Direct primary care, or direct care, is in some ways concierge medicine for the masses.
JULY 4, 2015 – Frustrated by insurance paperwork and then a yearlong effort to have a cash-only medical practice, Dr. Maribel Aviles gave up.
For a few years she just did volunteer and missionary work.
“I have fallen so many times, and if I died today, I want to be remembered for what I did, not what I lacked,” the family physician said.
So last year, Aviles picked herself back up and opened one of the first direct primary care practices in Central Florida.
The idea is simple: pay the primary-care doctor a monthly fee for full access. Unlike some concierge practices, most direct-care providers don’t work with insurance companies, and they tend to have lower membership rates.
Aviles’ monthly fees range from $30 to $60, and not more than $150 for a family.
Advocates say this fee enables doctors to have fewer patients instead of balancing low insurance reimbursements with a higher number of patients. It also allows them to move away from a fee-for-service model of care to one that’s more value-based.
“The idea of direct primary care was to create an environment in which we provided great care, with a smaller number of patients that are seen for longer periods of time and are seen in a relaxed atmosphere, in which people can actually talk,” said Dr. Garrison Bliss.
Bliss created one of the first direct primary care practices back in 1997 “for normal people,” he said, and coined the term. He is the founder of Seattle-based direct-care company Qliance, which serves individual patients, but also has contracts with small and large businesses.
The model is slowly getting more attention partly because of the Affordable Care Act, where some consumers are gaining coverage but with high deductibles, and recent studies that have shown better outcomes for patients who go to direct-care practices.
“The first time I came here, she spent 45 minutes with me,” said Sandra Stanford, one of Aviles’ patients. “She sits across the desk and talks about things and shows you things on the computer, and she takes good care of me.”
There’s no hard data on how many direct primary practices exist in the United States, but estimates range from a few thousand to more than 10,000 (Source: The Direct Primary Care Journal, July 2015).
The most recent survey by the American Academy of Family Physicians showed that about 2 percent of its more than its 100,000 members had a direct primary care practice. Less than 1 percent were in the process of converting their practices, and nearly 21 percent said that they’re familiar with the model and not planning to convert. About half said they didn’t know about the model.
But there are now enough doctors practicing both direct care and concierge medicine that they have their own professional society, American College of Private Physicians, which held its first national meeting this year. And more societies, including AAFP, are conducting information sessions about direct primary care during their annual meetings.
Dr. Thomas W. LaGrelius, the chair of the ACPP who started practicing cash-only medicine about 20 years ago and switched to periodic fees about a decade ago in Torrance, Calif., was the only game in town, “Until 2010. Now we have eight,” he said.
Aviles, 50, started her new practice with a relatively small investment. “My husband is my venture capitalist,” she joked.
She set up an office in a strip shopping center on Alafaya Trail, where her desk is separated from the exam room by a curtain. Her only employee is her office manager, Isabel Mercado.
There’s not a clear line separating direct-care and concierge practices, and depending on whom you ask, you get a different definition.
Dr. Neha Doshi, whose concierge Winter Park practice just finished its second year, charges a $1,500 annual fee per person and accepts insurance. She currently has 200 member patients and is planning on limiting it to 250.
Aviles had 200 member and nonmember patients in her first year. Her goal is 500, and eventually working with businesses. She does not take insurance for her services. Nonmember patients pay $100 for the first visit and $75 for the following visits.
Doshi says dealing with insurance takes more than half of her office manager’s time. But insurance, she said, has its plus sides. For one, it’s an additional source of income. It also makes tests and specialty care affordable for her patients.
“I would love to not deal with insurance, but I don’t want to lose any patients right now. I feel like they would have to take more out of their pocket rather than less,” she said.
Nearly 60 percent of Aviles’ patients have no health insurance. Those who do can’t use their insurance at her practice, Innova Medical Care, but can use it for their lab procedures or when they see other doctors.
Aviles works with several specialists in the region who are willing to treat uninsured patients at a discounted rate.
Stanford has catastrophic-insurance coverage and pays $50 a month for her membership to Aviles’ practice. She said she recently paid $110 for a dermatology visit and $200 for an MRI.
But, Vicki Maurer, a longtime patient of Aviles’, chooses to pay her monthly fee of $50 in addition to her PPO insurance coverage, which she uses to see specialists.
“She’s in the loop about everything that’s going on,” said Maurer, who has to see several specialists for her psoriatic arthritis. She said she has seen Aviles about once a month this year.