Cutting Out The Middleman

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Direct Primary Care can result in improved health outcomes as well as significant cost savings for patients

When his insurance marked his wife’s hospital stay “not medically necessary,” Matt Loeb, owner of Catalyst Visuals, LLC, made a life-changing decision: he was done with traditional healthcare and insurance. “I was frustrated,” he says, “because you have to fight tooth and nail for each claim and then at the end, they won’t cover the expense.”

In a time of rising out-of-pocket costs and frustration with third-party insurance, Loeb is one of many who have moved to a new type of healthcare called Direct Primary Care, or DPC.

The American Academy of Family Physicians defines DPC as a model that “gives family physicians a meaningful alternative to fee-for-service insurance billing. Instead of coordinating benefits through the major insurers, family physicians charge patients a monthly, quarterly or annual fee that covers all or most primary care services.” In short, the DPC model is a direct relationship between primary care physicians and patients—without the hassle of insurers.

And while they share many similarities, DPC should not be confused with “concierge” practices that still accept insurance and have annual, up-front fees of $2,000 or more.

The DPC model allows physicians to practice traditional family medicine while strengthening the relationship with patients. That results in improved health outcomes as well as significant cost savings for patients. 

Dr. Kimberly Nalda of Rekindle Family Medicine. Photo Rob Dubick

Back to the Roots

DPC allows physicians to more closely focus on patients and the community.

“The DPC model is about treating patients the old-fashioned way,” says Dr. Kimberly Nalda of Rekindle Family Medicine in Wilmington. “We’re taking family practice back to its roots by returning to when the small-town doctor took care of the entire community.”

Nalda opened Rekindle in 2016 after winning the Remarkable Ideas Competition, a pitch competition targeting women-owned enterprises hosted by Great Dames. That year the focus was innovation in the health sector and Nalda’s DPC-centered practice was a novel business concept.

“We were the second practice to open in Delaware,” she says. “The competition gave me a platform to educate the community about the DPC model and show how family medicine could evolve.”

She credits the “generous and supportive” DPC community for aiding her practice in its early days. She had an early mentor who guided her through opening her practice since she didn’t have any business or DPC experience. She also bounced ideas and best practices off her colleague, Dr. Ricky Haug, who began his DPC practice, Core Family Practice in 2016, in Kennett Square, Pa.

Both Nalda and Haug want to change the current healthcare system for the better. They have started with their own practices by sharing resources, such as flu shots, and by covering each other’s patients while the other is on vacation.

“Healthcare should be easy, convenient and available when people really need it,” says Haug. That includes the ability for patients to see physicians whenever the need arises, a key component of the DPC model.

Flexibility and Accessibility

One of the main benefits of DPC is the ability for physicians to accommodate a sustainable number of patients—hundreds versus thousands—and have longer, more in-depth visits. This allows DPC practices to provide same-day or next-day appointments, meaning less time in the waiting room for patients.

“I typically see 8 to 10 patients a day, with additional slots available for sick appointments,” says Nalda. Both local DPC practices set aside an hour for initial patient visits, and 30 to 45 minutes for follow-up appointments, depending on the nature of the visit.

Compare that to other full-time physicians who have more than 2,000 patients, averaging 25 to 30 patients a day with appointment windows of 7-10 minutes that sometimes are double-booked or overlap. This keeps physicians so busy they hardly have any time left to connect with patients.

Barbara Perry knew she had made the right decision when transferring her care to Rekindle after leaving an appointment feeling angry and distraught. Perry, a retired photographer who had been a patient of the previous practice for more than 16 years, described her experience with her doctor as the result of “physician burnout,” a common outcome of a stressful and emotionally exhausting profession.

After her initial visit with Dr. Nalda—an acquaintance from her church—Perry felt like she was under a doctor’s care for the first time. Diagnosed with diabetes a few years ago, Perry has worked diligently with Dr. Nalda to manage her blood sugar through monitoring of her blood sugar levels, medication and modifications to her diet.

“When I visit with Kim, I feel heard and validated and I know she’s willing to work with me,” says Perry.

Perhaps most important, DPCs also tout better after-hours communications and access to the physician via text, email, phone or video chat.

On one day last month, Haug had just finished an urgent care procedure on a patient who had sliced her finger and needed seven stitches. The patient called in the morning and Haug was able to fit her in the same day, and dedicate an hour to the procedure.

“Opening my practice has been a gratifying experience as a physician,” he says. “When patients really need you, you can take care of them.”

Loeb, his wife and two children see Haug, and they enjoy the 24/7 access to their doctor as well as their medical information and prescriptions through the online portal.

“It’s a game-changer,” says Loeb. If the kids are sick, he can send photos or text symptoms to Haug to verify whether or not they are sick enough for an office visit. 

Loeb also likes the easy prescription refill process. “I can re-order prescriptions through the portal and pick up the medication same day,” he says. Compare that to other practices where you call in, leave a message and then get the medication refilled two-to-three days later.

Dr. Ricky Haug of Core Family Practice. Photo courtesy of Core Family Practice

Patient Cost Savings

Another benefit of DPC is the potential for patients to better manage out-of-pocket health care costs. And for physicians, DPC streamlines revenue and allows practices to have a “direct relationship with the patient and cut out insurers,” says Haug.

DPC memberships are similar to “gym memberships or Netflix subscriptions,” says Haug, where you pay on a monthly basis. The fee covers most typical primary care services, including preventive care and certain in-office tests and procedures like EKGs, rapid strep tests and laceration repair. Here’s the current membership pricing for Rekindle and Core:

Rekindle Family Medicine
Age <18: $20/month (with adult membership)
Ages 18-44: $60/month
Ages 45-64: $80/month
Ages 65+: $100/month
• 5 percent discount for annual payment in full
• 5 percent discount for couples
• 10 percent discount for families
• 10 percent veteran or active duty military discount Home Visits: $100/visit

Core Family Practice
Age <25: $35/month
Age 25 and older: $70/month
Families of four (two adults & two children under age 25): $180/month and $20/additional child
One-time registration fee per household: $65
Home Visits: $100/visit

For specialty services like lab work and radiology services, DPC physicians “negotiate with each provider to offer its best or ‘contractor-grade’ pricing,” says Nalda.

For example, if a patient needs a mammogram, Nalda writes the script for imaging and instead of paying at the time of service, the patient pays the practice directly for the service.

Says Nalda: “This system incentivizes specialty providers like radiology centers to give me the best price.” This practice, also known as direct bill, is where service providers like radiology centers collect their fees directly from the DPC practice rather than the patient. This cuts out third-party insurers and the hassle of obscure pricing, which translates to pricing transparency, less paperwork and overhead for physicians, as well as quicker payment for service providers.

As for prescription medications, they aren’t treated as “revenue generators,” so DPC practices can pass on all savings directly to patients. For example, a generic medication like Cetirizine (Zyrtec) costs $4.80 versus $13 retail; and Atorvastatin (Lipitor) costs $4.80 versus $24 (estimated pricing provided by Core).

HealthShare Plans

It’s important to note that DPC membership is not insurance, so it’s recommended that individuals pair their membership with a high deductible health plan or “catastrophic” policy, to cover an unexpected injury or serious medical condition like cancer, or be insured through an employer. These plans tend to have low premiums but high annual deductibles.

As a small business owner and the production manager at Out & About, Loeb must balance finding decent coverage with affordable premiums, so another option that works for him and his family is a health share plan, also known as a Health Care Share Ministry. Most health share plans are faith-based, though the plan Loeb uses, Liberty HealthShare, accepts members from a wide variety of religious backgrounds. These plans are a more sustainable, lower-cost option to pair with a DPC membership.

Even though they are not insurance, health share plans function similar to a health savings account. Individuals or families choose a plan and pay a monthly sharing amount. These fees are significantly cheaper than traditional insurance bought through the Affordable Care Act or a catastrophic insurance provider. Depending on the program, shareable expenses covered include most routine and preventive visits, vaccinations and prenatal and maternity care, to name a few.

However, because Liberty HealthShare is a cost-sharing membership, certain medical expenses are not shareable, including voluntary and cosmetic procedures, dental and vision expenses and certain pre-existing conditions during the first year of membership (Full restrictions are on the website: libertyhealthshare.org/assets/public/2019-LHS-Guidelines.pdf). And with all health share plans, there is no guarantee of payment even if the cost is considered shareable. The New York Times recently published an article that found that since these “groups are…not considered insurance, they operate with no government oversight,” meaning some patients could end up paying most or all the out-of-pocket costs.

The DPC model has the potential to make powerful changes in the healthcare industry. It’s an innovative model where “…the patient is the customer and not the insurer, which really changes the incentives,” says Haug. This translates to a strong doctor/patient relationship through increased access to preventive care, which may lead to better health outcomes for patients.

Dr. Kimberly Nalda, Rekindle Family Medicine,
5590 Kirkwood Highway, Wilmington, rekindlefamilymedicine.com.

Dr. Ricky Haug & Dr. Paul Yerkes, Core Family Practice,
413 W Cypress St., Kennett Square, Pa., corefamilypractice.com.

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