In response to the managed care boom in the 1990s, many primary care physicians decided to change the way they practiced medicine. Some did so because they resented being forced to act as gatekeepers of healthcare dollars rather than as physicians to their patients. Others felt that financial constraints and practice managers were compelling them to spend too little time with patients in the consultation room.
Also as a result of managed care, patients began to miss the close relationships they previously had with their doctors. Many felt that office visits were too short and that their doctors were too busy with documentation. From this dissatisfaction grew two new models of care: concierge care and direct care. There are similarities between the two, but important differences as well.
What is Concierge Care?
Sometimes referred to as “retainer care,” concierge physicians charge their patients an annual or monthly retainer, in addition to accepting insurance payments for the care they provide. In exchange for this retainer, concierge physicians provide premium services such as house calls, and almost unlimited access, including accompanying patients at visits to specialists. The concierge payment model allows concierge physicians to reduce their panel size from the traditional 2000+ patients down to 200–300, or even fewer. The model permits same-day appointments and longer visits with the physician.
The distinguishing feature of concierge care is VIP service, not cost-reduction. As a result, the patients of concierge practices tend to be older and wealthier than the general population. For these and other reasons, the direct care model emerged as another alternative.
What is Direct Care?
Direct care practices do not accept third party payment; they contract directly with patients and families. Typically, a monthly fee will be less than $100, and many practices offer family rates. Panel sizes in direct care practices are larger than those of concierge practices, but still far lower than the traditional size. Rather than providing VIP services, direct care practices focus on providing excellent care while remaining vigilant about keeping costs down. As a result, direct care practice patients tend to be younger and less affluent than those in concierge practices.
Dr. Rob Lamberts opened his direct care practice in Augusta, GA in 2013. The advantage of the model, according to Lamberts, is first and foremost that the costs are predictable. Patients are never charged copayments and never receive surprise medical bills from his office.
Dr. Lamberts’ patients appreciate his accessibility. “My schedule is almost always open for folks who need me, and patients can access me after hours via texting, etc.” In the traditional model, many physicians have scaled back after hours communication with their patients for several reasons, not least because privacy guidelines and documentation requirements make even simple phone calls burdensome. Furthermore, even after years of protest from physicians, insurance companies do not reimburse doctors for communications that occur outside of the exam room.
Though direct care practices do not accept third-party payment, patients typically continue to carry insurance to pay for specialist visits and hospitalization. For this reason, direct care practices are particularly vigilant about affordability. Lamberts is “extremely sensitive to keeping cost down for the rest of care,” meaning care occurring outside his office.
Home Care and the Primary Care Doctor
The house call by physicians had all but disappeared prior to the advent of concierge and direct care medicine. Despite the fact that third party payors reimburse physicians for performing “sick visits” (but not routine check-ups), time constraints make it impossible for most physicians to see their patients in their homes. The new models of care eliminate the often-insurmountable barriers imposed on patients with limited mobility and transportation difficulties.
The Future of Direct Care
As long as individuals with means have the ability to pay for premium service, it is likely that there will be concierge physicians willing to offer their services. The future of direct care is less certain, depending on the success or failure of Medicare-for-All. The result may be a two-tiered system such as in the UK, where there is universal coverage for healthcare, while those who can afford it also pay for private physicians.
It remains less clear whether non-physician home service providers will begin to adopt the direct care model. It may be that solutions such as the direct care model will appear for home care as they did for primary care. In the short term, the expansion of home care services under Medicare Advantage will guarantee that home-based services will continue to be available for Medicare enrollees.
