Duane, MD: ‘Why the Direct Pay Model would work well for the poor population …’

By Marguerite Duane, MD, MHA

concierge medicine startup businessMARCH 24, 2014 – Five years ago, I became medical director of two community health centers that serve an almost exclusively poor and uninsured population in the DC metropolitan area.  More than 90% of our patients make less than 200% of the federal poverty line (about $47K for a family of 4 in 2013).  Our patients live paycheck to paycheck and often times have to make hard choices when it comes to paying for health care.  We request patients contribute $40 a visit towards their care and on average they pay $32 a visit at the time of care.  This is a good deal of money to our patients, but when asked why they contribute as much as they do, they respond with statements such as “I appreciate all the time the doctor spends with me” or  “it’s important for my health” or “I value all the work of the physicians and staff in helping me manage my problems.”

Albeit challenging, caring for this patient population has been extremely gratifying.  Since they pay out of pocket they are invested in the care they receive.  They ask questions about the necessity of tests and treatments, especially more expensive ones, but with minimum 30 minute visits, we have time to explain why a certain vaccine is important to receive or which labs we could consider doing at a later date.  The patient is truly at the center of care and as a physician, my role was to work with them, guiding them to make the best choices to support their health and well-being.   Almost all our patients are grateful for this type of care and with appropriate support can become actively engaged in their care, willing to pay what little money they have for the services they need.  However, there is a small sub-set of our patients that differ dramatically, the few patients we have with government health insurance.  From their perspective, health care is free, so they typically request tests that are not necessary because in their mind they do not have to pay for it.  Or, these patients refuse necessary services, e.g. counseling, even if it only costs them $20 for a 45 minute session.  They have become so addicted to “free” health care via their insurance, that they do not feel it is fair if they have to pay for anything.


Source:, The DPC Journal

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