of Direct Primary Care, it seems like something for a privileged few, elitist, even exclusionary. I’m not the only one that thinks about it this way, many others in healthcare do as well. Not to single out primary care, but any form of healthcare that requires upfront payment seems that way.
I may be changing my mind though. I know… What about poor people? What about SDOH? What about all the things?! Those were, and largely still are, my concerns as well, most Americans don’t have the cash in the bank to pay for unexpected expenses, let alone primary care services. Those are all true, and for it to truly work, it would require a change in how healthcare is paid for, but more on that below.
I get the appeal from the physician side, and I don’t blame physicians for wanting to adopt this method, it allows them to focus on the person, do what’s right for them, spend more time with them, and allows the physician to assign a value to their team’s time. But it still didn’t sit quite right with me for the reasons above.
For those not in the know with all the latest healthcare terminology, direct primary care is a model where people pay their PCP directly, either through a monthly rate/subscription, or an established price list for services. Publicly available pricing in healthcare, sounds like a fantasy, but it’s true, costs to the patient are actually known up front.
What has caused me to start coming around? A number of things…
1. A couple of posts from Out-Of-Pocket Health regarding physician independence and physicians as lifestyle coaches, as well as other articles regarding an increasing prevalence of these services.
2. A couple of posts in the HTN group, one specifically regarding TIA and their valuation/appeal.
3. HTN Community Forum with Zachariah Reitano, CEO of Ro, speaking about long term goals and vision for the company.
4. Reading Reframing Healthcare, by Dr. Zeev Neuwirth, for a book club.
5. Increasing number of B2C2B and other direct care companies, One Medical probably being the most notable of late.
What’s the appeal for people?
The focus of care returns to the patient, not the insurance company’s check list of activities for the physician to tell the patient to complete. Not to knock on preventative measures that are well studied and developed, but it’s not always a one size fits all kind of thing. If you’ve ever tried to visualize a clinical pathway you know the variability in individual patients is quite striking. Physician’s should utilize their base of knowledge to guide personalized recommendations without endless insurance justifications for variability. In addition, these insurance guidelines do nothing if the people aren’t engaged in healthcare early to avoid disease progression.
In the direct model the physician are able to work with the patient to set goals, discuss risk factors from lifestyle choices and family history. People choose the physician they want to see based on the factors that are important to them, not the one that is in-network. Bed-side manner may be important, family centered care may be important, LGBTQ+ centered care may be important, whatever centered care you want, you can find the physician that decides to focus on that. Building a relationship of trust is important in healthcare, especially when talking about changing behaviors that increase future risk, or building plans to accommodate for those behaviors to decrease risk.
Ro, Tia, Folx, and other companies are in this segmented strategy of providing direct care. In the forum with Zachariah Reitano, he discussed this as a strategy of focusing on men’s health. Allowing men to find the care they want, addressing the goals that men are actively trying to achieve and enabling that. From there you can work toward expanding to goals that are more difficult to achieve, or are long-term but with no immediate consequences (hypertension is the first one that comes to mind). Similarly Tia is focused on the Women’s segment. This was a question posed in the HTN group, what differentiates Tia? Seamless execution of a customer centered focus, a Disney-like customer experience for Women’s health (hopefully minus the snaking lines). When you look at their offerings and job postings they have a variety of clinical and non-clinical professionals, everything from massage therapists to physicians. Get the collaboration and information sharing tools right, you can create a seamless experience where every service is able to speak to how they are promoting your goals of well-being. Folx is focused on the LGBTQ+ community, offering tailored services such as prevention and gender affirming care, services that may resonate more with that consumer group. In each case the company is focused on tailoring their offering to a certain customer, creating a trusting environment where issues can be addressed and plans/interventions tailored to that person, creating the right mix of clinical and non-clinical professions to provide the best possible path to staying healthy. Before I forget, their prices are published on their website for all to see.
The patient becomes the customer, in the healthcare space you will often see DTP (Direct to Patient) rather than DTC (Direct to Consumer) used, or used interchangeably. Perhaps we should still keep it as DTC? Dr. Neuwirth covers this in his book, changing how we view the consumers of healthcare from that of patients to that of customers. Customers have choice, they choose a service to satisfy a want, need, and or goal. Patients do not have choice, it is a passive state of being where things are being done to you. While I do not agree on completely removing the patient frame of reference from healthcare, I agree that in preventative and well-care the focus should be on customers. Patient’s have different needs than customers, and the term is applicable where people are placed vulnerable situations, such as during procedures and in hospitals.
If the customer wants a physician as a lifestyle coach, why not? They’ll likely pay extra for it, otherwise someone on the physician’s team can help with that, or they can discuss their different options with the physician. If the primary care recommends an endocrinologist for diabetes management or education, the patient can choose one they like or go to one in the physician’s office. Physician’s offices can serve the needs of the patient’s they will cater to, and the services will be designed around that to provide it in the most efficient way possible.
Most people aren’t engaged with a primary care physician until they start to get older. Why? A lot of it stems from the complexity of navigating insurance options and choices, finding an “in-network provider”, knowing how much it will cost. If you can make engagement easy, you can start to build meaningful incentives to get people engaged in their well being.
Younger more well off people have more mobility and will often move away from their parents, and away from a PCP. Choosing a new one can be problematic, scrolling through in-network provider lists, asking friends to see who they use, then finding out they’re not in-network. Barriers beyond the financial to accessing well-care are certainly not insurmountable, but they are discouraging. If you’re younger and poorer, do you have the resources to see a doctor? Are you even covered by insurance? As with anything in life, things become more difficult and barriers even higher when you don’t have the resources.
Simplicity. Consider the following questions: What services does your health insurance cover? What is your maximum out of pocket? How much will it cost, with insurance, to see the physician? You don’t know. How do I know you don’t know? Because insurance companies don’t know. Every call with the insurance company or health system yields a different answer. Nobody knows. Price transparency is great and all, but I live in Maryland, and still, nobody can tell you what an individual will owe ahead of time. Being able easily to budget and plan for well-bring is an important first step toward lowering barriers, keeping costs and payment transparent is a way to accomplish this, to create a more consumer friendly environment.
Of course I am purposefully omitting dentists and opticians, because we all know that eyes and teeth are not a part of the body that require healthcare insurance (insert eye roll emoji).
How do you keep customers from becoming patients?
It’s not a secret, for the majority of issues it’s about prevention. Put the consumer in charge of choosing the service that best fits their needs and they will engage with it, one that prioritizes prevention built around a plan. Utilizing physicians to apply their knowledge of health to help customers build plans to achieve and maintain optimal health. Allow physicians to build the teams and tools to accomplish this based on the population they want to serve, and set up a fee structure that customers are willing to pay.
This is where technology comes in, open exchange of information among healthcare teams to best support the patient so they can utilize the tools and teams that best fit their needs. There is movement in the right direction, but there is still a lot of information that is controlled by health systems and insurance companies. Barriers to entry are decreasing, and it is becoming relatively easy to start a virtual practice now (after all that education, training and licensing is completed), hopefully as more and more companies move toward more accessible information competition can increase.
Can’t value based care help to accomplish this?
For all the hype, it is unlikely to have a large impact any time soon. There are plenty of articles about the pros and cons of value based care out there, I’m not going to rehash them here. But results are mixed for a variety of reasons. If you put people in charge of their health with a healthcare team that they trust to help guide, you can avoid or delay many chronic conditions and complications to begin with. Chronic conditions don’t develop overnight, and treating them is not a short term prospect for savings and quality outcomes beyond the low hanging fruit of making the healthcare process more efficient and easier to navigate. Of course I’m leaving out much of the complexity of value based contracts, simplifying or standardizing these will go a long way towards greater adoption.
Does it work?
Yes. It has been proven that direct primary care works, it’s been field tested on the wealthier population who can afford to do this, and I’m all for testing things on the wealthy (as long as I’m not wealthy of course). Direct primary care has been moving into the mainstream as technology as reduced the barriers to entry, expanded access to other services, and physicians have grown frustrated with health systems and insurance companies.
Will a model like One Medical work? Maybe, it can be an option, but shouldn’t a person be open to choosing any primary care practice, not just the one the employer selects? If we want to turn patients into customers, shouldn’t they have choice? This is an area where I disagree with Dr. Neuwirth, I don’t believe that consolidation in healthcare is good, and I believe people’s experience with these large corporations is not supportive of this.
Why don’t satisfaction results show this? Look at how nicely their questions are tailored. Do you actually believe the satisfaction surveys of companies you constantly have problems with? Likely not, you know how well cable providers and health insurance companies tailor their questions to get only the highest NPS. How helpful was the representative in solving your problem? The representative may have been helpful, but should you have even had to spend 1 hour waiting to talk to them in the first place? Corporate healthcare leaves a lot to be desired, and if we want to increase engagement in health we should probably look toward models that remove barriers, not throw more up.
How to pay for it?
Everyone is always so concerned about money! Healthcare is a calling, it’s a privilege to take care of patients! Insurance companies should be more than willing to turn over profits to support the healthcare calling!
Now that you’ve stopped laughing… We’re starting to see a payment model by way of corporate benefits, membership in One Medical and an HSA is a common benefit listed on job postings for tech companies.
Does everyone get an HSA to spend on preventative care? Who pays? Can insurance companies offer consumers a risk reduction payment at the end of the year? Something like a safe living discount, add an incentive to participate in well being. Can we push health insurance to more of an auto insurance model? Is that even possible?
Maybe? Far more questions than answers, but we’ll start to see how these models are working as some companies shift toward a direct care model as a benefit. If it is proven they work and can lower costs among a broader population, perhaps we can see a larger movement toward this model. Again, this will take time to definitively prove efficacy beyond a limited and wealthier population.
Hope for the future?
Like everything, the answer is a solid maybe. My skepticism regarding direct primary care was not based on efficacy, it was based on availability. It is still a premium offering, but as there is more focus on broadening the space, as well as a greater focus at all levels of healthcare of moving toward lower utilization. Healthcare corporations are moving (being dragged) toward allowing for greater inter-operability and information exchange to coordinate care and enable greater customer engagement, there’s still a ways to go, but it’s moving. Customers are demanding better access and value, not just in person, but also virtual access and broader choices to customize their health and well-being journey. Employers are becoming more vocal about rising healthcare costs and stagnant or worsening outcomes, we know the doctors and nurses haven’t been cashing in on all that the extra money, where’s it going?
My optimism lies in the fact that it is becoming more broadly available and that may, in the future, start to provide framework for a more global model of direct primary care. A model like this would, hopefully, remove the challenges of navigating complex and infuriating health insurance benefits, allow for continuity of a physician-customer/patient relationship not based on insurance networks, but based on choice. Maybe to get more funding and attention we should start calling it Value Based Prevention? Fee For Prevention, maybe that would help?
Only time will tell and hope springs eternal.
Thanks for reading this month’s musings! Feel free to connect with me on Linkedin.
Happy National Radiologic Technology Week!
Have a great Thanksgiving, make healthy choices!