Direct Primary Care | Hacker News Reader

Direct Primary Care

srconstantin.wordpress.com

62 pointsluu24 comments

Primary care is a pretty low overall component of healthcare spend, but a direct primary care model could have an indirect effect that is much more substantial -- reducing hospital costs

Hospital care is the biggest component of US healthcare spend at 30% and costs per hospital bed are dramatically higher in the US than other OECD countries

Much of this is due to local hospital monopolies, which are extending to include primary care. When a big hospital buys a primary care clinic the cost of care at the primary care clinic immediately increases, sometimes dramatically, bc the primary care clinic now bills using the hospital systems insurance contracts. Huge hospital systems can basically dictate price to payers in many geographies. These payers then squeeze independent docs even harder to try and make up for getting pushed around by large hospitals. Hospital employment of primary care docs is at an all time high, despite many physicians (even hospital employed ones) thinking that this trend hurts patients and costs more

Plus, the primary care clinics now direct all patients to the big expensive hospitals, and the hospitals can even dictate patient flow within the system ("steerage") beyond just passively capturing the primary care practices patient volume

> costs per hospital bed are dramatically higher in the US than other OECD countries

Both US government and private health costs are well out of line with the rest of the world. Certainly not getting value for money.

https://data.oecd.org/healthres/health-spending.htm

What’s your take on the increased cost component due to US hospitals mostly having private rooms? If the US were to build all new hospitals with multi patient rooms, how long before the cost curve bends down to rest-of-OECD levels?

While they no doubt increase direct construction costs, my understanding is that planning for hospitals in the UK is leaning towards private rooms because they have a bunch of not-immediately-obvious benefits that can reduce cost in the long term – better infection control, less bed-blocking, improved recuperation times, things like that. This information is third-hand though, and I don't have enough knowledge to say for sure. But it certainly doesn't seem unreasonable that this could be the case!

I'm not sure about the cost impact of that, but I think pricing in the US is more based on what hospitals can get away with in negotiations with insurers, and less based on cost. So if hospitals decreased their operating costs, but they were still able to negotiate high prices with payers because they have market power, then that would just result in higher hospital profits.

Just speculating though

Direct primary care used to be the only model; this in living memory. Insurance started out as disaster only care, and then bureaucratic creep took it from there. Now we have a system where nobody can practically tell you the cost of a service until after you’ve committed to pay for it. Beating a system with that level of information inefficiency by 95% isn’t even surprising.

The pendulum swings both ways? we started off with direct primary care, then moved to fully insured care, things are moving back towards direct primary care, i believe the model presented in the article or something along those lines will be what the US healthcare system will move to over the next 10-20years.

I run a competitor to Atlas MD, we've been testing our product by creating a clinic in South Carolina. Feel free to ask me anything (within reason) and I would be happy to do my best to answer your questions.

How easy or difficult is it to get doctors on board?

"Are there barriers I haven't thought of?"

Not sure, but one barrier not mentioned in the post is the health insurance industry and its enormous clout. Right now, direct kale care is not seen as a threat, but if it ever is seen as a threat, you can bet it will be targeted. Look at how the industry was able to protect itself during the passage of the ACA. And how many people in Congress have Direct Care lobbyists gotten elected?

The biggest hurdle is regulatory. There are a number of legal barriers to direct primary care, and the laws vary state to state. Most private practitioners don’t have the choice to start a direct primary care practice because their state laws classify the model as insurance. This makes “scalable” DPC hard to achieve unless these laws change.

The other barrier is the supply of primary care doctors in the first place. There simply aren’t enough primary care doctors to make DPC an efficient scaled model. Family medicine is sadly the lowest paid field in medicine; while DPC can lead to higher salaries for current practitioners, it won’t solve the supply problem in the short term.

"Direct primary care only works as a complement to insurance that pays for more catastrophic care like emergency room visits and specialists."

This is like saying: "I've found a solution to high auto insurance costs! You can save lots of money and pay directly for small fender benders! Oh, by the way, if your car is totaled, you'll need to find someone else that covers those very costly catastrophes."

I've negotiated direct-pay prices several times with auto-body shops, but I haven't tried with doctors.

Are most doctors set up to provide cash quotes and accept cash payment, or would I need to find specific doctors if I want to pay cash?

Very few doctors are set up to provide cash quotes. You are more likely to find this situation in primary care (general practitioner) than other specialties since you are more likely to use your primary care physician on a regular schedule.

If you are looking for a practice that is set up near you this site has a map of DPC practices across the US. https://www.dpcfrontier.com/mapper/

I have never seen a private practice that couldn't handle cash payments such as credit cards and, well, cash. They may not be set up to handle Stripe or Google Wallet, but they may be and not even know it. I have a friend who's father, an internal medicine doc in North Carolina, has actually taken farm animals in payment.

Ironically, for businesses that operate under HIPAA regs, any doctor I've had take my credit card had paper forms that were nowhere near PCI compliant.

> nowhere near PCI compliant

This I do not doubt at all...

My favorite - I had a routine-but-niche lab test done at a doctor I'd never been to before. They wanted a credit card "on file" in case insurance didn't pay.

They had a paper form for my name, address, SSN, credit card number, and even the CVV2 code off the card. I left the SSN and credit card info all blank, handed them the form and the card and told them I wasn't comfortable writing it all down (at least if there was a breach, it's not in my handwriting, right?). Which then got put in a pile on her desk until god knows when.

Insurance paid for the test ... at their negotiated rate of under $3. For that, I would have just paid cash and saved having personal information left laying around.

One could also argue the current model is more like "I found a solution to routine auto maintenance costs! Our super premium insurance includes oil changes, tire replacement, and other routine service."

Part of the problem with health insurance is that it's not just "insurance" in the true sense of the word - it's involved in minor and routine care as well. I don't have to involve my auto insurance company when I run over a nail and get a flat tire - why do I need to involve my health insurance when my kid has an ear infection?

I understand why we got here - preventative care reduces costs, and people would avoid it if not included in the main package. But there isn't a doubt in my mind it hasn't distorted the market.

Get a price quote for a windshield replacement paid directly and through an insurance claim. It's a LOT more expensive, overall, when insurance is involved. Health insurance is not fundamentally different in that way.

That's the Kaiser model, and was the original concept for the HMO model. 95% off, though? No way.

Depending on the test or procedure a 95% reduction in price is doable. Our clinic does every test and procedure at cost to remove the financial incentive to order. The wholesale price for most things is very low. For example, we charge patients $2.50 for a rapid strep test which would be normally be reimbursed at ~$16.50 with medicare/medicaid.

I would guess a reason why Kaiser doesn't have a 95% price reduction is that offering a huge range of options for medical care means the overall cost goes up a bit to counter the more expensive needs of a minority of their members. Unlike most of the direct care models that only take care of part of the comprehensive medical needs of their members.

I still think the Kaiser cost reduction is surprising though. The upfront cost of premiums isn't much higher, but the benefits are bonkers. My monthly premium may be slightly higher than other plans cost, but then I have a $0 multi-day stay after a c-section... and nobody is nickel and dime-ing me, or pushing me out sooner than I'm ready, and I even got a 2 person "fancy" dinner to celebrate the birth - we had a 3 course meal (steak and salmon!) with sparkling cider and flutes to boot.

Kaiser can be very cost effective, but they're no better than anyone else in terms of pushing people out of their cost centers (errr... hospitals). My experience has been that prescription and OTC drugs (even if you're not an active Kaiser member) are especially cheap through Kaiser pharmacies.

There is a Free Thoughts episode talking about DPC, if you are interested: https://www.libertarianism.org/media/free-thoughts/why-cant-...

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