Direct Care or “Concierge Medicine” is a reformed way to pay for health care that is gaining in popularity in the United States, there is even a SitCom about a Direct Care practitioner in the wealthy Hamptons but this is not only for royalty. This model has the potential to create a new health-care sector accessible to all classes, and, as such, to embarrass, out-compete and denormalise the NHS.

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The traditional US model is comprehensive “insurance” which includes cover for catastrophes and accidents, as well as pre-payment for the kind of common ailments that may just require a little advice and some medicine to manage: everything from minor infections, stitches for your sports or domestic injury, or help managing your blood pressure or diabetes. Insurance for the routine “family” medicine. Of course, as proponents of private health care we will have all heard of the mandatory insurance benefits for frivolous items, and the shrill controversy over subsidised birth-control.

Paul Hsieh makes this comparison clear in Forbes:

What most people consider health “insurance” is actually genuine insurance combined with inefficient pre-paid medical care. Contrast that with standard car or homeowners insurance policies. Those plans protect us against unlikely but expensive events, such as a bad car accident or a house fire. But we don’t use car insurance to cover routine predictable expenses such as oil changes.

Another part of this traditional system is the “co-pay”: small additional payments for care designed to be an obstacle to insurance claims, to share some of the accountability for health care with the recipient. We all worry that the UK system of tax-payer accountability encourages reckless obesity and hard-drinking here, the co-pay is designed to solve a similar problem of over-claiming on insurance.

Wikipedia Contributors note:

Insurance companies use copayments to share health care costs to prevent moral hazard. Though the copay is often a small portion of the actual cost of the medical service, it is meant to prevent people from seeking medical care that may not be necessary (e.g.: an infection by the common cold). The underlying philosophy is that with no copay, people will consume much more care than they otherwise would if they were paying for all or some of it. In health systems with prices below the market-clearing level in which waiting lists act as rationing tools, copayment can serve to reduce the welfare cost of such waiting lists

Concierge doctors in the states are continuing to experiment with co-pays, but the direct model dispenses with this system and works more like a gym membership, or perhaps a little like broadband. You pay a standard price (though often a discount applies) and you get unmetered access to the pool of health facilities. In the Direct Care scenario that means you can make as many appointments as you wish, and even consult over the phone. Interviewed by The Objective Standard direct care practioner Dr. Josh Umbehr explains:

A per-visit cost encourages patients to make a difficult decision based on cost. When you remove the per-visit cost, you enable him to maximize the care he receives. When you maximize the care, you maximize the potential for good outcomes, saving him even more money downstream. A diabetic can come to me every day for a week or until the condition is truly under control, with no additional cost to the patient.

I also prefer routine costs in other fields. I don’t want to talk to my lawyer or my accountant if it’s going to cost me $50 a pop. But I might make a decision that isn’t as wise as it could be and that may cost me thousands because I didn’t want to spend $50 to talk with my attorney to clarify something. I think the same is true with health care. When you level the payments, just like a gym membership, you remove that obstacle. You have no idea how much the people are going to use it, but if you maximize their opportunity to use it, you maximize your potential value to them and the benefit of their unlimited access to care. I think this best serves the patient’s long-term health goals.

The sales pitch is compelling. Unlimited access to a doctor who wishes to maximize the value he offers to me. This would be a thousand times better than being asked to jump through bureaucratic hoops to access rationed specialists or getting funnelled down standardised treatment pathways in the NHS. Or worse, being trained to lie about the urgency of your need in order to get an appointment while you are still sick.

This last problem is a serious one for casual workers and honest businessmen, because if you cannot work you might not be paid. OK so we could accept having to lie to work the system as a trivial cost to society, but I suspect (and please excuse me if this seems a stretch) that a national institution that you must lie to in order to gain anything from has a serious design flaw and one that is corrupting of the society it exists to serve. But I digress. For people like me who shoulder the risks of ill-health themselves the real issue is staying at your desk. Paul Hsieh explains how this new model can help:

[Doctors] are establishing “concierge” or “direct pay” practices, where patients pay a monthly or annual fee for enhanced services, including same day appointments, 24/7 access to their doctor, e-mail consultations, and longer appointment times.

The national average wage is equivalent to £100 daily. If you are a plumber, a casual labourer, retail worker, shop owner, freelancer, a skilled consultant or an entrepreneur then that wage is conditional on your being fit to work on any given day. If an NHS appointment is only available after a 7 day wait then you could be better, without help, before you even see a doctor but you would have lost at least £500-700 pounds. In contrast, if some access to medical advice saves you from spending the whole week in bed, and gets you back into the office for Friday then you will be £100 richer than you would have been. This is exactly what happened to me after a lingering bout of food poisoning. It cost me a well spent £40 on a private GP, and some non-prescription medication worth less than a tenner.  Compared to where I was when I made that decision I was at least £400 better off, and this was for a relatively simple problem. If I had a chronic condition to manage I might face that kind of trade-off regularly.

The pricing of Josh Umbehr’s AtlasMD service is comparable to a gym membership or daily coffee, $50 per month for any adult via a company policy. Let’s assume we do not get the benefit of the exchange rate and this is likely to cost you £50 a month. Yes you would still pay for the NHS, it’s mandatory, but the more you earn the higher the probabity this kind of support will pay off economically; and of course the pay off is twice as fast if your spouse is nursing you and has similar circumstances. On average, for a single adult, the payoff would be 6 days. For me – a backend web developer – the payoff would be there if less than 2 days were saved in the year. Of course, this doesn’t cover major catastrophic illnesses, but I would be able to rely on the NHS for that. I’m thinking of incremental reform, and also in terms of triggering a debate about NHS quality.

This is what I’d like to see happening. At the moment, I am able to find just one GP offering a service on a monthly fee in the UK and that is in the rural out-of-hours niche. I’d like this to be commonplace, and available all-day. It would not need to be the dominant form of healthcare, but merely to be available for about the price of a gym membership to 10% of the population. We can then start to use this kind of care as a counter example to the sainted NHS. To get there, we need to stimulate demand. We need to talk about this idea with friends and talk about the various ways in which this would be more pleasant and more convenient than the GP service we get from the NHS. We would then be able to talk about the NHS as something like a safety net for very serious medical catastrophes, not something we rely on every day for every kind of medical assistance.