Direct Pay Model Has Direct Benefit on Patient Care

CHARLOTTE, NC — Practice models in which patients pay directly for physician services without insurance company involvement certainly offer financial advantages to physicians. But do they foster better health care?

Dr. Brian Forrest, medical director of Access Healthcare, a direct-pay primary care practice in Apex, NC, contends that they do.

With 10 years’ experience running an independent direct-pay practice, Dr. Forrest is among the leaders in the emerging movement of physicians who’ve opted to work outside the framework of insurance-controlled primary care. He holds that by eliminating the costly overhead and paperwork burden imposed by insurance plans, doctors can provide better care at lower cost, while preserving their own health and well-being.

Speaking at Holistic Primary Care’s second annual Heal Thy Practice: Transforming Primary Care conference, Dr. Forrest shared clinical outcomes data from his practice, which represents about 6,000 patients total, including many individuals who do not have health insurance.

“Our patient population is severely high-risk initially, due to the high number of uninsured that come in. The average systolic blood pressure among my new patients is 192 mmHg. The average hemoglobin A1C is 11.9%, and the average LDL is 173 mg/dl.” The patients at Access Health are hardly a “worried well” luxury service crowd; many are people with modest means and significant chronic disease burdens.

An independent audit of patients in Dr. Forrest’s practice for 6 months indicates that the concentrated attention and stronger practitioner-patient relationship fostered by a direct-pay model can modify the risk profile fairly quickly.

After 6 months as members of Access Healthcare, the patients showed an average LDL of 92 mg/dl. The average A1C was down to 6.3%. During a period of 8 years, there has only been 1 fatal stroke among Dr. Forrest’s patients, and this was in a patient who stopped taking the prescribed medications.

There have been no fatal myocardial infarctions and only two nonfatal MI’s during the 8-year period. Access Healthcare patients average less than 4 hospitalizations per 1,000 patients per year.

Dr. Forrest says there’s no mystery behind these encouraging outcomes, which echo similar reductions in utilization among patients in “concierge” practice models (see Despite Recession, Concierge Practices Show Brisk Growth, Excellent Outcomes). The direct-pay model allows him to keep scheduled office visits down to no more than 10 per day. This means more time spent with patients, and greater attention to their needs, problems, and obstacles to healing.

The relatively low daily patient volume facilitates open-access scheduling where by Dr. Forrest can accommodate walk-ins, sometimes as many as 6 per day. Problems can be dealt with immediately, rather than festering and progressing, as often happens in conventional insurance-based models when patients must wait weeks for appointments with their doctors. It also obviates patients’ needs to seek care at hospital emergency rooms.

“This model reduces physician stress, which also reduces errors,” said Dr. Forrest, adding that the likelihood of medical errors—which can sometimes be fatal—is strongly associated with the organizational climate and atmosphere of the office. An office full of angry patients, stressed physicians and overwhelmed staff is highly conducive to errors and poor judgment.

“Primary care offices could be made safer by promoting a culture of quality and improving the hectic environment.”

To learn more about Dr. Forrest’s innovative direct-pay primary care practice model, visit

To purchase recordings from the 2010 Heal Thy Practice conference, click here

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