When Dr. Heather Bartlett was working as an outpatient doctor for a hospital system in Seattle — right out of residency — her idealism ran headlong into the reality of much primary care medicine in the United States.
Too many patients. Too little time.
“It was a real eye-opening experience how many people you had to see,” said Bartlett, now a family medicine doctor at The Bartlett Medical Clinic & Wellness Center, a direct primary care practice in Ohio.
To make ends meet, many primary care practices squeeze more patient visits into their week.
As they do, the length of each visit shrinks, giving doctors barely enough time to assess a patient’s main concern, let alone connect with them.
“Patients become herded through the cattle gates and physicians become hamsters in the wheel,” Bartlett told Healthline. “And it doesn’t make for a good relationship for anybody.”
So Bartlett did what a small but increasing number of physicians are doing — ditching insurance companies altogether.
Instead they are setting up cash-only medical practices where doctors deal directly with patients on financial matters.
This immediately shifts the doctor-patient relationship.
“The main benefit of not billing through insurance is that you no longer work for the insurance company. You work directly for the patient,” Dr. Carmela Mancini, an internal medicine doctor who has a direct primary care practice in Massachusetts told Healthline.
What is ‘cash only?’
The cash only model is known as direct care or direct primary care.
Patients pay an annual or monthly fee for access to their doctor. This covers most primary care procedures — things like physicals, tests for strep throat, EKGs, and stitches.
Patients also get 24/7 access to their doctors, longer office visits, and often same-day appointments.
Direct primary care differs from concierge medicine, which still bills insurance but uses the membership fees to provide patients with greater access and to pay for procedures not covered by insurance.
According to the John Locke Foundation, the average monthly payment for direct primary care is $25 to $85.
Some practices also offer different membership levels.
At Mancini’s practice, the fee ranges from $30 per month for 18- to 21-year olds, to $125 per month for people 65 years or older who often need more intensive care.
With only 800 to 1,000 patients — or fewer — direct primary care practices are smaller than typical primary care practices, which may have 2,000 to 3,000 patients.
This allows time during the day for longer office visits — and lets doctors maintain better work-life balance.
Typical primary care doctors may spend no more than 10 to 15 minutes with each patient.
A direct primary care doctor may spend at least 20 minutes with a patient. Or more.
A follow-up visit with Mancini is 30 minutes. For people with multiple chronic conditions, she’ll book one-and-a-half hours.
This hearkens back to your great-grandparents’ time.
“This is how it used to be back in the day before you had back-to-back patients,” said Bartlett, “before insurance became the norm for outpatient care around the 1950s.”
Doctors connecting with patients
Longer visits help doctors see the big picture when it comes to their patients’ health.
“To do good medicine, you need to know what’s going on with somebody,” said Bartlett. “If you tell somebody, ‘I only have time to hear your top two things,’ but their third thing was chest pain, you haven’t done your job.”
Direct primary care doctors also have more control over how they interact with patients. Phone consultations, text messages, and Skype are common.
Most insurance companies will only reimburse a doctor when a patient comes into the office.
“I don’t need to force people to come into my office for things that don’t need to be handled that way,” said Bartlett. “Telemedicine is booming. There’s a reason for that.”
With telemedicine, patients can avoid unnecessary trips to the doctor — and hours away from work or having to pay for a babysitter — just to find out the results of a lab test or to ask a simple question about a rash or a cold.
And because doctors are accessible around-the-clock, patients may be less likely to put off seeking help.
After talking to a patient on the phone or getting a text, a doctor can write a prescription, refer a patient to the emergency room, or just ease their concerns.
“There are so many patients that have so much anxiety,” said Bartlett. “A lot of anxiety is triggered by a concern that there’s something wrong with them.”
Quicker care can also keep small problems from turning into larger ones — like a cat scratch becoming a major infection or symptoms of a heart attack or stroke going untreated.
People get urgent care when it’s needed and avoid it when it’s not.
“With three of us in the office getting to know patients, we can save so many ER visits, so many unnecessary urgent care visits,” said Dr. Jeffrey Gold, a family practice doctor at Gold Direct Care, a direct primary care practice in Massachusetts.
Cutting out insurance companies
Many advocates of direct primary care say these benefits result from no longer dealing with insurance companies.
Part of this is that insurance companies don’t reimburse doctors enough to cover the cost of longer visits.
And there are many hoops for doctors to jump through to get reimbursed, including the use of electronic medical records for billing purposes.
“Most of us chose primary care to build relationships with people and take care of people,” said Gold. “How do you do that in an eight-minute visit, where 75 percent of it you’re standing at a computer checking boxes and typing stuff in?”
Cutting out insurance billing also cuts costs.
“[This model] definitely is sustainable, and what makes it sustainable is my overhead is really low,” said Mancini. “When you’re not billing through insurance, you don’t need 10 people doing coding and billing for you.”
Although direct primary care physicians have fewer patients, the monthly membership fees plus lower overhead means that their practices can still be financially viable.
Direct primary care doctors can even do something else your great-grandparents might have been familiar with — the house call.
“I have quite a few patients that can’t get out of the house because they’re homebound for a variety of reasons,” said Mancini. “In the insurance-based model, it’s really hard to do a home visit.”
Putting consumers in charge
A big part of the direct primary care model is price transparency, which puts more control back in the hands of consumers.
“How do you become a consumer if you don’t have the right tools?” said Gold. “The biggest thing we’re bringing to light is transparency in pricing, which does not exist.”
Practices list membership fees on their website and clearly explain what patients get for their money — no surprise bills when an insurance company says a doctor’s visit wasn’t covered.
Direct primary care practices can also offer inexpensive medications to patients.
“You can have a small wholesale pharmacy in your office and dispense noncontrolled and noncompounded medications at amazing prices,” said Bartlett.
And doctors negotiate prices with private companies for better rates on lab tests, imaging, and other medical services — some of these are even cash-only businesses.
These rates are sometimes lower than what an insurance company would pay for the same service.
Like their insurance-taking counterparts, direct primary care physicians can refer patients to a urologist, cardiologist, or other specialist.
But because direct primary care doctors spend more time getting to know patients’ medical histories and assessing their symptoms, they may be less likely to refer to a specialist just because they are in a hurry.
Many patients still carry some form of health insurance to cover these visits, hospital stays, and other nonprimary care services.
However, even some people with insurance that covers primary care visits find it worthwhile to pay a membership fee for 24/7 access to their doctor, longer visits, and a shorter wait for an appointment.
Not everyone is as enthusiastic about the promises made by direct primary care advocates, especially given the small amount of research available on these practices.
In 2016, only 6 percent of physicians participated in a cash only practice, according to Medscape's Physician Compensation Report. But interest is growing.
The Wall Street Journal sees direct primary care as an important piece of any replacement for the Affordable Care Act (ACA), largely because of its free market approach and focus on price transparency.
Advocates say the direct primary care movement highlights the need to keep the doctor-patient relationship up front in any discussion of the future of the U.S. healthcare system.
“Insurance does not equate to care,” said Gold. “It’s all well and good to have Medicaid or any other subsidized health plan, but if you can’t get access to a doctor who knows you and cares about you, a lot of good that [insurance] card does.”
Downsides to cash only
While advocates of direct primary care feel strongly about the ability of this approach to produce better care for patients, there are some downsides.
For doctors, switching to a direct primary care model is a big step. And like any business, they may have to invest heavily up front before their practices have enough patients to be sustainable.
They may also need to spend more time on the business side of their practices — marketing their practices, negotiating prices on lab tests and radiology services and medications.
They may even have to educate communities about the benefits of letting go of insurance for primary care.
“I knew this was the right thing for me, and I knew it was the right thing for patients,” said Gold. “But I also knew that 99 percent of the patients were also going to think it was bad for them.”
Many new primary care doctors are trained to assess quickly and refer to specialists. So they may not have a broad enough medical background to handle patient care with the intensity required for a direct primary care practice.
And when doctors switch to direct primary care, it can affect their current patients and their communities.
If current patients choose not to follow a doctor into the new direct primary care practice, they may lose a long-standing relationship with their physician.
Not every community has enough primary care doctors to go around, which can be exacerbated when doctors cut their patient lists in half.
Cost is also an issue. Even at the lower membership fees, not everyone will be able to pay this out-of-pocket expense, particularly those on Medicaid. Some practices offer “charity care” to those in need, but this may not meet the demand.
Qliance, a larger direct primary care business shows that this may be less of a concern. The company has roughly 35,000 patients, about half are enrolled in Medicaid.
Some doctors have raised concerns about the lack of oversight offered by insurance companies, which monitor doctors to make sure they are following clinical care guidelines and practicing evidence-based medicine.
By Shawn Radcliffe