Remember back in the day, where your doctor would come to your house if you couldn’t get to them, fees were reasonable and you never had to wait days or even weeks for an appointment?
It’s highly unlikely anyone reading these words can remember that, because it’s a relic of a bygone era before HMOs, provider shortages and sky-high healthcare costs. However, direct primary care is emerging as a potential return to more patient-focused healthcare settings.
It's a newer, developing model, and it works like this: You, the patient, pay (or your employer pays) a monthly fee to a direct primary care practice. That doctor doesn’t bill insurance or charge you an extra visit fee over the monthly subscription. Instead, your monthly fee is what you pay. Prescriptions and lab services are provided by the doctor at cost.
The five most common lab tests – complete blood count, lipid profile, etc. – that you likely get at least once a year are between $6-7 each. Common meds are dispensed by the doctor and typically run less than a dollar for a full course of most antibiotics. A month’s worth of a common statin drug for cholesterol might be $3. And typically, you can see your doctor the same day you call to make an appointment, and appointments last not a rushed 20 minutes but a full hour.
Dr. Paul Thomas is a direct primary care provider and founder of
Plum Health in Corktown. He says bypassing the usual system, where a doctor is employed by a practice or a large hospital, is good both for physicians and patients.
Most doctors who are in that sort of practice have a “panel” – the roster of patients they see – of around 2400, and to break even they need to see 1 percent of their panel every working day. In a typical 8-10 hour workday day that translates to only 20 minutes per patient, and that doesn’t include time for charting, writing prescription refills, or advocating for a patient to get a particular treatment with their insurance company.
Implementing the direct primary care model, he is able to keep his panel at right about 500 patients, keep a predictable schedule, and help patients find a specialist should they need one. “Under the typical model a doctor won’t have a the time and capacity to do that,“ he says. “I can be more hands-on with people.”
And don’t confuse direct primary care with concierge medicine, which is aimed at a high-income slice of the population who hand over big fees to have a doctor at their disposal any hour of the day or night. Many of Thomas' patients make between $30,000 and $50,000 per year – too much to qualify for Medicaid or much of a subsidy on the health care marketplace, but not enough to shell out the high premiums of typical insurance.
A monthly subscription to Plum Health is $75 for an individual and goes up to $200 a month for a family of four, which is less expensive than marketplace plans and gives them quick and focused access to a doctor for the most common problems they might face.
“We tell people if you can afford a cell phone bill for your family you can probably afford direct primary care for your family,” he says -- although Thomas does recommend patients carry some insurance to cover them if a more serious condition or injury happens.
Detroit faces a major shortage of primary care doctors – there are only about 200, Thomas says, and to meet the need for primary care there would need to be about ten times that. That means people often end up in the emergency room for non-emergency conditions, because they can’t get in to see their regular doctor for non-life-threatening conditions like a urinary tract infection or a sore throat. ”It’s very costly and very inefficient,” he says.
“We’d love to see more people engaging in direct primary care -- then when you have a heart attack there’s not 20 people with a UTI ahead of you. It’s kind of a bulwark against the lack of primary care in the city.”
More people have. Thomas' Corktown locale, founded in 2016, now claims a title in the first of a chain. Plum Health has since expanded to offices in Royal Oak, Lansing, Van Buren, and Corunna.
One concern many prospective patients might have is the lack of a network – specialists that work with your doctor and are covered by your insurance within a big health system. Thomas points out that when you work in a network you’re relegated to referrals within that network, whether or not the specialist you can refer to is the best doctor or even the best choice for that patient.
It also means that primary care doctors become “referral machines”, Thomas says. Primary care is a loss leader for many health systems, he adds, but they make money on referring treatment and testing to specialists that can charge insurance companies higher prices even when the primary care doctor would be perfectly capable of handling the care.
The standard model of medicine is rife with dissatisfaction for physicians, patients and medical staff, Thomas says. It can even inflict a type of trauma called moral injury, he says.
“You know you can take care of someone in their darkest hour of need – you have the skills and knowledge to do it, but you just don’t have the time," Thomas says. "You feel terrible you can’t do it, so you suffer this moral injury.”
The direct primary care model allows doctors to practice the kind of medicine they wish they could provide, and patients feel heard and respected in a way they can’t when they’re one of 2,400 their doctor sees in a year. It’s not the old-school model of care we might have seen in old movies, but Thomas believes it’s healthy for physicians and patients alike.