The gym club model. For healthcare?

Addressing those new to the idea, direct primary care partisans often start to explain the model by comparing it to membership in a fitness club with nearly unlimited access for a fixed monthly fee.

I’m puzzled.

Gym clubs are subject to high member churn rates. Is this wise for health care?

High churn owes in part to people signing up who then turn out for whatever reason to have low utilization. Low utilizers pay the same price as those who use the club’s resources more frequently. In the health care context, that seems similar to kind of subsidization built into the ACA’s community rated, full benefit packages. Yet, some of the most strident voices opposing such subsidization in Obamacare lead the charge for a primary care model in which low utilizers subsidize high utilizers rather than a model in which each person pays for the primary care they get.

The demand for time on the best exercise machines at gym clubs cycles up and down, varying enormously by time, day of the week, and date of the year. Periods of excessive demand are likely result of an unlimited access model. If your gym is slammed on January 2nd because of New Year’s resolutions, you just go home and no harm is done. Your unlimited access clinic and its two doctors might, on the other hand, be slammed with flu case appointments that, in the absence of “unlimited access”, might never have been made. If you need a truly urgent appointment, you might wish you had elected fee for service primary care.


Once fixed fee arrangements are in place, there is no “skin in the game” to keep a lid on overutilization. Yet, some of the same organizations that spent decades touting “consumer driven”, high deductible policies as an important response to overutilization, currently endorse prepaid, fixed fee direct primary care.

To pursue a revenue boost for its clinics, the direct primary care establishment seeks federal legislation that would allow HSA funds spent for direct primary care subscription fees to fulfill high deductibles. Yet, to a consumer, DPC membership fees work quite like payments of health insurance premiums in transferring most of the immediate, specific costs of a doctor from the patient to a different payer. Why do institutions that have long argued that “skin in the game” is paramount, specifically support taking skin out of the primary care game?

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