Pre-authorization hurdles. Ever-changing coverage stipulations and regulations. Denials. Reduced reimbursement. Everyone in healthcare knows of the stress associated with healthcare payments. Psychologists have long understood this dynamic, often fighting for needs that are viewed as less of a priority than traditional healthcare (i.e. mental and behavioral health). A recent practitioner survey by the American Psychological Association (APA) noted that one third of those surveyed (34%) were currently not participating in any form of insurance, and of that group, roughly half (48%) used to participate with insurance and now do not (American Psychological Association [APA], 2024). This may be signaling a growing trend to move away from third-party payors. Because the vast majority of healthcare activities function with an insurance model, however, it may seem daunting to consider leaving, especially for psychology specialists whose work is often embedded in healthcare systems, collaborating with physicians. But some of our physician friends are leading the way with a new model, forging new paths for providing care entirely independent of third-party payors, and not just for the well-to-do.
Direct Primary Care (DPC)
A little over a decade ago, physicians who had become dissatisfied with increasing demands (e.g. greater administrative tasks, push for ever-increasing productivity, less control over medical decision-making) started striking out on their own, gravitating to a simplified process of contracting directly with their patients to provide care, and no longer taking insurance. This began among primary care physicians and became known as Direct Primary Care (Tecco et al., 2024). For some, this was viewed as a last-ditch attempt to practice medicine in a meaningful way and escape the “moral injury” of working in healthcare systems that limit effective care of patients (Dean et al., 2019). Some crafted practices that offered extensive services and access for increased costs (i.e. the “Concierge” model, see Dalen & Alpert, 2017), catering to those with ample resources. Others had a different emphasis, focusing on carefully stream-lining costs of operation and sourcing products and medications at cost or nearly so, for a model that emphasized affordability and ready-access to physicians (Tecco et al., 2024). This latter model seems to be dominant in what has come to be known as the Direct Care movement.
It may seem counterintuitive to ask patients to pay directly for their own healthcare in a context of rising costs and limited resources, and yet those who have insurance are also facing rising costs (many will never meet their deductibles), in addition to limits on benefits, and in many cases, difficulty with access to care (i.e. long wait lists). For many providers, the overarching question has become “What will insurance cover?” instead of “What does my patient really need?” By contrast, in the Direct Primary Care (DPC) model, by removing the middleman, all decisions made (i.e. tests ordered, medications prescribed, number and timing of follow-up visits) are determined solely between provider and patient, based on the unique needs and constraints of the situation. These new DPC plans were able to provide ready access and assistance, and became attractive to some already covered by traditional insurance plans, and also to those with no insurance at all (Tou et al., 2020). As might be expected, health outcomes improve with ready-access and responsive care, especially for those with chronic conditions that require close monitoring (Mechley, 2021). The DPC movement has continued to grow over time, and is now spreading beyond primary care.
Direct Specialty Care (DSC)
In the last few years, a wide range of medical specialists are now joining the Direct Care movement (e.g. neurology, endocrinology, rheumatology, cardiology, etc.), and building Direct Care (i.e. no insurance) practices, a new movement which has come to be known as Direct Specialty Care (Girnita, 2021). We are even witnessing the growth of fully independent surgery centers functioning outside third party insurance systems (Pflanzer, 2017), perhaps one of the greatest proofs of the possibilities of this model. While this movement is more recent, there appears to be significant interest in successfully conquering the challenges and getting established, even faced with the particular challenges of specialists (e.g. costs of specialized medical equipment, smaller pool of potential patients than DPC, providing consultation and short-term services rather than ongoing care, etc.). In many ways, the challenges of the Direct Care model for those who are specialists may be quite similar to those faced by psychology specialists who may consider this model, and it may be instructive to follow these medical specialists who are pioneers in the Direct Specialty Care movement (Girnita, 2022). But just how is a Direct Care practice different than one that simply doesn’t take insurance? As noted above, many psychologists have already left insurance models.
What is different about Direct Care?
The Direct Care movement may have been driven initially by the frustrations of operating within an insurance model, but it appears to have migrated away from simply removing unwanted barriers to care, and toward a complete revisioning of the care itself. In other words, it is not just the payment model that is different, but the way care is delivered, and in some cases, even the care itself (i.e. the services offered). This starts with the dawning realization of the freedom of the Direct Care model that care no longer has to be conceptualized in terms of allowable billing codes, but instead focused solely on the specific needs of patients, and how those needs can be met most effectively. In essence, this opens the door to innovation, and quite possibly, significant improvements in patient care, as those on the front lines have the freedom to adapt and adjust in real time to meet needs. This is reflected in some of the emerging trends evident in the Direct Care movement, such as a focus on responsiveness to patients. A common feature of DPC and now DSC practices is prompt access to providers, often by text or phone. This allows problems to be addressed before they grow in complexity, and often requires less time than a scheduled office visit. Patients have unique needs and lives, and being able to respond to that complexity in a timely way (e.g. clarify understanding, provide guidance for urgent situations or new developments) has the potential for significantly improved outcomes.
Related to responsiveness is a trend to spend extra time with patients to simply get to know them, to build trust, which then helps care delivery become more accurate and effective. Another distinctive feature of the Direct Care world is a focus on transparency, with extensive information provided up-front about the process of care and care options, and often explicit information about prices, and simplified pricing such as bundled services with no hidden costs. These things can reassure patients. Finally, a trend seen in the Direct Care world is a drive to innovate and improve care, often reflected in collaborative approaches with different specialists and including alternative healthcare options. Overall, it is easy to imagine how these features of a Direct Care model have evolved, because they can be highly beneficial to patients, and in the Direct Care world, this makes sense because the providers are directly accountable to the payors, which are the patients.
An example of Direct Care Psychology
After years of working in a hospital-based practice, I was dedicated to my chosen field, clinical neuropsychology, and truly enjoyed my time with patients. At the same time, I was well aware of what I would change if I could. Specifically, I found that I often wanted to spend more time interviewing the patient and family because in the telling of their stories, I discovered the need for patient education. It was often the case that they were confused about what they had been through, and had little understanding of the diagnoses (e.g. traumatic brain injury or stroke). Stopping to help dispel some of that confusion was important in their own process of making sense of their new realities, although this didn’t fit well with the allotted interview timelines. Other times, it was the family, and not the patient, who really needed the time to discuss symptoms and talk about their fears and concerns (e.g. dementia), and yet time educating and assisting families, although it could directly benefit the patient, did not fit any billable codes. And then there was the constant pressure to increase billable hours, which runs contrary to the impetus to pay more attention to patient needs, which requires time. Beyond all of this, as it becomes increasingly clear that nutrition and lifestyle factors can make a real difference in the course of chronic disease, including dementia, I found myself wanting to focus on health and prevention, which does not fit the typical structure for reimbursement for neuropsychological services. I had been following the DPC world for some time, watching their increasing success. When my life circumstances changed and I needed to move out of state to a different region, I took the leap and founded a private practice with a Direct Care model in late 2021. As this is very recent, I am still working to evolve and modify my neuropsychology services to more effectively take care of my patients, and that process will likely go on for some time. One of my goals is to create an ongoing channel for communication as my patients’ needs change, so that long-term consultation is a feature that will support effective care. It is a work in progress. The challenges are significant, and I find myself working hard to communicate about my different process not only with other medical providers around me, but also my patients, who have been conditioned to expect a traditional process. But in spite of these challenges, the future looks bright. I would encourage others who may have had ideas over the years for how care could be more effective, or responsive, or ideas for new services that could be provided, to consider this new business model. The Direct Care model allows for these ideas to be explored and tested in ways which could never be possible in a third-party payor system, and may just help propel improved care overall.
Time for a Change?
In summary, Direct Care models have been tested and found successful in the world of Primary Care, and these DPC practices have been steadily increasing for more than decade. The trend has now migrated to physician specialists, and some of the early pioneers in Direct Specialty Care (DSC) are seeing success as well. As yet, psychology specialists have not organized or published their own attempts to transform their practices into the Direct Care model, although we know that many are walking away from insurance models, and it is likely that many could benefit by considering the Direct Care pathway. Certainly, the formidable challenges should be soberly considered. There is little in the way of ready-made solutions, or support. It will take some courage and tenacity. But the success stories out there are quite encouraging (Concepcion, 2024), and the community of collaborators is growing quite rapidly, especially with the world of social media. This movement has even begun drawing the attention of the business world, as employers are discovering that adding DPC plans to their benefits packages tends to reduce overall healthcare costs (Busch et al., 2020). In other words, businesses are starting to contract directly with DPC providers because of the positive outcomes. There are even those building systems to contract on a large scale to meet corporate needs, as well as provide support for physicians and other providers considering a Direct Care model (Watson, n.d.), although there is also a persisting drive among many providers to keep their autonomy (Girnita, 2022). This movement started with a simple break with the insurance reimbursement model and a move to directly contracting with patients for healthcare, but it soon evolved into a model that started changing not just payment models, but service delivery, and in some cases, even services themselves. For psychology specialists, these developments may just open the door to increased freedom, flexibility, and innovation in their own practices, and along the way, allow for improved access and excellence in care for the needs of those we serve.
References
American Psychological Association. (2024). Barriers to Care in a Changing Practice Environment: 2024 Practitioner Pulse Survey. https://www.apa.org/pubs/reports/practitioner/2024/index
Busch, F., Grzeskowiak, D., & Huth, E. (2020). Direct Primary Care: Evaluating a New Model of Delivery and Financing. Society of Actuaries. https://www.soa.org/globalassets/assets/files/resources/research-report/2020/direct-primary-care-eval-model.pdf
Concepcion, M. (2024). Reflecting on 2024 and Looking to 2025. www.myDPCstory.com, December 22, 2024. https://www.mydpcstory.com/post/reflecting-on-2024-and-looking-to-2025
Dalen, J., & Alpert, J. (2017). Concierge Medicine Is Here and Growing!! The American Journal of Medicine, 130 (8), 880-881. https://www.amjmed.com/article/S0002-9343(17)30358-3/fulltext
Dean W, Talbot S, Dean A. (2019). Reframing Clinician Distress: Moral Injury Not Burnout. Federal Practitioner, Sep;36(9):400-402. Erratum in: Fed Pract. 2019 Oct;36(10):447. https://pmc.ncbi.nlm.nih.gov/articles/PMC6752815/
Girnita, D. (2021). The Emergence of Direct Specialty Care. KevinMD.com, September 6, 2021. https://kevinmd.com/2021/09/the-emergence-of-direct-specialty-care.html
Girnita, D. (2022). Direct Specialty Care: Concierge Service Without the Price Tag. Medscape, March 1, 2022. https://www.medscape.com/viewarticle/969129
Girnita, D. (2022). Ten Steps to Start Your Direct Specialty Care Practice. www.dscalliance.org, October 22, 2022. https://dscalliance.org/ten-steps-to-start-your-direct-specialty-care-practice/
Mechley, A.R. (2021). Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine. American Journal of Lifestyle Medicine. 2021;15(5):557-562. doi:10.1177/15598276211006624
Pflanzer, L.R. (2017). There’s a Growing Movement of Surgery Centers and Specialists that List Their Prices and Don’t Take Insurance. Business Insider, April 8, 2017. https://www.businessinsider.com/surgery-centers-and-specialists-that-take-cash-not-insurance-2017-3?op=1
Tecco, H., Rahim, F.O., Lalwani, P., & Palakodeti, S. (2024). Direct Primary Care: Financial Analysis and Potential to Reshape the U.S. Healthcare Landscape. Journal of General Internal Medicine https://doi.org/10.1007/s11606-024-09038-5
Tou, L.C., Prakash, N., Jeyakumar, S.J ., & Srekar, R. (2020). Investigating Social Determinants of Health in an Urban Direct Primary Care Clinic. Cureus 12(10). https://www.cureus.com/articles/37438-investigating-social-determinants-of-health-in-an-urban-direct-primary-care-clinic#!/
Watson, J. (n.d.). Hint Health: Empowering DPC Providers in 2024. www.hint.com/blog, https://blog.hint.com/product/empowering-dpc-providers-in-2024
Lisa A. Riemenschneider, PhD, ABPP
Board Certified in Clinical Neuropsychology
Correspondence: lisa.riemenschneider@lakeshoreneuropsych.com