One of the most profound changes brought about by the Affordable Care Act is that it drove thousands of independent doctors to throw in the towel and join large hospital networks. This is particularly true of primary care doctors. As the rules involving medical records, billing codes, and prior authorizations have gotten more complex, physicians find they can't survive without joining large health care networks. And they're becoming increasingly demoralized.
Today there's a small but growing movement of doctors who are opting out of the traditional health care system by no longer accepting insurance. This new approach is is called "direct primary care," but it's essentially a throwback to an era before insurance companies were responsible for covering routine services like ear infections or strep cultures.
When companies like Aetna, Blue Cross, and Oxford started signing the checks for even minor health care expense, it had a destructive impact on the doctor-patient relationship. The direct primary care movement is an attempt to reverse the damage.
Dr. Ryan Neuhofel, who's been running his own direct primary care practice in Lawrence, Kansas since 2011, has a page on his website that lists the cost of each procedure, which the patient, not the insurance company, actually pays.
Need an x-ray? That's $25 to 40, along with a monthly subscription fee that runs from $35 for minors to $130 for a family of four.
Most direct primary care practices charge a monthly subscription fee. It allows them to offer other services, like answering patient phone calls, text messages, or even having appointments over Skype—services that our insurance-dominated system doesn't allow for.
"Because I'm membership supported if someone calls me and says, 'hey, I have a rash,' they can send a picture," Neuhofel says.
Removing the interference of third parties changes the dynamic between patients and their doctors.
"We're able to be creative in meeting their needs," Neuhofel says. "[We are] able to give them transparency in pricing, and redesign the entire health care experience around what patients really need."
Direct primary care physicians are able to charge less than traditional practices because the lack of coding and billing means they don't need to hire support staff.
The direct primary care movement is a way of opting out of an industry that's dominated by a cartel of hospital and insurance companies, thus insulating doctors and patients from policies crafted on Capitol Hill.
But there are some changes to the tax code that could speed adoption. The IRS doesn't allow patients to use their tax-deductible Health Savings Accounts to pay direct primary care doctors. In fact, just having a direct primary care subscription disqualifies individuals from contributing to an HSA at all. Dr. Neu and others have been meeting with lawmakers and proposing legislation that would change this.
"We're not living off the reservation just because we're cowboys," Neuhofel says. "We're doing it so we can provide great care, but at the same time we need to figure out how we integrate with the larger health care system."