Direct Primary Care — where’s the quality?

greedydoctorHappy doctors seeing fewer patients and making more money — what’s not to like?  According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.

The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork.  So, they developed a model of care where the patient pays $65/month and receives all the primary care they need.  And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article).  Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.

The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss.  For the libertarian-minded physician it’s nirvana.

Piece-work is indeed a hard life as physicians and many in the garment industry know.  A monthly salary is much easier on the worker.  And, the salary model is not new in terms of primary medical care.  The physicians working for the National Health Service (NHS) in the UK have had this system since WWII.  However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work.  And, they found it necessary to monitor quality since quality slips without oversight.

So, this “Direct Primary Care” is not new in the world.  In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US.  But, physicians need to realize they need to be part of a large organization to ensure quality care.  The future for primary care is to be an employee, not a mom-and-pop store.  Most of doctor’s patients work as employees, is that so bad?

$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!)  So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?

  1. Measure and report quality in a transparent way — like on the office website.  And, keep it updated.
  2. Deliver patient-centered care and prove it.  Survey patient’s expectations and record whether the expectations are met with office visits.
  3. Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
  4. Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
  5. Take a financial stake in what is prescribed or ordered.  Pay some fraction of the cost of all medications prescribed and all tests ordered.  They need to have some “skin in the game”.  (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).

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