Beyond 7 minutes

Insurance is a card in your pocket, health care is a relationship with a doctor you know and trust. This is a recurrent mantra for doctors across the country who have broken away from fee-for-service, insurance-based health care. This simple phrase illustrates the idea that health insurance in and of itself is not a path to better health. It is important to acknowledge that lack of health insurance is strongly correlated with poorer health outcomes and under-utilization of health care. If the goal is to improve the health of our nation, it would be nice if the solution were as simple as extending health insurance to all people. Unfortunately, as in much of health care, the answer is not that simple.

As a doctor who has dedicated a career to primary care and public health I have more than a strong feeling that our health care system is heading towards change—and soon. Costs are too high, patients are too sick, and doctors are too burnt out to keep going on the current track. History has shown that systemic change often comes in fits and starts. But when change comes, it can be revolutionary.

We live in a world where there will always be stressors. If we take the hot stove as an example, certain stress responses may even be adaptive. However, for many people the chronic stress of work, home life, money, and illness is maladaptive. If we don’t implement strategies to manage stress it can easily overwhelm us.

The medical miracles of today couldn’t have existed without the trials and errors of generations past. It may seem to some that medical knowledge is owned by the people with the training to use it. With a historical analysis this view quickly breaks down. Dr. Henry Heimlich could not possibly “own” the Heimlich maneuver nor could Dr. Charles Drew “own” the blood transfusion. Both of these advances were developed with and for patients. Therefore it is the patients that benefit from the treatments and physicians that administer them that collectively own this knowledge.

As a Family Physician and fellow New Englander I was excited to read John Seabrook's June piece on virtual care. The piece illustrated the breadth of applications for virtual care and also some of the economic drivers that have influenced our current healthcare model. It did not mention an up and coming model called Direct Primary Care (DPC). DPC doctors were using virtual care as well as text messaging, app based appointment scheduling, and in house medication dispensing long before COVID. The reason DPC is more adaptable than traditional fee for service medicine is that practices are by and large small and operate independently from insurance reimbursement. Patients simply pay a monthly fee (usually less than the monthly cost of a cell phone plan) directly to their doctor. This frees up practices to innovate and accommodate services that are best for the patient. Not only is this a more adaptable health delivery system, it's also more sustainable. Since most DPC practices already had virtual care built into their monthly fee structure there was little to no impact on revenue or patient retention for these offices. As we evaluate the future of primary care in the US we should consider the risks and benefits of alternative models, such as DPC.