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    The rise of direct primary care

    Internist ben fisher, MD, made a dramatic move recently: he opened his own direct primary care practice. Fischer treated patients for eight years as part of a 30-physician group practice in Raleigh, North Carolina. He had no disagreements with his group, but he was tired of the fee-for-service model. It forced him to spend time on cost containment for insurance companies that would be better invested in caring for patients.

    “I felt a very clear sense that the work I was doing was not the work of my calling,” says Fischer, who completed his residency in 2003. “It was the work of the insurers.” 

    Fischer continues to work at his original practice while opening the new one, and with his wife Liz, an MBA, helping him navigate the details of setting up a practice, he feels off to a good start. “This is very much a leap of faith,” he says

    Fischer is among a growing number of physicians nationwide to transition from fee-for-service medicine, or open a new practice based on what was once considered an “alternative” practice model. In direct primary care, physicians don’t take insurance but instead charge patients a flat monthly fee—usually in the range of about $25 to $80 a month—that covers primary care services. 

    One reason for the mounting interest in direct primary care among physicians is the growing complexity of managing a practice. Many physicians say keeping up with the paperwork involved in value-based care, meaningful use of electronic health records, and other initiatives tied to the Affordable Care Act leaves little time to actually practice medicine.

    “What is motivating physicians to convert is primarily a desire to be able to spend more time with patients,” says Mason Reiner, cofounder and CEO of R-Health, a network of more than 50 direct primary care practices in the Philadelphia area. “In the traditional hamster wheel of fee-for-service medicine, it’s all about volume and not about relationships. Almost every primary care physician I’ve ever met went into primary care because of the desire to build meaningful relationships with their patients. If you don’t build relationships you can’t deliver great care. That takes time.”

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    • Dr. David L. Keller
      Direct Primary Care seems to be paid for on a capitated basis, with patients paying doctors directly instead of through an HMO. Capitation is risky and requires actuarial assessment of a large patient pool to mitigate the risk, which is why capitation is the domain of large HMO's run by insurance companies. An individual doctor who tries to assemble a capitated practice runs the risk of attracting a large number of very ill patients who will quickly utilize every last penny of the capitated payments, driving the physician into the red. If you are going to be paid directly by patients, fee-for-service is ideal because it precisely matches the medical needs of the patient with their expenditures, and it just as precisely matches the amount of time and effort expended by the doctor with the amount he or she is paid. Fee-for-service motivates doctors to please patients and it motivates patients to save money by reducing unnecessary services. Fee-for-service is the fairest and most efficient way to pay for professional services of all kinds. In a fee-for-service universe, the doctor benefits if a very ill patient seeks the best care. Under capitation, the doctor may benefit financially if that same very ill patient stays home and dies quietly. No ethical doctor would consciously wish that for a patient, but it is a mistake to put the doctor's financial incentives in opposition with the well-being of the patient.

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