Patient Focused | No Insurance Networks | Better Care

“only by creating free-agents of both physicians and patients will we bring together the stakeholders for a meaningful exchange of value, thus substantially lowering medical costs in the outpatient arena.”   –  R. Nelson, MD

 A Word To Readers By Way Of A Brief Introduction To Direct Care Medicine

Direct Primary Care or Direct-Pay Medicine is the really nothing new.  Some have called it the “oldest new idea in healthcare”.  A doctor and patient working directly together was the norm before the advent and Medicare and third-party health plans of the 1980′s.These prepaid health plans (not really insurance) brought us impersonal networks, mountains of regulation, red tape and soaring costs.  The “old fashion” system, now known as Direct Care, served us well for many generations and we  didn’t have the rampant runaway medical price inflation that we have now.

I say we get “back to the future” by restoring healthcare to the way it used to be; the way it works the best:  One doctor – One patient – No interference!

Below are some very well written articles about the subject and some data to go with it.  I have referenced them to original sources where possible and/or listed the authors.  If you are unfamiliar with the concept of the Direct-Pay movement, how/why it was re-invented and why it so integral to fixing our Health Care, then please read on.

Thank you,

Dr. Nelson

This is a must see. In this 4:49 video John C. Goodman explains not only the problem with our current third-party payment system, but how we got here and how to fix it.



By Joel Strom, Fellow Unruh Institute of Politics, USC

June 20th, 2013 –  It was not that long ago, as late as the 1960’s in fact, when third party payers – insurance companies and the government – did not play such a large role in the American health care system.  In those days, a majority of patients paid their doctors directly for primary health services while relying on other vehicles to pay for more extensive and expensive care.  Many physicians strongly believe that direct pay care provided more efficient, more available, better and cheaper care than is usually available today.Under such a direct pay care system (DPC), patients shouldered more of the upfront costs for their primary care which helped keep overall insurance rates down for everyone.   This also created an environment for more value-oriented decision making with a distinct disincentive to over-utilize the system.

In short, the basics of a successful health care system, were rooted in a direct, transparent and trusted doctor patient relationship.As third party payers assumed more of the primary care expenses, insurance rates began to rise noticeably.  And as patients began to pay smaller percentages for services while paying more and more for their insurance, the old disincentive was transformed to an incentive to spend; if patients paid so much for coverage why would they not seek to take advantage of their insurance benefits?The third party payer system requires that physicians hire employees just to manage the interface between patients and insurance companies or Medicare, expending precious human resources on non-patient care.   Moreover, doctors are left to fight with insurance companies or the government in order to get paid for services rendered, sometimes waiting months to receive reimbursements.With the passage of the ACA, physicians are feeling even more crammed by what they see as an endless bureaucratic black hole and an increasingly heavy-handed federal government;  ACA establishes over 100 regulatory boards and commissions certain to create countless new regulations as well as a far more complex billing system.

This has created a new sense of urgency for physicians to find their own solutions. And in a growing number of cases, they are deciding to back to the basics of private medical practice – direct pay.DPC offices have been around for many years, but just after the turn of the Century, physicians slowly began adopting this model for their practices. The passage of the ACA has only accelerated that growth. Today, physicians from Maine to Florida from California to Washington are re-recasting their practices based on the old direct pay model.Most DPC offices charge their patients a membership fee often less than $50 per month, with pediatric care below $20.   Appointments for routine services may require small co-payments in the range of $10 and patients can obtain referrals for specialty care at greatly reduced rates.Patients then purchase high deductible plans solely for the more expensive surgical, hospital and high end testing procedures. Taken together with a direct pay relationship, patients can choose their own doctors, receive more prompt preventive care, experience a more transparent financial transaction and become better consumers of health care.From all indications, doctors and their direct pay patients are happy with their arrangements.

Most believe that DPC achieves the stated goals of health care reform, without a byzantine, intrusive and costly third party payer system.   The jury is still out as to whether California’s health policy officials will agree and support these practices.Patients and doctors nationwide are hoping that federal and state officials remember the last words from that wonderful Allstate ad – “it’s back to basics…and the basics are good”.- See more at:

A Better Way: Direct Primary Care

Direct primary care practices offer a membership-based approach to routine and preventive care that can dramatically reduce health care costs for individuals, families and businesses.

At the core of a direct primary care facility is a medical practice dedicated to providing routine, everyday care, essential for the well-being and ongoing maintenance of a patient’s health. This is where patients go for check-ups, vaccinations, sprained ankles, or frequent headaches.

Direct primary care providers know their patients. They have talked with their patients in detail, gotten to know them, treated past conditions and know what recurring problems are experienced. If a patient has a chronic illness, like arthritis or diabetes, their primary care provider is already a partner in management every step of the way. And, in the unlikely event of a life-threatening accident or disease, the provider serves as the patient’s advocate, coordinating care across multiple providers, facilities, and prescriptions.

How does it work?

Direct primary care practices serve as a patient’s “primary care medical home” (D-PCMH) where they go for all routine primary, preventive and chronic care management types of care. Patients pay one low monthly fee-sometimes as low as $49-directly to their direct primary care facility for all of their everyday health needs. Like a health club membership, this fee gives patients unrestricted access for visits and care, so patients can use the services as much or as little as they want. Many direct primary care practices are open seven days per week and offer same-day or next-day appointments. At many clinics, physicians are on call 24/7.

There is none of the paperwork and expense required today by insurance reimbursement – no procedure or billing approval, deductibles or co-payments. With a lower business overhead and dramatically less paperwork, primary care providers are no longer forced to squeeze in an unmanageable number of patients and can instead take the time necessary with each patient to deliver high-quality, personalized care.

Accidents and the unexpected do happen, so the typical patient in a direct primary care practice keeps an insurance plan to cover emergencies and serious illnesses. Because this insurance doesn’t need to cover routine care, many patients choose a less comprehensive plan with a higher deductible and lower premium.

Lower costs

With insurance-paid primary care, where each and every part of your medical care is billed to a third party payer, reimbursement costs consume more than 40 cents of each dollar. Eliminating insurance from primary care makes that 40 cents available for actual health care – more time with each patient, more extensive office hours, more on-site services and diagnostics, and more patient-provider support technology.


Patients Save

The combined cost of the primary care provider monthly fee and a lower-premium insurance plan is significantly lower than paying for soup-to-nuts health insurance that covers even basic primary care needs. This is important when more than three-quarters of America’s uninsured are working families. The annual income from a full-time, minimum wage job is only a few hundred dollars more than the cost of an average family insurance plan. With direct primary care, supported by a low-premium “wrap-around” insurance plan that covers everything primary care facilities do not, cost to families can drop by as much as 50%, saving hundreds or even thousands annually.

Employers save

Even with a combination of direct primary care membership and lower-cost “wrap-around” insurance policies, employers opting for this combined option have routinely saved 20 to 35 percent on comprehensive health care benefits over what they currently spend, while employees’ payments (including premium cost-sharing, deductibles, co-payments and co-insurance) drop significantly. Downstream savings from unnecessary diagnostics and specialist, hospital and/or emergency room care add to these savings. In states where workers compensation insurance premiums are based on claims history, employers may be able to significantly reduce their costs as direct primary care practices do not file insurance claims, even though they do complete any legally required paperwork. Many employers also appreciate the impact that high accessibility direct primary care practices have on lowering absenteeism and improving patient health.

Higher-quality care

By eliminating unnecessary insurance costs, we also eliminate the need for primary care providers to flood their practices with thousands of patients that require reams of paperwork. A smaller patient pool allows primary care providers to spend more time with each patient. Instead of being rushed through a 5- or 10-minute appointment on what feels like a conveyer belt, patients are allocated what each needs – even if it is an hour or more – to discuss health details with doctors or nurse practitioners. There is time to actually treat, not just get an overview then refer to an expensive outside specialist. Most Americans have never experienced this level of care. For patients with chronic illnesses such as diabetes or high blood pressure, the unrestricted access to a primary care physician can have dramatic – often life-changing – positive effects on the individual’s health. As a result, doctor visits are no longer restricted by bank accounts and patients are seeing their providers whenever necessary to manage their health issues and improve their quality of life.

Reinvigorating Primary Care

By eliminating insurance burdens from direct primary care practices, physicians, nurse practitioners and physician assistants have more time to do what they were trained to do – practice medicine. This allows direct primary care practices to serve as a patient’s “medical home.” They develop deep, personal relationships with their patients and have ample time to diagnose and treat underlying problems. Providers can get off the treadmill of seeing 25 to 35 patients a day (national average for insurance-based practices), providing a balanced life-style. Physicians act based on what is in their patients’ best interests rather than those of the insurance company. Direct primary care can stave the exodus from primary care that has been occurring over the past decade:

Many former primary care physicians who discover this model  actually return to primary care.

  • Many former primary care physicians who discover this model actually return to primary care.
  • Medical students are once again selecting primary care as their career of choice.
  • Primary care physicians discover that with this model they no longer need to retire early to escape the stress of insurance-based primary care.

Why is it better?

The Direct Primary Care Difference

To understand why membership-based direct primary care offers better solutions, it’s important to first understand the difference between primary care and specialist/hospital care:

  • Primary care should be the home base or “medical home” for your health care. Your primary care provider is responsible for your overall wellness. Any time you have a health concern, your first visit should be to your primary care provider, who knows all of your medical history and can help you make the best decision about your health. With most health issues, your primary care provider can diagnose and heal the problems you’re experiencing.
  • Specialist and hospital care should be for serious, complex illnesses and life-threatening emergencies. If you’re severely injured in an accident, for example, an ambulance takes you to the emergency room. Or, if you’re diagnosed with cancer, you may need hospital care such as surgery, radiation, or other treatments.
Primary Care  Specialist/Hospital Care
FrequentHighly predictableReadily affordableTo be encouraged RareDifficult to predictExtremely expensiveTo be avoided

Insurance is an important part of specialist and hospital care. Similar to automobile insurance, our health insurance system was originally designed to pay for rare, unpredictable, and extremely expensive problems. It is essential when patients need emergency care or an operation and chemotherapy treatments, care provided by specialists and hospitals.

Primary care is frequent, highly predictable, and relatively inexpensive. It doesn’t make sense to pay for primary care using insurance. Paying for primary care with insurance has caused the cost of primary care and the downstream specialist/hospital care to rise considerably, and has made health care cost-prohibitive for millions of Americans.

Direct primary care practices eliminate insurance overhead, which can extend health care to more Americans.

Learn How: Insurance-Based Primary Care v. Membership-Based Primary Care

The figure below shows the typical process that occurs in insurance-based care when a patient comes in for possible pneumonia. The red boxes indicate insurance processing, the yellow boxes are tasks completed by the patient, and the blue boxes show the actions of the health care provider. (Click to make it larger.)


Compare the complex process shown in the figure above with the simple process below. The figure below shows how simple the same pneumonia visit is with Direct Primary Care. The cost and complexity of the health care event are dramatically reduced. (Click to make it larger.)


It’s easy to see how much more efficient the direct primary care practice is for a typical primary care visit. This efficiency means lower costs, and doctors spending time with patients instead of insurance forms.

Healthier patients

Direct primary care enables doctors and nurses to provide better care for patients. Unlimited visits and a smaller patient pool mean patients get more time with providers. Without unnecessary co-pays and referrals there is greater continuity of care, which means better, more informed decisions about a patient’s health.

Happier providers

Primary care has been a victim of the health care crisis.

Family health practices across the nation are closing because they can’t stay financially afloat.

Whereas 50 percent of medical students once chose primary care as a profession, that percentage is now in the single digits. This migration is fueled by growing dissatisfaction with the insurance-laden business models in primary care that make specialization options more attractive, due to less paperwork and increased income.

The result? The average primary care office visit “face time” is now seven minutes and rarely longer than 15 minutes. In order to see the 25-35 patients in person per day required to sustain a traditional clinical practice, providers must manage between 2,500 and 3,500 regular patients. Contrast this with a busy day for a direct primary provider, containing about half the number of office appointments, providing doctors ample time to examine patients and explore diagnosis and treatment options, preferences, concerns and fears. Additionally, providers are not tied to insurance reimbursement requirements of in-person visits so they can be flexible and offer phone and/or secure email consultations if it’s more convenient for the patient and appropriate to the kind of care needed.

Providers report increased satisfaction and renewed commitment to provide the kind of care that initially inspired them to dedicate their lives to medicine. In short, direct primary care facilities enable physicians and nurses to do what they felt called to do: treat patients.

With traditional insurance models, providers are forced to view people with health issues as a collection of symptoms.  In a Direct Primary Care practice I get to develop a therapeutic relationship with patients.  This relationship allows me to understand the patient’s context, i.e. who they are not only physically, but socially, emotionally, and mentally.  I am able to take the time to find out what’s important to them and what their barriers to wellness are.  This is the accurate definition of health care.”Lynne Duran, ARNP, Family Nurse Practitioner in Seattle, WA

The bottom line: Doctors and nurses have less burden and are free to focus on patients, not paperwork.

What Can I Do To Support Direct Primary Care?

We believe direct primary care is a vitally important solution to our nation’s health care crisis.  We are working hard to make sure that legislators, government regulators and other leaders in health reform recognize and understand how direct primary care can lower costs and improve quality and access for Americans.

The problem? Most conversations about health care reform focus solely on insurance options, which do little, if anything, to get to heart of the problems in our health care system today.

We need your help to make sure that direct primary care is recognized as an integral part of our nation’s health care system. Americans, employers, and state and local governments need real alternatives and choices to elect the right type of coverage for their specific needs.

Help spread the word!





 | Physician | November 12, 2013

To what end?

Those three words have become something of a mantra, a mission, a philosophy of care.

  • To what end do I prescribe a medication?
  • To what end do I make a diagnosis?
  • To what end do I order tests?
  • To what end am I documenting?
  • To what end is there a patient record?
  • To what end do I send a person to a specialist?
  • To what end do patients need to come to see me in the office?
  • To what end do my patients have me as a doctor?

This is tied closely to the thought process of a recent post in which I discussed the flawed idea of a problem-oriented health care system.   When we treat a problem as the center of a person’s care, we look at one end in their care: fixing the problem (usually using a procedure).

You may rightly ask the question: “To what end are you writing this blog post?”  Touché.  To answer that smart aleck question, let me go through several of the above bullet points for doctors who work for the usual employers: insurance companies and government bureaucracies, and those who work for my current employer: the patients.

1.  To what end do I prescribe a medication?

This is actually what started me thinking on this line, as I found myself spending much more time talking people out of medications than I had ever done in my past life.  The goal of medication in the old system is often muddled and confused:

  • Q:  Why give an antibiotic for an upper respiratory infection, or for “bronchitis” lasting less than a week?
  • A:   Because it takes too long to convince people they are not useful, and they have already waited for 2 hours to be seen and will be angry to leave the office without an antibiotic.

I find I am far more likely to hold off on medications now, as people know I won’t force them to come back in if they get worse.  The cure for antibiotic overuse is “watchful waiting,” in which the body generally gets better without medication assistance.  The problem with the old system is that pesky first word, “watchful,” which implies paying attention (aka communication).

  • Q:  Why use a cholesterol medication?
  • A:  To lower cholesterol.  (Duh)

This, of course, is not the right answer for the sake of the patient.  Cholesterol is a risk factor, not a disease, and there are plenty of circumstances where the risk heart disease or stroke is low enough that the of the medication becomes significant.   I am now turning my patients’ attention away from cholesterol or other risk factors, and toward their risk.  My goal is not to fix a little problem, but avoid a big one.

2. To what end do I make a diagnosis?

It’s a really complicated topic, actually, made much worse by the need for diagnosis (ICD code) to get paid in many/most cases.

  • Q: Is obesity a disease?
  • A: It is as long as the insurers pay for the diagnosis.  They never have in the past, but recently have been doing so more and more.

I don’t actually care that much if it’s called a disease or not.  To me, it’s something that increases the risk of certain things and reduces the quality of people’s lives.  I don’t think it’s something that people should be ostracized for, but I also know that my weight struggles have been directly related to bad choices I make.  The only reason to call something a disease is if doing so opens opportunities to reduce people’s risk or improve their quality of life.

  • Q: What about symptoms like fatigue, irritability, or foggy-headedness?
  • A:  They go on the problem list as long as there’s an ICD code for it.

Symptoms are not diseases, nor are they risk factors.  They are a report of the person’s experience in life.  Symptoms are significant only in context of a person’s risk.  If a person has chest pressure and shortness of breath, is that significant?  The answer to that question is different for a 20 year old female and a 56 year old male diabetic smoker.  In the former, even classic angina is not likely to be heart related, while in the latter even atypical pain is taken as possible equivalents to angina.  Again, it all comes back to risk.

3.  To what end do I order tests?

There is only one reason to order tests: to gather more information to make a decision.  The end goal (as stated in #2) is not to make a diagnosis, but to decide what the path of action should be.  I recently had a patient come to me (as is often the case) asking for me to order an MRI scan.  In this case it was because of knee pain.  When I suggested that perhaps a visit to orthopedics the patient resisted, feeling that I was somehow offering a lesser alternative.  I countered with the following options:

1.  We get the MRI and it is normal – in which case you still have pain in the knee that has not been addressed.   I would probably refer them to surgery as I had suggested.

2.  We get the MRI is abnormal – This would cause me to refer as well.

3.  We don’t get an MRI and the orthopedic doctor decides to order one.  This won’t cost you any more

4.  We don’t get one and the orthopedic doctor decides to go straight to arthroscopy.  This would save you hundreds, perhaps more.

For lab tests, it’s really important to understand the situation you are in, and there is no better statistical tool than the pretest probability (chance it is present) of the condition you are trying to diagnose or rule-out.  I usually think of pretest probability in three main categories:

  • The problem is unlikely to be present
  • The problem is likely to be present
  • I am not sure.

It helps me to ask two questions:

  • Would I believe a positive or negative result?
  • What would I do with a positive or negative result?

So if I swab someone’s throat for strep and they have a high pretest probability (red throat, fever of 102, no runny nose or cough, exposure to strep) a positive test would simply confirm what I know, while I’d wonder about the accuracy of a negative test .  On the other hand, if the pretest probability was low (the person felt normal), I’d mistrust the positive result.  It’s the exact same test, but the result is interpreted entirely on the pretest probability.

One more scenario in which a test is run is in the case of something that is low risk, but needs to be ruled out.  This is generally done when the problem is too dangerous to miss (cancer in an adult, meningitis in an infant).  It’s extremely important to have a very sensitive test in this case, that has a very low rate of false negatives.

4.  To what end do people come in to see me as a doctor?

Back in the day when I was paid by insurance companies, the answer often was, unfortunately: “because it’s the only way I get paid.”  There are many cases where the care could have been given over the phone, but that would shoot my business in the foot.  Unfortunately, you can’t take care of people if you can’t pay your bills.  Even though the business was not my primary goal in terms of priority, it was the highest priority in terms of order.  I first had to have enough money to pay my staff, our office lease, my salary, and all the other expenses, then I am free to give care.

In my new world I am paid just the same if the office is empty (something that would have worried my in my previous life) than if it’s full.  So why come in to be seen?  There are really two reasons:

1.  The patient wants to.  Some people just would rather come in and talk to me.  I am not sure if this is due to my sweet personality or some chemical imbalance on their part (just kidding, of course).   That’s perfectly fine with me.

2.  I can give better care by having them here.  The physical exam is sometimes important.  Sometimes I need to be able to look them in the eye when I talk to them.

5.  To what end am I people’s doctor?

In my old practice the answer was often: to help them in case they are sick.  The patient would probably say the same, with the addition of: so I can get medications and tests when I need them.

My new practice has two main goals:

  1. To get my patients as old as possible.
  2. To keep them as healthy and happy as possible while they do the old-growing.

The goal is no longer medical intervention, it is avoidance of care.  The goal is not to treat problems, but to avoid them.  The goal is not to order tests, but to not need them in the first place.  The patient is my employer, and so my I do what keeps them happiest with my care.

And that’s a nice world to live in.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at Musings of a Distractible Mind.


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