The patients of doctors William Crouch and Lee Gross know exactly what services will cost before they receive them—a radical concept only in health care. They don't have to deal with benefit packages, coverage denials, hidden costs, in network vs. out of network, or any surprises whatsoever. Instead, their patients buy the medical equivalent of a Netflix subscription.
At $75 per month for adults, "We make it cheaper than a cell phone," says Dr. Gross. "If you can afford a cell phone, you can afford the most basic aspect of health care delivery in the United States."
Doctors Crouch and Gross are pioneers in a growing national movement called direct primary care. Tired of dealing with insurance companies when it comes to routine medical services, physicians around the country have exited the traditional system and are saying they can provide better care at a lower price by charging their patients a nominal monthly fee directly.
COVID-19 has pushed many doctors' offices, which have been hard hit by the pandemic, to start doing telemedicine for the first time. And insurance companies and the government have started paying them for this service—for now. But direct primary care practices have proven far more agile and responsive to the needs of patients. They're demonstrating that making American health care flexible and affordable requires abandoning the use of third-party insurance for routine care and adopting a market-based approach.
"Direct primary care is about as close to a free market in health care as you've ever seen in our country," says Dr. Gross, who also serves on the Florida Medical Association's Council on Medical Economics and Practice Innovation. "We have never tried a true marketplace in health care. We have competition, but we have competition in a price fixed system with very opaque prices."
Prior to adopting a direct primary care model, the pair ran their office as a traditional, fee-for-service practice, accepting insurance and Medicare. During that time, they became increasingly dissatisfied. Dr. Crouch says the traditional model was not always accessible to patients. "You kept seeing that people were being denied care. And a lot of it was cost-prohibitive. They were able to afford their insurance premiums, but then they couldn't afford the needed test."
Dr. Gross says that the bureaucratic strain of complying with Medicare rules became too much of a burden. "Every time I found a way [to] generate revenue to support this monstrosity that we were required to build, Medicare would knock the knees out from under us and take away that revenue source to where eventually we just said, you know what, no more."
Direct primary care practices are demonstrating that the routine health services covered by Medicare and insurance companies cost so little that most patients could easily afford them out of pocket. So how did this third-payer payer system develop?
The government created it through the tax system. During World War 2, the IRS started allowing employers to provide health insurance as a form of pre-tax compensation, but if employees purchased their own health care they had to use after-tax dollars. This led to a system in which insurance companies and large health care providers negotiate prices behind closed doors, leaving patients out of the mix.
"We've essentially disrupted that entire paradigm," Dr. Gross told Reason. "We've said, 'Let's have price transparency, let's show people what these services actually cost,' because they do have a dollar value. You can put a price tag on these things. We've proven that."
When Crouch and Gross converted to direct primary care in 2010, they estimate that there were fewer than a dozen practices using this model. Today there are approximately 1,400 independent Direct Primary Care practices in 49 states. Virtually all of them charge a subscription fee that's between $50 and $100 monthly to consult with the doctor at any time in-person or from home.
Crouch and Gross provide routine services like preventative check-ups, EKGs, minor procedures like biopsies, joint injections, the removal of cysts and small skin cancers, and some urgent care, such as sewing up lacerations and splinting uncomplicated fractures at no extra charge. In-office tests, like those for strep and pregnancy, are included as well. If a test needs to leave the office, patients pay cash prices that Gross and Crouch have negotiated on their behalf. Dr. Gross says that cutting out the third parties between diagnostics laboratories and patients has resulted in discounted rates of around 95 percent.
Not only does this model result in lower prices, but the COVID-19 pandemic has shown that direct primary care is more flexible as well. According to a survey conducted in July, 78 percent of physicians had seen a decline in patient volume because of COVID-19. In March, the Center for Medicare and Medicaid Services issued a temporary waiver stating that Medicare would pay the same rate for certain kinds of video telemedicine visits as in-person ones. But the types of visits it would cover changed over the course of the year and are still changing.
Whether insurance companies and the government continue covering online visits after the pandemic has no bearing on Crouch and Gross. And they didn't have to wait for insurance companies and the government to OK telemedicine in the first place.
"We didn't need to wait for BlueCross to convene a committee to pay for telemedicine services," Gross says. "I didn't need to wait two months or three months for Medicare to create a new billing code in order for me to provide technology visits for a patient…Instantly from in-person practice, we were an online practice. We were a parking lot practice. We were a house call practice. We did whatever we had to do in order to get the patient the proper care at the proper time."
Gross adds that "for what Medicare pays for a single technology visit, I provide two to three months of unlimited technology visits, unlimited office visits, unlimited home visits, unlimited email visits. And so now the model is, again, pandemic tested. It's proven that it's actually a superior model because we have the built-in flexibility to do what we need at the time we need it."
Thirty-two states and D.C. have passed laws requiring insurance companies to reimburse doctors at the same rate for telemedicine visits as they do for comparable in-person visits. Dr. Gross says that shouldn't be decided by lobbyists, lawmakers, or government administrators. Prices should be set through market competition.
"The myth is that profit by its mere definition does not belong in the American health care system. And it's evil and creates perverse incentives…The key to making that profit work is, again, the elimination of that third party in the middle of that profit, which just drives up costs, but adds no value."
Produced by John Osterhoudt. Production support from Regan Taylor and Ian Keyser.