Direct pay: An ounce of prevention or a pound of trouble?

While less controversial than its concierge cousin, direct-pay primary care--in which members forego most insurance and instead pay a modest monthly access fee for primary care services--is gaining its share of discussion.

According to proponents, the direct model supports the goals of national health reform because it emphasizes prevention and therefore cost reduction through lower use of "downstream services" to treat symptoms of disease, California Healthline reported.

"Direct primary care is simply an atypical payment arrangement between patient and doctor for primary care services rendered," Michael McClelland, an attorney with McClelland Advocacy in Sacramento and former chief prosecutor for the state Department of Managed Health Care, told Healthline. "It is neither health insurance nor a health plan and is not marketed as such."

Members of direct pay programs can be either patients or employers who cover some or all of the fees. Companies ranging from Las Vegas-based Zappos to Glacier Fish Co. in Seattle like the model because it keeps their costs steady and keeps their workforce healthy, noted an Workforce article, adding that numerous fisherman getting care through Seattle-based Qliance have headed off medical emergencies by getting their blood pressure under control.

However, while the model is catching on, with expansion of practices such as Qliance in Washington, MedLion in California and others, critics assert that it may place too many risks on providers, as well as on patients. So far, only Washington state and Oregon have passed legislation establishing the new model, Healthline reported, adding that the California legislature earlier this year rejected a bill to establish a statewide framework for the direct pay model.

Some of the concerns, according to Workforce, are that eliminating insurance from primary care would exclude patients who can't afford the monthly fee, although direct-pay fees are generally lower than those seen in more concierge or "boutique" practices. Another criticism is that healthy patients would waste money paying the monthly fee for services they don't use, "much like an underutilized gym membership," according to the article.

To learn more:
- read the post from California Healthline
- see the article from Workforce (registration required)