Direct primary care is no excuse for parsimony.

I am currently trying to get the following published as a newspaper op-ed. AJC has a version like this one.


In a December 16, 2016 column, “Trump’s win opens the door for Medicaid alternative in Georgia”, the AJC’s  Kyle Wingfield promoted a Georgia Public Policy Foundation plan for Georgia’s 565,000 uninsured adults. Legislation partially paving the way for the plan is before the Georgia legislature as Senate Bill 50 and House Resolution 182. The Foundation’s plan is parsimonious to point where it should not be taken seriously, either by those concerned to improve health care access and quality for low incomes persons or even by those whose primary concern is to save costs.

The underlying concept is that adults below the poverty line can receive all needed health care at a cost of $2500 per year. $1750 of that budget provides for a catastrophic care insurance policy, intended to address all medical needs beyond primary care. That leaves $750 to pay for primary care to be received in an insurance-free direct primary care (DPC) setting in which a single annual membership covers all primary care costs. Such practices would have very modest copayments and deductibles, or none at all.

According to direct primary care advocates, reducing overhead expenses by eliminating insurance radically transforms health care delivery. Doctors have more time for patients and the resulting superior care ends up reducing those patients’ need for costly additional services like expensive medications, specialist consults, emergency department visits, and hospital stays.

However promising direct primary care may be, it simply cannot manage the miracle of bringing the health care costs of an adult down to $2500.  And, the actual experience of two DPC clinics, each highlighted in recent Georgia Public Policy Foundation publications, make clear just how far off the Foundation’s budget is.

To start with, the membership fee for each DPC is at least twice the $750 in the Foundation’s model.  A lot higher. The Union County, North Carolina, employee programto which the Foundation refers pays a direct primary care company $1500 a year for each adult enrolled. The current price for membership in the Empower3 clinic in Altoona, Pennsylvania, is even higher. For 565,000 adults, the Georgia think tank’s 425 million dollar primary care clinic budget comes up more than 425 million dollars short. This does not make them half right; it makes them all wrong.

What about the Foundation’s $1750 budget for services not provided in a direct primary care clinic?  Because Union County self-insures, it is uniquely positioned to capture the savings, if any, generated by direct primary care for those non-primary services like non-generic drugs, specialist visits, and hospital stays.  Even so, beyond the $1500 DPC annual fee, the remaining medical expenses for Union County employees come to well over $4000 per person. The Foundation’s $1750 budget for these same expenses is plainly inadequate.

At Altoona’s Empower3, clinic members insure expenses beyond those in the clinic’s $1560 per year package by purchasing high-deductible insurance policies. For just under $1750, such a policy is available in Altoona only to those under 27 years old, and it comes with a deductible of about $7,000.  If, instead, you are a 42 year-old, whether in greater Altoona or in comparably-sized Athens-Clarke County, Georgia, a similar high-deductible policy runs $3,000 a year.

The Altoona direct primary care model – the Foundation’s first poster child – adds up to $4560, $1560 for the DPC member fee and $3,000 for the insurance policy.  But how would indigents receive non-primary items (like ER visits or hospital stays) that fell in the $7,000 deductible hole? Low income Georgians could manage only a very modest share of these costs. Major burdens, like the first few days of a hospital stay before the high-deductible policy kicked in, would have to be borne, just as they are now, by Georgia hospitals.

For the Foundation’s second poster child, the Union County direct primary care plan,  its $1560 membership fee and its additional expenses of well over $4000 add up to well over $5500.

What does not add up is the Georgia Public Policy Foundation’s $2500 per person plan.  That policy is plainly aimed at something other than improving health care access and quality for Georgia’s low-income uninsured population. Direct primary care is no excuse for parsimony.

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