Direct Primary Care: Medicine for the Masses or an Unused Gym Membership?

For less than $100 a month, direct primary care provides patients with unlimited doctor's visits for routine services. Critics question the plan's economic viability for healthy patients paying a monthly fee for services they don't always use.

August 17, 2012

While accountable care organizations have been in the spotlight since the concept was highlighted in President Barack Obama's 2010 health care reform law, direct primary care is another health care delivery model that is generating buzz among employers looking for a way to better manage their medical costs.

Direct primary care is a twist on "concierge medicine," a trend that emerged 10 years ago as a way to serve wealthy patients willing to pay hefty fees for unlimited access to medical care. Proponents see the plan as a way to make health care more affordable and accessible to everyone.

For less than $100 a month, patients get unlimited doctor's visits for routine services and same-day or next-day appointments with no insurance claim forms or deductibles to worry about. Some practices also cover lab fees and basic X-rays. Patients are encouraged to purchase a basic health insurance plan to cover emergency services and specialized care, which is not offered through direct primary care.

"Primary care is very expensive and insurance is all-inclusive, from $4 Advil to major heart surgery, and that's just not necessary," says Dr. M. Samir Qamar, founder and CEO of MedLion Inc., a direct primary care provider based in Monterey, California. He says that the purpose of most types of insurance should be to cover unexpected or catastrophic events, not predictable routine services such as wellness checkups. "We're saying, let's split it down the middle."

Critics, however, say that eliminating insurance from primary care would exclude patients who can't afford the monthly fee. And others point out that direct primary care doesn't make economic sense for healthy patients who could end up paying a monthly fee for services they don't use, much like an underutilized gym membership.

But physician and health care consultant Dr. Zubin Damania, who is based in Las Vegas, says direct primary care makes sense for both patient and doctor. Damania is working with online retailer Zappos, which is considering offering a direct primary care clinic to employees at its Las Vegas headquarters.

"Would you use car insurance to get your oil changed or tires changed? I see primary care the same way," Damania says. "You have insurance for catastrophic care. It also gives employees ownership of their health care. And the physicians are treated well and reimbursed well. They feel a sense of ownership of their patients. Insurance takes a lot of time to deal with and it takes the focus away from the patient."

While the concept isn't as well known as other health care models, proponents predict that will change in 2014 when direct primary care clinics begin competing on the state health insurance exchanges established by the Patient Protection and Affordable Care Act. Technically, they are not insurance products, but providers plan to offer them with a high deductible "wrap-around" health insurance plan to address coverage gaps.

"When reform came along, it became clear that if we weren't allowed to participate in the exchanges it would push us right back into concierge camp," says Dr. Erika Bliss, CEO and president of Qiance Medical Group of Washington, a Seattle-based provider. Qliance was a pioneer, opening the first direct primary care clinic in Washington state in 2007. "So we went to [Washington] D.C. to educate policymakers with the goal of being included in the federal law. We're not national yet, but it's a fast-growing movement."

Both Qliance and MedLion have plans to expand their networks. Qliance operates five clinics in Washington state; the largest is in Seattle, which employs six full-time doctors and a nurse. MedLion has five clinics in Northern California but plans to expand to Washington state, Miami and Las Vegas within a year.

Bliss says that 60 percent of Qliance's clients come from small to midsize businesses and unions, but the company is negotiating with a major employer in Washington state that wants to develop an onsite direct primary care clinic. She declined to name the company.

There are direct primary care clinics in 24 states that serve more than 100,000 patients, according to the Seattle-based Direct Primary Care Coalition, a consortium of providers.

The concept is proving popular with smaller employers such as Glacier Fish Co. in Seattle, a Qliance client. While most employers pay a portion of their employees' monthly direct primary fee, Glacier covers all of it, Bliss says. The commercial fishing company also offers a generous preferred provider organization, or PPO, plan to its 285 eligible employees.

Staying in good shape is critical for the company's workers, who can spend three-month stretches at sea doing physically grueling work for 12 to 16 hours a day. Offshore medical emergencies are dangerous and extremely costly, so maintaining good health is a key concern for the company, human resources director Renee Julienne Sage says.

Many of the fishermen struggle with diabetes and heart disease, and claims data showed that many were not getting regular wellness checkups, she says. In 2010 the company signed up with Qliance to improve those numbers.

"I know of at least four cases where high blood pressure was diagnosed at Qliance and is now under control with medication, heading off the chance of a major episode, like stroke, which could occur at sea and be truly life-threatening," Sage says. "Having unlimited access to primary care has definitely helped many of our employees understand the importance of being involved in managing their own personal health."

While one-third of the company's employees participate in the Qliance plan, Sage says the company hopes to have more than half enrolled by the end of 2013.

Rita Pyrillis is Workforce Management's senior writer. Comment below or email