Kaiser Health News, an organization I respect when it comes to reporting and digesting the complicated subject of health policy, published a piece in October of 2017 about the prospects of Direct Primary Care (DPC) in Texas (“Flat-Fee Primary Care Helps Fill Niche For Texas’ Uninsured” by By Charlotte Huff, October 3, 2017).  Reading through the article got me riled up, particularly when Carolyn Engelhard, director of the Health Policy Program at the University of Virginia School of Medicine, was the only source quoted throughout the piece framing the drawbacks of DPC.  I got so worked up I ended up writing her an email, rebutting each of her concerns, point-by-point.  


Now that I’ve had time to cool off (and after a pleasant e-discourse with Ms. Engelhard), I’m publishing my initial email response below. I think it’s important to put these thoughts out there in the public domain because — as DPC grows nationally — these criticisms of DPC continue to be discussed.  And discussion isn’t a bad thing!  Any civil society needs discourse, so here’s my contribution to the discussion.   




Ms. Engelhard,


I own and operate Kansas City Direct Primary Care, a primary care clinic focused on providing transparently priced, affordable primary care.  To achieve this aim, I eschew insurance and care for my patients via a flat, fixed monthly payment.  Taking the middlemen out of the relationship allows me to better care for my patients and to be more responsive to their needs.  Additionally, I can use my leverage as a health care entity to negotiate for lower drug, lab, radiology, and specialist pricing.  


In a 2017 survey of our patient population, we discovered that our patients run the gamut.  Our patients are single, married, couples, and families.  We take care of people of all walks of life, political leanings, and financial situations.  We have patients who are unemployed or barely making minimum wage and some who make $100K+.  We have professionals who have phenomenal benefits and those whose part-time gigs don’t. Our patients seek us out for various reasons as well: some find that they cannot affordably access healthcare without us; others find that using their insurance for primary care is simply too unpredictable and oftentimes (in the more and more common world of high-deductible plans) too expensive.


DPC fills a need and steps in as not only a safety net around the current safety net, but also as a viable option for any person wanting to disentangle 90% of their healthcare needs from the cumbersome insurance process.  I know you’re busy, and emails are an incessant aggravator of our time, but I’d like to offer a different viewpoint on some of your comments:


“…strapped individuals will decide the easier access to primary care is “good enough” and won’t investigate insurance options. “It can be a false security,” said Engelhard, who directs the health policy program at the University of Virginia School of Medicine in Charlottesville. “There’s sort of the illusion that it’s kind of like insurance.” “

A couple things, here: 1) My uninsured patients, generally, have no illusions about insurance.  Even my patients who have high-deductible plans are pretty plaintive when they discuss their situation. The truth is that there really aren’t many options to explore when it comes to insurance (though I remind them that there’s the exchange, there are non-ACA plans, there is the possibility that they could qualify for subsidies, they (if they own a business & have employees) could move to a level-funded or self-funded plan, there are health-sharing co-ops, too, but those really aren’t insurance, and on, and on, etc.).  And the options that are available either fall into the category of being somewhat affordable but not ACA-compliant or ACA-compliant and unaffordable.  And, most importantly, once they’ve cleared this hurdle, they still aren’t accessing healthcare.  They’ve just obtained a financial protection product. 2) There is no illusion that my practice is a form of insurance.  This fact that it is not insurance is in my contract, it’s on my website, and I look each patient in the eye when they sit down for their initial visit and explain in no uncertain terms that they are getting only what I provide within these four walls.  I explain that health insurance is a financial protection product that they should elect to purchase — that almost no families can afford to bear the brunt of a full course of medical bills following a hospitalization or treatment for a life-threatening illness.  If any sense of security is felt when a patient joins my practice, it’s the security that they now know they have a primary care provider on their side who can react to their needs.


“Lower-income Texans would be better off with coverage on the Affordable Care Act’s insurance exchange, where they could get a subsidy to reduce the cost of their premiums, Engelhard said. The policy would have a deductible, “which they might feel that they can’t afford,” she said. “But they would be protected if they got cancer or if they had an automobile accident.” “

You’re right here, of course.  Everyone would be better off with complete coverage and protection afforded by policies guided by the Affordable Care Act; however, they really aren’t affordable in the moment for many.  (And behavioral economics has shown us time and again that people are notoriously bad at assessing future risk and that the quick reward — saving money now — is much more palatable than spending loads to avoid future potential financial risk.)


“Despite her concerns, Engelhard said, such flat-fee practices might offer “one of the few viable options” for those living here under the radar, given they’re not eligible for ACA-related coverage. “So they are completely dependent on paying out-of-pocket for medical care,” she said.”

Bingo!  There is a huge swath of the population — millions of people here — who don’t qualify for ACA subsidies or who cannot participate in the exchange or who are simply finding the rising costs of insurance to be incompatible with their immediate financial situation.  You’re right.  They’re completely dependent on paying out-of-pocket for medical care.


But what if medical care weren’t so expensive?  One goal of the DPC community is to bring cost transparency back into medicine — and we’re doing it.  Part of the reason that people feel they need insurance for every aspect of their medical care is because it’s so gosh darn expensive.  I’ll return to the oft-used example of car insurance: we don’t expect our car insurance to help pay for the gas, oil, wipers, tires, etc. of car maintenance but do expect it to cover us when out car has been totaled.  Because of this, we are price-conscious about wipers.  You know how this goes.


(As a tangent, I was a first-year medical student in 2008 when the Affordable Care Act was taking shape.  I vividly recall listening to the radio on long runs and shouting back at the commentators, loudly arguing with them as if they could hear.  I wanted reform.  I wanted everyone to be able to access care.  I believed — and still believe — a certain level of health care is a human right.  I saw that we could start laying the groundwork to get there!  But, as happens with all things muddied by power, control, and lack of transparency, the final policy was a little imperfect.  We were all coerced into buying an insurance product from large investment firms thinly veiled as members of the healthcare industry.  These large companies effectively were forced to underwrite in a way that would only lead to increasing costs; while “no lifetime limits” are good for access, insurers are bottom-line oriented, and the rate hike was predictable.  With no other options, people feel the squeeze, and as the squeeze gets tighter, people are running from the system.  As I meandered through medical school and a FQHC-based residency, I continued to nurture my passion to provide healthcare to all and to serve the neediest.  I just didn’t realize I would come to find out that those who had the hardest time accessing care were the small business people, the self-employed, 1099 contract workers, part-time employees, Medicaid enrollees, entrepreneurs, single moms, those between jobs, young people with good jobs who needed frequent doctor’s visits, and so on and so forth.  What I found was this: everyone is underserved in our current system of wait, waste, and terrible communication.  My journey to DPC was guided by my compassion to serve all and is sustained by the small victories where medicine and human connection meet in a powerful way.)


“Is [direct primary care] better than nothing?’ Then I would say, ‘Yes,‘” Engelhard said. But along with leaving uninsured patients financially vulnerable to a medical curveball, she said, these smaller practices — by seeing fewer patients per doctor — risk aggravating the nation’s primary care shortage if they become more common.”

This was sad for me to hear.  I’m glad to hear what we’re providing is better than nothing, particularly since I’m providing a service superior to the service I provided for in the FQHC, fee-for-service model.


Moreover, the constant drumbeat that we’re aggravating the nation’s primary care shortage drives me bananas.  You won’t have any more primary care doctors in the future if something doesn’t change.  Lines like this signal me to remind you of a few things: in the world of medicine, primary care isn’t highly regarded as a specialty.  It’s one of the lower-paying physician specialties.  If a primary care physician were to do all the work expected of them for a full panel of patients (i.e. the care itself, the documentation, the follow up, the preventive screenings), it’d take an absurd number of hours and borders on impossible*.  Primary care is being turfed to midlevels, and midlevels are great extenders but don’t replace the years of understanding and training that a physician can offer.  Perhaps this is one of the reasons we have such poor health outcomes when it comes to chronic disease — the backbone of our healthcare system is weak and getting weaker.  People react to the push/pull of any industry; nascent medical students are no different.  We won’t have a primary care workforce in the future if something doesn’t change about primary care.  And direct primary care just might be that change.


Thank you for your time and your ear (or, as emails go, your eye).  It was cathartic to get this out, and I appreciate the audience.  I can only imagine that you’ve heard much of this before, but I felt so moved by the piece that I felt I had to reach out.  


Please keep the conversation going!  I, as an academic and a lifelong learner, am always happy to learn something new.


Allison Edwards, MD

*This citation wasn’t included in my email to Ms. Engelhard, but is the basis for the claim can be found here:  https://www.ncbi.nlm.nih.gov/pubmed/19289002; Yarnall KS1, Østbye T, Krause KM, Pollak KI, Gradison M, Michener “Family physicians as team leaders: “time” to share the care.” JL.Prev Chronic Dis. 2009 Apr;6(2):A59. Epub 2009 Mar 16.