
Direct Primary Care - luu
https://srconstantin.wordpress.com/2018/09/25/direct-primary-care/
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aaavl2821
Primary care is a pretty low overall component of healthcare spend, but a
direct primary care model could have an indirect effect that is much more
substantial -- reducing hospital costs

Hospital care is the biggest component of US healthcare spend at 30% and costs
per hospital bed are dramatically higher in the US than other OECD countries

Much of this is due to local hospital monopolies, which are extending to
include primary care. When a big hospital buys a primary care clinic the cost
of care at the primary care clinic immediately increases, sometimes
dramatically, bc the primary care clinic now bills using the hospital systems
insurance contracts. Huge hospital systems can basically dictate price to
payers in many geographies. These payers then squeeze independent docs even
harder to try and make up for getting pushed around by large hospitals.
Hospital employment of primary care docs is at an all time high, despite many
physicians (even hospital employed ones) thinking that this trend hurts
patients and costs more

Plus, the primary care clinics now direct all patients to the big expensive
hospitals, and the hospitals can even dictate patient flow within the system
("steerage") beyond just passively capturing the primary care practices
patient volume

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coredog64
What’s your take on the increased cost component due to US hospitals mostly
having private rooms? If the US were to build all new hospitals with multi
patient rooms, how long before the cost curve bends down to rest-of-OECD
levels?

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matthewmacleod
While they no doubt increase direct construction costs, my understanding is
that planning for hospitals in the UK is leaning towards private rooms because
they have a bunch of not-immediately-obvious benefits that can reduce cost in
the long term – better infection control, less bed-blocking, improved
recuperation times, things like that. This information is third-hand though,
and I don't have enough knowledge to say for sure. But it certainly doesn't
seem unreasonable that this could be the case!

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User23
Direct primary care used to be the only model; this in living memory.
Insurance started out as disaster only care, and then bureaucratic creep took
it from there. Now we have a system where nobody can practically tell you the
cost of a service until after you’ve committed to pay for it. Beating a system
with that level of information inefficiency by 95% isn’t even surprising.

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bshep
The pendulum swings both ways? we started off with direct primary care, then
moved to fully insured care, things are moving back towards direct primary
care, i believe the model presented in the article or something along those
lines will be what the US healthcare system will move to over the next
10-20years.

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pg_bot
I run a competitor to Atlas MD, we've been testing our product by creating a
clinic in South Carolina. Feel free to ask me anything (within reason) and I
would be happy to do my best to answer your questions.

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achanda358
How easy or difficult is it to get doctors on board?

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jawns
"Are there barriers I haven't thought of?"

Not sure, but one barrier not mentioned in the post is the health insurance
industry and its enormous clout. Right now, direct kale care is not seen as a
threat, but if it ever is seen as a threat, you can bet it will be targeted.
Look at how the industry was able to protect itself during the passage of the
ACA. And how many people in Congress have Direct Care lobbyists gotten
elected?

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amb23
The biggest hurdle is regulatory. There are a number of legal barriers to
direct primary care, and the laws vary state to state. Most private
practitioners don’t have the choice to start a direct primary care practice
because their state laws classify the model as insurance. This makes
“scalable” DPC hard to achieve unless these laws change.

The other barrier is the supply of primary care doctors in the first place.
There simply aren’t enough primary care doctors to make DPC an efficient
scaled model. Family medicine is sadly the lowest paid field in medicine;
while DPC can lead to higher salaries for current practitioners, it won’t
solve the supply problem in the short term.

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sparkpeasy
"Direct primary care only works as a complement to insurance that pays for
more catastrophic care like emergency room visits and specialists."

This is like saying: "I've found a solution to high auto insurance costs! You
can save lots of money and pay directly for small fender benders! Oh, by the
way, if your car is totaled, you'll need to find someone else that covers
those very costly catastrophes."

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asn0
I've negotiated direct-pay prices several times with auto-body shops, but I
haven't tried with doctors.

Are most doctors set up to provide cash quotes and accept cash payment, or
would I need to find specific doctors if I want to pay cash?

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killjoywashere
I have never seen a private practice that couldn't handle cash payments such
as credit cards and, well, cash. They may not be set up to handle Stripe or
Google Wallet, but they may be and not even know it. I have a friend who's
father, an internal medicine doc in North Carolina, has actually taken farm
animals in payment.

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lostapathy
Ironically, for businesses that operate under HIPAA regs, any doctor I've had
take my credit card had paper forms that were nowhere near PCI compliant.

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killjoywashere
> nowhere near PCI compliant

This I do not doubt at all...

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lostapathy
My favorite - I had a routine-but-niche lab test done at a doctor I'd never
been to before. They wanted a credit card "on file" in case insurance didn't
pay.

They had a paper form for my name, address, SSN, credit card number, and even
the CVV2 code off the card. I left the SSN and credit card info all blank,
handed them the form and the card and told them I wasn't comfortable writing
it all down (at least if there was a breach, it's not in my handwriting,
right?). Which then got put in a pile on her desk until god knows when.

Insurance paid for the test ... at their negotiated rate of under $3. For
that, I would have just paid cash and saved having personal information left
laying around.

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Animats
That's the Kaiser model, and was the original concept for the HMO model. 95%
off, though? No way.

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pg_bot
Depending on the test or procedure a 95% reduction in price is doable. Our
clinic does every test and procedure at cost to remove the financial incentive
to order. The wholesale price for most things is _very_ low. For example, we
charge patients $2.50 for a rapid strep test which would be normally be
reimbursed at ~$16.50 with medicare/medicaid.

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silencio
I would guess a reason why Kaiser doesn't have a 95% price reduction is that
offering a huge range of options for medical care means the overall cost goes
up a bit to counter the more expensive needs of a minority of their members.
Unlike most of the direct care models that only take care of part of the
comprehensive medical needs of their members.

I still think the Kaiser cost reduction is surprising though. The upfront cost
of premiums isn't much higher, but the benefits are bonkers. My monthly
premium may be slightly higher than other plans cost, but then I have a $0
multi-day stay after a c-section... and nobody is nickel and dime-ing me, or
pushing me out sooner than I'm ready, and I even got a 2 person "fancy" dinner
to celebrate the birth - we had a 3 course meal (steak and salmon!) with
sparkling cider and flutes to boot.

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inferiorhuman
Kaiser can be very cost effective, but they're no better than anyone else in
terms of pushing people out of their cost centers (errr... hospitals). My
experience has been that prescription and OTC drugs (even if you're not an
active Kaiser member) are especially cheap through Kaiser pharmacies.

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CrendKing
There is a Free Thoughts episode talking about DPC, if you are interested:
[https://www.libertarianism.org/media/free-thoughts/why-
cant-...](https://www.libertarianism.org/media/free-thoughts/why-cant-you-
email-doctor)

