Direct Primary Care is the Future of Health

Imagine the perfect doctor’s visit.

You schedule a convenient same-day appointment. You arrive at the clinic, skip the waiting room and the clipboard, and walk right into the doctor’s office. Perhaps you are offered tea. The doctor — who you know and like both personally and professionally — is prepared with your basic info and recent lab results, and takes time to talk through any issues you want to discuss. The two of you celebrate the fact that you’re healthy, and make a plan together to keep you that way.

If this sounds like a fantasy, the truth is even worse: today’s fee-for-service healthcare system actually punishes doctors who want to treat you this way.

This is personal for me.

My parents, Mike and Sara, are retired primary care doctors who enjoyed practicing medicine and loved their patients. They had long careers in family practice before moving into executive roles at Group Health Cooperative, an award-winning HMO in the Pacific Northwest that served 650,000 members. But when they talked with me and my sister about work, they always added the same caveat: This is the worst time to become a doctor in the last 50 years.

Why? Like most doctors, they got into medicine to serve patients. But Americans today face skyrocketing healthcare costs, and hate their health insurance more than everything but Comcast. As the influence of administrators, middlemen, and financiers has risen, healthcare’s focus has shifted from keeping patients healthy to making large insurance companies and hospital systems more money.

>95% of new healthcare employees since 1975 aren’t actually thinking about your health.

The root cause of healthcare’s problems is that all key stakeholders, except the patient, benefit when costs go up. When traditional health insurance companies propose new rates to regulators each year, they are governed by a medical loss ratio: they have to spend 80% of the premiums they charge on care, and can hold up to 20% back to cover administrative costs and profit. This means they can only make more profit when the expected cost of care goes up — they’re taking a fixed percentage of a growing pie. Large hospital systems make more money when the cost of care goes up too. And one sure way to push up the cost of care is to make doctors see as many patients as possible (one every 11 minutes!) and maximize “billable events” — ordering a test or a referral or a prescription before pushing you out the door.

If you always got 20% of a donut, wouldn’t you want it to get bigger every year?

For patients, that means less time with doctors and less personalized care. You are a number in a giant database controlled by people who can raise their rates every year if you get sick. For doctors, this means less time serving patients and more time slaving away at administrative tasks — asking for permission from insurance companies for treatments (prior authorization), categorizing every action in a complex insurance schema to request reimbursement, and justifying their position when the pushback comes. This adds to the stress of an already stressful job: one doctor commits suicide in the U.S. every day, contributing to the highest suicide rate of any profession. In less extreme cases, doctors just work harder, fighting despair, and wondering when large corporations became more important than the patients they have always aspired to serve.

I watched this happen to my parents, and I’m angry. I know the pain of healthcare as a patient too. That’s part of why I started Decent. But the issue goes deeper than one family. The core incentives in the current healthcare system are working against you and your health. And to paraphrase the great Charlie Munger, the outcomes won’t change until the incentives do.

Direct Primary Care treats the cause, not the symptom.

Direct Primary Care (DPC) is a fast-growing value-based alternative to the fee-for-service model that dominates healthcare today. Every practice is a bit different, but as a member, you typically pay a flat fee ($50 to $150 per month) for access to a concierge-style clinic that covers all of your primary care. You get unlimited extended monthly visits with the same doctor, with no extra charges or hidden fees. Same or next-day appointments and telemedicine (video calls) are available, along with 24/7 phone, texting, and email support for your health questions. Your doctor manages all of your care, including referrals to specialists and guided care in the case of surgeries or procedures needed outside the clinic. The clinic schedules any needed surgeries and your doctor manages pre-op and post-op care to ensure that you get your questions answered. Many types of routine lab work, like blood testing or strep throat cultures, are offered for free, along with preventative treatments like routine physicals and flu shots.

DPC works better for the patient and the doctor.

Paying a flat monthly fee for unlimited primary care changes the core incentives in healthcare. Your DPC doctor gets to focus on keeping you healthy, since their clinic spends money rather than making money when you need more care — and since they know you’ll be coming back to them with any issues, they think about value when they refer you out for specialty care too. They make pricing transparent and don’t hit you with unexpected charges. And they work to maintain your loyalty, since they know if you aren’t getting the service or the relationship you expect, you’ll change doctors. To folks in the tech industry, these advantages may sound similar to the ones that helped software as a service (SaaS) displace traditional packaged software. You know what you’re going to pay every month. And the perfect doctor’s visit suddenly makes sense — for you and for your doctor.

With evidence that the model leads to happier patients and lower costs, it’s no wonder many patients and doctors love DPC. In the words of Dr. John Meigs, president of the American Academy of Family Physicians, “You’re not on the hamster wheel of getting paid based on the volume you do. Patient satisfaction goes up. Physician satisfaction goes up. Quality goes up and costs go down because you don’t have to prove it to Uncle Sam or an insurance company.”

DPC works better for a new kind of insurance company.

At Decent we believe that “First do no harm” should apply to insurance companies too. The concept of risk pooling via health insurance is right: without it, we’re all just hoping not to be the one who gets really sick. But traditional insurance companies have misaligned incentives and power disproportionate to their function. You don’t need approval from your car insurance to get an oil change, and you shouldn’t need approval from your health insurance to get a checkup. The doctor/patient relationship has to come first.

With that in mind, we are building the world’s first comprehensive health insurance plan with DPC at the center. We include the DPC’s flat fee in our monthly premium — so patients don’t need to pay twice — and provide access to high quality, affordable, and coordinated specialty care options at transparent rates for anything that can’t be handled in the primary care setting. We don’t require prior authorization, or costly administrative work that takes DPC doctors away from their patients and their families. We aren’t governed by a medical loss ratio, and we benefit alongside our members and DPC partners when costs are kept in check. We’ve consulted with DPC innovators like Dave Chase and Sean Schantzen of Health Rosetta and Jay Keese of the Direct Primary Care Coalition, and partnered with Hint, which provides software infrastructure for hundreds of DPC clinics, to build the care model my parents wanted and that we want as patients today. And we are on track to launch in April of next year: first in Austin, Texas, and then beyond.

If you buy your own insurance, you can sign up at Decent to get notified when enrollment starts in your area. If you have questions or want to work with us, reach out at hello@decent.com. Or if you just want to check out DPC options in your area, try DPC Frontier’s interactive map.

Direct primary care is making the healthcare industry better for patients and for doctors. Our team at Decent can’t wait to help.

Direct Primary Care is the Future of Health was originally published in Hacker Noon on Medium, where people are continuing the conversation by highlighting and responding to this story.