Healthcare in the US is in a horrible state. It's too expensive for patients and not lucrative enough for doctors. We don’t measure up to most European countries in terms of access, affordability, and health outcomes.
It wasn’t until I talked with my friend Anne Richter, president of healthcare payments technology provider, Accresa, that I realized it doesn’t have to be like this. We can go back to the healthcare of old—and reimagine healthcare the way it used to be.
There’s a new approach in which the employer wins, the patient and his or her family wins, and the doctors and insurance companies come out ahead. It’s called direct primary care. I’d never even heard of this healthcare possibility until my conversation with Anne opened my eyes to it, and I’m guessing that unless you live and breathe this insurance stuff each day, as Anne does, you probably haven’t either.
Direct primary care is not new; Anne and her colleagues didn't invent it. It may now be an emerging model for healthcare delivery, but really, this is healthcare the way it once was delivered and accessed. It is characterized by a strong relationship between the individual and their primary care provider, with a retainer-based payment arrangement that gives patients access to certain medical services for a set amount each month. And that's the distinguishing feature: You're removing the inefficiency of a third-party payer for primary-care preventative services. Of course, the payer still has its role—Anne isn’t advocating for getting rid of insurance companies altogether because they have to be there to insure against catastrophic, high-cost events.
Think of it this way: If you have a car, you could never use your auto insurance to pay for something like gas or a car wash. So, why shouldn’t health care work the same way? Why involve a third-party payer, an insurance carrier that should be focused on expensive,
low-probability-risk events, for something like, “Help me get this splinter out of my finger!” or, “I need a prescription for this rash.” These situations should be handled by your family care physician.
For the smaller issues patients have—a tough cold, a lingering sinus infection—direct primary care is ideal.
You’ve heard of the concierge medicine model? It’s a direct financial relationship between a patient and a doctor under which the patient pays an annual fee for services, which can range from hundreds to tens of thousands of dollars per year. The problem is, the average American can't afford to pay so much out of pocket each month just for these extra services. That’s why Anne wants to make this kind of exceptional health care accessible to more Americans.
Direct primary care is an update on this model for the middle class. It’s a solution to the premium increases and limited access to care that people are experiencing lately. It cuts out the middleman and removes barriers to the healthcare system. Insurance is a risk-mitigation tool—something that you use for those rare, major-medical-cost events. Primary care should be handled differently.
The concierge and direct primary care models both rely on a membership-based fee arrangement, so they’re a departure from the traditional fee-for-service model. And direct primary care is completely removed from the third-party payer system, so doctors are not billing a third payer for primary care services. That makes it a lot more efficient for physicians—the administrative costs associated with the fee-for-service model are astronomical.
For patients, there's no co-pay, so all routine preventative care. It's a white-glove concierge experience that’s more affordable. The average monthly cost for a direct primary care membership tends to be around $70 a month.
Direct primary care isn't a replacement for health insurance; it's a complement to it. You can't get rid of insurance and just have primary care, because you need that insurance to protect against the truly catastrophic events life sometimes throws at us. And it needs to work with an employer-sponsored benefit plan in order to make this “friendly” for employers—so Accresa is trying to take all the good things about this model and build it into the framework of that plan. It also strengthens patient-doctor relationships and results in cost savings for employees and employers who offer it as a benefit option.
“I think we've reached a tipping point where these types of solutions really have a platform upon which they can take off if there's the right infrastructure in place to allow for that scale and allow for that to happen,” says Anne.
Anne and Accresa are working to make healthcare easier for employers to manage and to democratize the concierge medical model. Employers who implement this type of program typically experience a 25–35 percent reduction in high-dollar claims, and many of them are seeing flat insurance premiums.
“Insurance carriers don't like having to deal with the inefficiencies of these small-dollar claims for primary care services,” Anne says. “They want to do what they do best. This is really just a systemic issue, and they have a role to play, just like the employers do, just like the doctors do. So, it's really bringing it all together in a more efficient way to adapt to the reality of how healthcare is delivered today in America.”
Let’s start having the important conversations with our employees, so that everyone can have a clear understanding of what’s out there in terms of healthcare benefits—because that’s how everybody wins.
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