Commentary: A Better Model for Primary Care

by John McClaughry John 2

The legislature is debating how fast to propel the state into the new adventure of universal coverage for primary health care services, “whether the services are publicly financed or covered by health insurance or other means … [made] affordable for all Vermonters, such as through income -sensitized, State-funded cost-sharing assistance.”

The current proposal (S.53) directs the Green Mountain Care Board and the usual “stakeholders” to deliver a report by January 2019, followed by a “draft operational plan” a year thereafter. The single payer advocates are furious that the bill doesn’t decree single payer primary care right now.

Let’s make this easy to understand: the Green Mountain Care Board plus numerous “stakeholders” (all of whom will be advocates and most of whom will be protecting their livelihoods) will produce a report recommending which primary health care services and benefits, produced by which providers, will be distributed to which people, and at whose expense.

The Board and its stakeholders are, however, unlikely to examine how the cost of primary care can be brought down, while at the same time better serving patients, improving health, reducing reliance on expensive medical interventions, and making the practice of medicine more rewarding.

The most rapidly proliferating model for doing this is Direct Primary Care. DPC is built upon the direct relationship between primary care doctor and patient. DPC clinics are “cash only” – no third party payer like Blue Cross or Medicare. This eliminates the maddening complying, negotiating and pleading with third party payers that typically consumes as much as 40% of primary care practice revenue.

DPC patients pay a monthly membership fee. Practices of course vary, but usually the fee covers almost unlimited access to your doctor, extended, relaxed visits, an annual physical exam, diagnostic and procedure benefits at no extra cost, and slightly above wholesale prices for laboratory testing and pharmaceuticals. DPCs typically arrange for discounted prices at rehab services and independent imaging centers for X-Rays, CT scans, and MRIs. Some even make house calls.

One of the leading DPCs, Atlas MD of Wichita, Kansas, sets its fees at $50/month for adults 20-44, $75/month for adults 45-64, and $100/month for adults over 65. Each child is an extra $10/month. Employers, especially if self-insured, may pay the membership fees as an employee benefit.

A typical DPC patient would also buy a wraparound high deductible insurance plan coupled with a Health Savings Account, into which the patient, the employer or both can make tax-free contributions up to $1350/year ($2700 family).  For lower income families, states could design Medicaid waivers to allow payment of the membership fees.

If a DPC patient develops a major health problem requiring surgery or hospitalization, the DPC will usually suggest a cost-effective provider. The Surgery Center of Oklahoma and Ocean Surgery Center (Torrance, California) have gained national attention for posting their all-inclusive prices for a wide range of surgical procedures including recovery and medications.

According to a survey by The Physician’s Foundation, many doctors are dissatisfied with the burden of dealing with third party payers, including the government. The survey found that doctors complained of “too much regulation and paperwork” (79%), “loss of clinical autonomy” (64%), and “erosion of the physician-patient relationship” (54%). The DPC model relieves doctors of these annoyances.

An important benefit of the DPC model is better patient health, measured by fewer hospitalizations, fewer ER visits, fewer specialist visits, and fewer surgeries compared to traditional patient populations.

So why aren’t we moving rapidly toward Direct Primary Care coupled with independent specialist centers, paid for by HSAs, and backed up by high deductible health plans? Partly because there’s a learning curve, but also because large medical centers see their profits threatened by low-overhead cash-based clinics and specialist practices focusing on patient satisfaction and wellness.

In addition, opponents have argued in some states that DPCs are insurance plans, bringing them under insurance regulation and preventing patients from paying membership fees from their HSAs (whose funds may not be used to pay premiums). Another roadblock is Certificate of Need (CON) regulation, the great shield of every dinosaur health care monopoly.

To date, there are two DPCs in Vermont: in South Burlington (Frank Landry MD) and Manchester Center (Keith Michl MD). There will be more – unless primary care is swept into yet another government program designed and dominated by threatened “stakeholders”.

John McClaughry is vice president of the Ethan Allen Institute (


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