ACP: Consider Low-Income Patients With Direct Pay

This report from the ACP has to be the most sanctimonious and fundamentally flawed “position papers” that I have had the displeasure of reviewing.

Here is the official “focus”… of the paper: “how DPCP models can challenge the ethical obligations physicians have in regard to providing nondiscriminatory access to care.”

Do they really think our current system is non-discriminatory as-is; and by association, that doctors are taking the high road by going along with it? Yes, I do believe that is what they are saying, and I couldn’t disagree more. Going along with it is part of the problem.

“The ACP urged physicians to seriously consider the impact of their change in practice model, including:
1.Downsizing of the patient panel and its effect on patients and the community.
2.How those disbanded patients will find access to care.
3.How setting or raising DPCP retainer fees will affect patients, especially low-income patients, and the local community as a whole.
4.How DPCPs can reduce barriers to care for low-income patients that might arise from no longer accepting insurance.”

Has the ACP forgotten how healthcare costs got so out-of-reach in the first place?

If they are serious about “barriers” to care, then they should be asking how panel sizes get so unmanageable in the first place and why prices are so high. But instead they mislabel “moral obligation” by equating it with blind acceptance of the inevitability of a government program that adds huge costs but negligible benefit to its enrollees. As if Medicaid was the only viable healthcare solution to “the problem of the poor”.

Who has declared that the average panel size is the ideal one? All practicing docs will tell you it is too high. Patients trying to be seen in timely manner will tell you it is too high. Yet we are told to be wary of solutions that might result in a healthy reset of this exaggerated number.

The knee-jerk response of the arm-chair elite is to “consider what down-sizing your panel might do”. Well for starters, it might just attract more doctors into primary care because they can have better impact on care outcomes and reduce risk of burn-out and have better relationships with their patients.

Instead, they hold up their self-proclaimed ethics and proceed to admonish one of the few real solutions to cost and access “to consider the impact of their change…” And the sad part is they are serious; not to mention seriously misguided in perspective.

Another implicit idea within this misguided perspective is the flawed assumption that the price points of these public & private payment programs along with the obligatory third-party contracts by which it is accessed, and the billing protocols that support this cartel-like inflation machine, are indeed normal. Far from it.

I believe they have the paradigm backwards. DPC is not the aberration or the threat. Our system of third-party financed and government regulated healthcare is the aberration and the most immediate threat to good care for all, precisely because of how care is financed. Stated differently, DPC and similar non-third-party models seek to decrease the unit cost of care and remove as much of the “insurance cost barriers” as we can. This puts more resources to work directly for clinical care, rather than just paying for a place in the queue via over-priced policies that most can’t afford to use even in face of subsidies. Why can’t they afford to use them? Because of inflated CPT billing that is used to calculate balance billing or go towards deductibles. Even in face of so-called “network discounts”, these billed prices are often multiples above what they would be in a healthier price driven market.

The irony of the coverage myth is this…Due to unwise public and tax policy towards healthcare, the government (wittingly or out of incompetence or both), has codified and sanctioned the monopolistic-like domination of healthcare financing. The price appreciation (inflation) caused primarily by the way we are forced to pay for healthcare ironically creates even more reliance on its product. In this self-perpetuating cycle, all of the dollars get sent through tightly controlled and mandated billing channels making it nearly impossible to render care or receive medical care unless you subjugate yourself to the process. All of this, of course, is being fueled by exorbitant health plans premiums.

So instead of having the option to use resources to pay directly for care in a more cost-effective manner or venue such as DPC, all the money is tied up in an artificially inflated, tightly controlled process that requires predetermined price agreements on both the care provider’s side and also the recipient’s side.

By design and application, this system creates two basic economic problems that have resulted in rampant medical inflation and all too often a “service” industry that has become indifferent to customer service.

1.A lack of real meaningful prices due to the way charges are derived and reimbursed, thus the inability to determine real value because price signals between buyer and sellers are basically non-existent; instead replaced by fractional co-pays on the recipient’s side and reimbursement schedules on the provider’s side.

2.The inability of patients to influence prices with their own dollars in that their fractional cost-sharing, mandatory to access the queue, was simply a way to initiate the billing sequence; the emphasis being on the coding, not on the curing.

So here is the result of the system that ACP admonishes us to be oh-so-careful-how-we-impact-it:

1) Healthcare Inflation
2) Barriers to access for those that don’t have network coverage due to lack of non-insurance market for healthcare. This is because most of the dollars are sequestered within premiums and within the billing cycle which network subscribers and network providers are forced to for all encounters, regardless of how minor. For those without insurance or those out-of-network, it makes it exceedingly hard to pin down a meaningful price and when they do it is usually grossly inflated.
3) Making Medicaid mandatory for certain income level, as opposed to it being the real public option and competing for program dollars where patients can dis-enroll or enroll with their own tax subsidy money, it forces people into a two-tiered system. A system that was created by government meddling.

The ACP Ethics manual asserts: “Physicians opting for cash-only practices must consider the impact that the practice model will have on their community and low-income patients struggling with to access care”.

The ACP position on this issue is shortsighted and blind to the truth about barriers to care.

DPC helps remove many more barriers than it could ever erect. And if we are serious about care for those at the lower socioeconomic scale, we will reform Medicaid, rather than declaring that participation in medicaid is the only way to meet our “individual and collective” responsibilities is to patients.

The ACP can keep its moral high ground and peddle it to someone else. I’m not buying it.


  1. Funny, perhaps they don’t see narrowed networks creating challenges to access to care, or networks at all for that matter. Perhaps they don’t understand as we price care to un reachable levels we eliminate the most vulnerable and millions more up the income ladder from accessing care. Perhaps they didn’t bother to learn that 1/3 of all patients are putting off care due to high out of pocket costs.

    I am sure they don’t know that the current system is the reason costs are high, access is scarce and physicians are being maligned.

    But hey they are free to post an article.

    I know of several DPC practices in impoverished areas servicing lower income patients quite well, maybe they didn’t bother to do any research before purporting to preach an agenda.


  2. Well said, good points all. Also, as you allude to in last paragraph, DPC over-all carries roughly a 5 – 7% scholarship rate for memberships… basically free care. I don’t see that happening in FFS insurance-based practices very much unless some are doing it covertly just to be charitable. But unfortunately, they can’t let anyone know because it would violate contracts or Medicare agreements. The system is indeed a perverse one for all the reasons you laid out.


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