Functional med paywalls in DPC, The concerning ethics of paywalling patients for comprehensive functional med care

I’ve identified a concerning trend in the Direct Primary Care movement. The cash pay model offers a flat monthly rate for primary care. Mainstream medicine doctors are opting out of the insurance system due to layers of administrative duties and ever reducing medicare reimbursement rates. Commercial insurance companies can at a whim decline payments for services or require lengthy forms and boxes to click in order to be paid correctly. Overhead goes up for small primary care offices with billing experts and compliance officers. Mom and pop primary cares are being bought out by hospital systems that have stronger leverage to negotiate payment tiers with insurance companies or purchased Private Equity firms that see a cash cow.

Overall DPC is the correct move for healthcare reform.

When a DPC clinic no longer has to comply with arbitrary boxes to check and have more time to think about their patient’s problems they may naturally find themselves considering hormone replacement therapies and some functional medicine modalities.

DPC rates are typically cheaper than functional medicine consult fees or “TRT clinics”. The DPC CEO will naturally consider creating price tiers for what they consider as outside conventional guideline dictated primary care. I’ve seen a DPC clinic post prices for a conventional DPC monthly rate and then offer another tier 3x the price for “functional medicine”.

Take a hypothetical example of a middle aged patient on your basic DPC plan for $99/month who presents with chronic nonspecific pain, fatigue and brain fog. Conventional medicine would refer to rheumatology or in a conventional DPC you’d order some rheumatoid markers, CBC, CMP and and a1c.

Results come back normal. In a busy insurance primary care clinic with 15 minute follow ups you probably refer this patient out to psych and interventional pain management.

But say you are a DPC clinic and you’ve gone to the additional lengths of relearning medicine from a functional lense. You’ve taken courses like HRTPCP.com (shameless plug for my course) and you know that this patient likely has low hormones and will greatly improve their quality of life with HRT. After that basic workup do you then paywall your care? Do you then offer $599/month for “Functional medicine DPC”?

How can you ethically waste that patient’s time at the $99/month rate when you knew you should probably have ordered a free and total LCMS testosterone and estradiol level. You know there’s better treatments for their fatigue, low sex drive, pain ect but paywall them.

Now I must attack the functional medicine-only practice. This same patient pays a high price and is hormone optimized and has done gut testing and spent lots of money on regenerative peptides to heal their IBS, but has come down with an acute illness. Since you style yourself as functional medicine you don’t treat a common cold and you don’t repair lacerations. That is beneath you.

This patient goes to an urgent care and gets some sutures placed and given ciprofloxacin prophylactically (yep that’s a real and idiotic thing that some lobotomized providers at chain urgent cares do if they know how to suture in the first place).

Your patient returns to you with an achilles tendon rupture and the patient progresses over the year towards a constellation of flouroquinolone-related symptoms. This patient pays many more thousands of dollars for your workup of “mitochondrial myopathy” and expensive and research-online mitochondrial peptides.

I strongly urge everyone in this DPC movement, be it if you are a strict “evidence based medicine” purist or a functional medicine guru to charge one flat rate and treat the whole patient. Patients cannot be boxed into a price tier. If we want Direct Primary Care to implement true healthcare reform, to stop the overuse of ERs, the endless specialist referral mill and the fragmented care we need to charge a flat rate and provide comprehensive care.

This is how we Make Primary Care Great Again. Every DPC needs to take extreme ownership of their patient. Charge what you are worth, but please lets get rid of price-tiers and paywalls for HRT or “functional medicine”.

Anti-Aging Medicine is Primary Care