Direct primary care for the vulnerable

David Balat

Direct Primary Care (DPC) is not really a new model for health care in Texas. Long before employer-based insurance (with the safety nets for the elderly and disabled, Medicare and Medicaid) became the standard, patients paid doctors for their care. There were no middlemen—only the patient and the physician, and they made the decisions.

DPC seems innovative now because we have moved so far away from that model. Government regulations combined with ever-more complex insurance standards have put third-party payers in charge of the decision making.

The current system frustrates not only patients, but also physicians. No health care provider wants to be second-guessed by a middlemen behind a computer screen hundreds or thousands of miles from the examination room. No doctor wants to be limited to a maximum number of minutes of face time per patient, because human beings and their ailments are rarely so conveniently compartmentalized. And doctors and patients alike want the ability to follow up on treatments to ensure the best health outcomes possible.

DPC practices seek to resolve the flaws of our current health care system by providing transparent pricing and strength­ening the doctor-patient relationship. Direct care has gained momentum in primary care, surgery, pharmaceuticals, and dentistry. Direct care functions differently in each setting, but the central idea is that third-party payers are not involved, and prices are known before the patient sees the medical professional.

It’s really simple. Patients contract with DPC practices to receive a wide range of care at a convenient monthly price. Patients are allowed to see their doctor as often as they like for preventative, wellness, and chronic care, and certain medi­cal tests are included in the membership fee, depending on the membership agreement. They also use telemedicine—often in the form of an app—to make reaching a health care provider as convenient as possible.

State Rep. Matt Shaheen understands the value of DPC and filed House Bill 484 to make this type of service available to many of our Medicaid beneficiaries who wouldn’t normally have access to this high level of service and care. Many Medicaid patients use the emergency department (ED) for primary care and that’s an inappropriate and expensive way to provide care for non-urgent medical conditions. According to a Texas Department of State Health Services analysis of hospital emergency department data from 2018, the most frequent payer source from all avoidable ED visits in Texas was Medicaid (29.2%).

Barriers to timely primary care have been associated with increases in ED utilization. Reported barriers include:

• An inability to contact the office

• An inability to get an appointment soon enough

• Excessive wait times to see the doctor after arriving at the office

• Inconvenient office hours

• Lack of transportation

• Lack of child care.

Research from the Texas Public Policy Foundation demonstrates that DPC has shown the potential to reduce unnecessary ED utilization substantially. Clearly, DPC hits those barriers by allowing for telemedicine, flexibility and after-hours contact with staff.

The case study included in the 2020 Society of Actuaries analysis reported a 40% reduction in ED visits and a 53.6% reduction in ED claims costs in the DPC group as compared with the group in traditional primary care. According to an analysis by United Health Group, the average cost of treating common primary care treatable conditions at a hospital ED ($2,032) is 12 times higher than the cost ($167) in a physician’s office. If even a portion of the inappropriate ED utilization can be reduced by including DPC as an option in Medicaid, it could have a positive fiscal impact on state budgets.

But more importantly, it will allow our most vulnerable to get the care that they need when they need it. Allowing Medicaid patients access to DPC would allow patients and their families to have the peace of mind they want and need.

David Balat is the director of the Right on Healthcare campaign at the Texas Public Policy Foundation.

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