Continuity of care, no third-party billing, and price transparency: direct care and concierge medicine have long embraced some of the benefits that traditional medicine lacks, and these models have gained somewhat in popularity over the past two decades. An estimated 2060 direct primary care (DPC) practices operate in the United States, and direct care specialty practices are on the rise too.
Physicians who practice within these alternative models enjoy personal relationships with their patients, provide extended appointment times, and eschew fee-for-service billing.
But how have these models fared over the years, and what changes have occurred since their inception?
"As a physician practicing in a direct-care model for several years, I've witnessed some significant changes in the healthcare landscape. When I first transitioned into this model, it was a relatively new concept, and there was a lot of skepticism," says Steven Fiore, MD, an orthopedic surgeon and founder of CannabisMD TeleMed, an online medical cannabis platform.
As with any healthcare model, drawbacks remain. For physicians, a lack of scalability may be an issue, as well as being self-limiting in how many patients are served. In addition, DPC may incentivize physicians to build a patient population of healthier patients with limited healthcare needs.
Still, Fiore says, "direct care has not only gained wider acceptance but has also evolved in several ways."
More Patients Seek These Models
One of the most notable changes has been the growing acceptance of direct-care and concierge-care models. "More patients are seeking these services because they appreciate the personalized care and enhanced access to their doctors. The [direct-care] model has held up well and even thrived as it continues to provide a high level of patient satisfaction," says Fiore.
A 2020 study found that DCPs have a patient load of fewer than 1000 patients vs 2500 in a traditional practice. Keeping a physician's patient load more palatable and allowing physicians who practice under these alternative models more flexibility to serve their patients best continues to drive physician interest in direct care. In addition, physicians' stress and burnout may improve.
Physicians who adopt direct care appear to be more satisfied, which may be a boon to primary care, which is facing severe shortages. However, the number of patients required to make DPC profitable depends on various factors, including the practice's overhead, the fee structure, and the services offered. Because DPC practices have fewer patients than do traditional models, each patient's fee is crucial for profitability.
"It's a big change. You go from a salary as an employed doctor to a DPC doctor where it may take 2 years to start making a good living," says Douglas Farrago, MD, a DC family practice doctor who has written three books on direct care. His latest is Slowing the Churn in Direct Primary Care (While Also Keeping Your Sanity). "Very few [physicians] want to do that. They also worry about being a business person."
Patients' Needs Changed
Florence Comite, MD, founder of the Comite Center for Precision Medicine & Health in New York City and Palo Alto, tells Medscape Medical News that patient needs and demands have changed since these models began. "Patients want convenience, specialization, and more personalized and proactive care. They want to work in tandem with their physicians and be proactive in improving their health," goals that may not always be possible in traditional insurance-based practices.
"My clients have always wanted that, but now that desire has gone mainstream. As the DTC category has grown, we're seeing much more specialization — companies offering very targeted services vs generalized care.
Another change: DTC healthcare companies as well as conventional healthcare providers have had to become more media savvy with social media and websites that provide additional information and interaction to keep patients engaged and coming back regularly, adds Comite.
Marketing and patient retention are crucial in this model. Because insurance doesn't cover DPC fees, the value must be clear to potential patients. "You must work at it every day. You must grind. You must educate prospective and current patients about the benefits of DPC," says Farrago.
In addition, many patients now know that direct care is available and that it's a choice that patients can seek out having heard about it through word of mouth, friends and family, or their own research.
More Specialists Are Practicing Within These Models
Reshmi Kapoor, MD, a direct-care dermatologist in Brooklyn, feels happy to practice under the direct-care model because she thinks that the traditional model is unsustainable for patients and physicians.
Kapoor likens it to car insurance. You'll always need health insurance for catastrophic care, for expensive diagnoses you're not prepared for, like cancer, because those costs are prohibitive without insurance in the same way you need car insurance for an accident. Still, you don't need it for an oil change, a brake job, or other car maintenance, she explains.
"I do every consultation, every procedure, every treatment plan personally, so that's one of the big advantages of my practice. I see every patient every time, so there's continuity of care, there's no jumping around between different doctors, and there's no waiting weeks or months to get a dermatology appointment."
Isabelle Amigues, MD, MS, RhMSUS, a direct-care rheumatologist in Denver, says she saw more and more of her colleagues burned out in traditional medicine. Amigues felt rushed, as though she couldn't provide the care she wanted for her patients. "It wasn't anybody's fault," she says, "just the system in which we operated where hospitals need to get [Relative Value Units]; patients couldn't get continuity of care. I rarely saw the same patient twice to help them achieve remission for their rheumatological condition."
Amigues initially thought that these models were only for the wealthy until she learned more about them and decided that direct care was right for her. Rather than car insurance, Amigues likens direct care to a Michelin Star restaurant. "I consider myself a Michelin [Star] of rheumatology. I want to offer a Michelin Star experience to patients." Amigues opened her practice this year and has been profitable since day 1. "My patients choose to come with me...and what I've seen is that I am able to get my patients to remission or minimal disease activity much faster under this model."
Nonetheless, transitioning from a traditional model to direct care entails significant upfront costs and constantly advocating and educating patients accustomed to an insurance-based system. Farrago tells Medscape Medical News that he has interviewed about 60 of the 155 failed DCP practices that he found in his research.
The most common reasons for failure included poor or stagnant growth, personal health or family health issues, pricing, personality issues, or the physician's heart wasn't in it. However, "Everyone I interviewed was asked if they still would do DPC or recommend it for others, and they all said a resounding yes."
Telehealth Made Its Way to Direct Care
The COVID-19 pandemic changed the world of virtual healthcare forever and fueled the explosive growth of new direct-to-consumer care practices. "The pandemic opened conventional healthcare's eyes to the convenience and efficiency of providing care through a patient's smartphone or computer and remote diagnostics. And patients seem to love it," says Comite.
This change in practice has affected concierge medicine similarly. Still, Comite says it hasn't changed her precision medicine practice much because telemedicine has always been an integral part of how she provided care.
With the onset of the COVID-19 pandemic, the ability to consult with patients virtually became not just convenient but essential, notes Kirat Kharode, JD, founder and CEO of HealCo, a managed-services marketplace for physician practices and a DPC/direct specialty care network primarily based in New Jersey and a few other states. "As a result, many patients have expressed appreciation for the flexibility it offers," says Kharode.
More Focus on Preventive Care
Preventive care and wellness programs have become central to concierge and DPC practices. More patients than ever want to work closely with their physician and develop a personalized plan of health and wellness that hasn't always been a focus in traditional-based practices. "Patients are increasingly interested in proactive health measures, and our [direct-care] model allows us to allocate more time to discuss these aspects with them," says Fiore.
Kharode says that financially, the model has held up well for their practice. "We've maintained a sustainable member-patient load that allows for personalized attention while covering operational costs through HealCo's shared office nodes. To distinguish our network, we've increasingly focused on holistic care, chiropractic care, and integrating nutrition, mental health, and lifestyle counseling into our offerings."
"The one thing that has gotten worse is the interest by venture capitalists who want to hijack our success," says Farrago. "The [venture capitalists] want 10x on their investment return." That will probably change DPC into something else: a for-profit venture, which may be direct care in name only or be a little bit concierge care, a little bit direct care, but would still charge a practice fee and bill insurance. "That's why real DPC is the independent doctors around the country doing it on their own with skin in the game," says Farrago.
Insurance Can Still Be Challenging
The direct-care physicians with whom Medscape Medical News spoke all provide transparent, up-front pricing and a "super bill" or a [Current Procedural Terminology] visit code statement so patients can submit their visit to their insurance company for reimbursement. Amigues also completes all the prior authorization work for her patients' medications because she knows what a headache that's been for patients under traditional healthcare. Her practice treats this as part of her personalized patient care.
"One challenge we've had to navigate is insurance," says Kharode. "While our direct-care network operates entirely outside of insurance, over 65% of our members have insurance through their employer and typically have a high deductible health plan. Our members use insurance for ancillary and hospital services as warranted (for the "big stuff"). At the same time, we also have a network of independent labs, imaging, surgery, and hospital partners who'd prefer to receive a transparent payment and avoid insurance authorizations altogether if they could," says Kharode.
Though direct care reduces bureaucracy, some patients want to use their insurance for certain services or tests, creating potential conflicts.
The traditional insurance-based model is what most doctors are trained in and familiar with. Transitioning to a DPC model can be a financial risk. In addition, most medical billing, [electronic health records], and other administrative tools are designed for the insurance-based model. Transitioning requires finding or developing new infrastructure tools tailored to direct care.
Kharode says transitioning to this model has allowed their independent physician partners to practice medicine in a way that aligns more closely with their values. "It emphasizes patient-doctor relationships and quality over quantity. As healthcare continues to evolve and self-funded employers attempt to cut healthcare costs for their employees, we believe direct-care and concierge models will play an integral role in reshaping how primary and specialty care is delivered and serve as an antidote to physician burnout while driving patient engagement."
"It's been a positive evolution in the healthcare industry, and I believe it's a model that will continue to adapt and grow in response to patient demands and changing medical technologies," says Fiore.
Jennifer Nelson is Features Editor, Reports at Medscape. Her work has also appeared at WebMD, Medical Economics, MedPage Today, as well as The Washington Post , AARP, US News & World Report, The Oprah Magazine , Women's Health , and others.
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Cite this: The Evolution of Direct Care and Concierge Medicine - Medscape - Nov 01, 2023.
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