Making the Case for Direct Primary Care

When M. Samir Qamar, a family medicine physician, was in residency in Lancaster, Pa. and contemplating his future, he started questioning the way things were with fee-for-service medicine.

"The response I got was, 'That's the way things are when you get into the real world. You'll have to see an average of 25 to 40 patients per day.' That wasn't good enough for me," Qamar recalls.

He came across the newly emerging idea of concierge medicine and decided to start his own practice. The practice started up in Monterey, Calif. and by the time he got over there from Pennsylvania, he had already had patients by advanced advertising while he was in residency.

For a while, Qamar had a nice job, catering to the rich and famous of central California. He even served as the house doctor for the famous Pebble Beach golf resort. However, he said there was more that he wanted to do with medicine. His vision included offering patients lower-cost premiums per month for high-quality primary care. At the time, the idea of a direct primary care (DPC) practice was even more nascent than concierge.

"Very few doctors were doing something similar around the country. Most doctors who were doing memberships were charging excessive fees, typical of concierge, which also requires patients to have insurance to be billed for medical visits. We wanted to offer a simple membership fee for primary care, with no copays and without confusing it with concierge medicine," he says.

With this in mind, Qamar and his wife Hisana Qamar, a family medicine physician who had gone into fee-for-service medicine before seeing a decline in patient visits from the economic downturn, began MedLion, their DPC medical group. Qamar has taken a unique approach to growing MedLion: He licenses the model to solo, independent, and larger group-practice doctors in other states. In a few years, he has gone from contracting with doctors in four states to 25 states.

"We started as solo practitioners ourselves and we are a little ahead of those trying to get into this now. One of the things direct primary care doctors learn quickly, the reason they get into [DPC] is to practice medicine for the reasons they went to medical school," says Qamar. "The problem is when you are trying to grow your practice, you end up having to play salesperson as well, especially to employers, which is the most sustainable way to grow a DPC practice, rather than go after individual patients … Doctors have a difficult time doing both at the same time; practice medicine and obtain new patients."

MedLion acts as the healthcare benefits arm for these DPC practices, explains Qamar. They can speak and sell to employers and work with them to package MedLion's services with an outside insurance product, such as catastrophic wrap plans, which don't include coverage for primary care.

The company also knows the rules surrounding DPC legislation, or lack thereof, in the different states, which are not universal across the country, making it hard for physicians to set up shop. "We know those rules. While many states have passed DPC legislation, there are many that have not for DPC. For doctors in those states that want to get into DPC, to give them mental piece of mind, we guide them in proper structuring of patient agreements, so they don't violate catastrophic insurance rules," says Qamar.

Licensees of MedLion's model don't have to worry about finding and implementing technology on their own. The company advises doctors on an EHR product that is customized to DPC care, although doctors are independent and physicians can use whatever product they choose, Qamar says. More than all of that though, the doctors' biggest advantage is they remain independent, says Qamar. He considers MedLion as a supplementary service to help the independent doctor's practice grow.

Advantages and disadvantages

Beyond his own model, Qamar sees a lot of advantages in the DPC model of care, especially when compared to fee for service. "For doctors, you don't have to code, you don't have to file claims. It's a huge advantage because you don’t have to rely on a system that has nothing to do with medical practice … Number two, you no longer have to see X number of patients per hour … Third, there is less paperwork and overhead for the practice," he says.

For patients, there are advantages in that DPC can lead to better and expanded access - through next-day appointments and telemedicine. "If a doctor is seeing 30 to 40 patients per day [under fee for service], patients become a number, rather than a human being. Doctors don't like it and patients don't like it," Qamar says.

The biggest challenge as a DPC doctor is changing the culture around U.S. healthcare, he says. The system has been entrenched in fee-for-service medicine for the last 50 years. It's hard for some people to separate primary care from health insurance. "Many of us have been born into a country where we think health insurance means healthcare. Health insurance is not in the business of healthcare, it's in the business of insurance," Qamar says. He says if people used their car insurance for everything, such as windshield wiper fluid, premiums would go up. "That's what you see in healthcare."

Yet, it's a hard sell to individual patients. This is why his model pairs with lean insurance plans and markets to employers. However, this model means in some fashion, MedLion has to operate under the same principles as an insurance company. Thus, it's not easy to sell to employers either. "When are you catering to employers, your competition is the insurance industry," says Qamar. Selling is also hard because of the long sales cycles of employers, he says.

These challenges are one reason why Qamar says he tells new DPC doctors to accept primary-care insurance in the beginning, then grow DPC within. Despite this, he is bullish on the future of DPC. "Direct primary care is one of those unique models where the doctors are back in control and they are back in control with their patients - the only two characters needed in a healthcare scene," Qamar says. "Changing the healthcare [system] won't be easy, it will require a collective effort and the courage to go out there and do your own thing, to not have to rely on insurance companies to give medical care to your patients."