Patients Prefer Independent Doctors. Payment Policy Doesn't.
Americans prefer independent physician practices over hospital-owned ones by nearly five to one. Yet only 18% of physicians now practice in physician-owned settings, a new low.
Charles Sauer of the Market Institute points to Washington's payment rules. Medicare can pay more for the same service when a hospital owns the practice, and MedPAC has warned that gap encourages hospitals to buy up independent doctors. He backs the Patients First Act's practice-cost updates, paid for with site-neutral reform and cuts to Medicare Advantage waste.
Direct Primary Care (DPC) offers a way to stay independent that doesn't wait on Congress. Doctors and patients set a fair price together with a simple membership, so a reimbursement formula never decides whether your doctor stays independent.
$5,000 Before the Neurosurgeon Would See Him
Thomas Zordani flew from Denver to Phoenix for a Mayo Clinic neurosurgery consult. Brain scans. Debilitating headaches. He thought he was in network.
Then the financial office asked for $5,000 before anyone would see him. Mayo had decided it did not take his plan. He was labeled self-pay. He refused. The appointment was canceled.
KFF Health News has the story. The clinic later said a portal note had estimated $565, not $5,000. An Arizona arbitrator eventually awarded him $47,500 after finding Mayo failed to warn him in time that he was out of network. The deposit demand still stands as the point.
This is not a rare glitch. Hospitals are collecting more money before care because deductibles climbed and unpaid balances climbed with them. The average deductible sits around $3,762 per person for people on employer family coverage. ACA deductibles jumped 37% this year to about $3,786. People are asked to self-insure the gap, then hand the hospital a chunk of that gap at the front desk.
I am not shocked. Insurance was supposed to open the door. Now the door has a cash drawer.
I am not anti-insurance. Keep a policy for the wreck. I am anti a system that makes you fly across the country, then auction the consult at the cashier window. Direct care already skips that theater. Flat monthly fee. No claim. No network. No $5,000 permission slip to talk to your doctor. The number on the door is the number you pay.
$5,000 is a price. It just showed up before the medicine did.
Entrepreneurship Lock: When Your Health Plan Decides Whether You Start a Business
Plenty of people have the idea, the skill, and the nerve to start a business. Then they price health insurance on their own, and they stay put. In Forbes, Christopher Jin calls it "entrepreneurship lock."
The number is hard to ignore. Economists have found that for every 1% premiums climb, the rate of new self-employment drops by roughly three-quarters of a percent. Self-employed workers and small-business owners make up about a quarter of everyone on the ACA marketplace, and their premiums just jumped after enhanced subsidies expired.
That's why Direct Primary Care (DPC) matters beyond the exam room. A flat monthly membership covers everyday care, and paired with lower-cost coverage for the big stuff, it brings the cost of going out on your own back within reach. Cheaper care is pro-entrepreneur.
Contact Points
In 1844, Ralph Waldo Emerson picked up a French word: croisements. Crossings. It's pronounced roughly krwahz-MAHN. I had to look it up too.
He got it from the French philosopher Charles Fourier, who wrote that nature loves cross-breedings. Emerson noticed his best ideas came from contact points: an old book reread with new eyes, two metals touching, a friend arriving or leaving. So he tried to arrange his life to present, in his words, "as much transitional surface as possible."
I came across that in a Daily Stoic email, which pulled it from Robert D. Richardson's Emerson biography, The Mind on Fire. My first thought was that this is exactly what the insurance model took out of medicine.
Count the contact points in a normal primary care relationship. There's a visit you booked weeks out and a short appointment with a screen between you. There's a phone tree, a message relayed through staff, a portal, and a billing office in the middle of every conversation. Each layer was added for a reason, and each one shrinks the surface where a doctor and a patient actually meet.
That matters because medicine works like Emerson's crossings. The useful stuff happens at the point of contact. A mom texts a photo of a rash on Saturday morning instead of sitting in urgent care. A patient mentions the chest tightness on the way out the door because the visit wasn't rushed. A follow-up question gets asked because asking doesn't cost anything.
Insurance doesn't pay for contact. It pays for codes. So contact gets rationed.
Direct care does the opposite. There's one monthly membership and no copay for asking a question. Our doctors answer their own phones, take their own texts, and manage their own email. There's no phone tree and no message relayed through staff, and visits last as long as they need to. That's more transitional surface, on purpose.
It's also a reread. Direct care isn't new. It's the old family doctor relationship, read again with modern tools: texting, wholesale medications, and a posted price. When you return to a book that shaped you, you find something new in it. That's not nostalgia. It's a crossing between an old relationship and new tools.
I am not anti-insurance. Keep a policy for the wreck. But you shouldn't need a claim form to ask your doctor a question.
Croisements is a hard word. More time with your doctor is an easy one.
Indiana's Doctors Picked a Direct Primary Care Physician as Their 180th President
A few years ago, Teresa Lovins was thinking about leaving medicine.
Not retiring. Leaving. She worked in a group practice owned by the local hospital, and the ownership came with quotas. Patients were limited in how many complaints they could bring to one visit, so she could move on to the next one. She once sent a patient to a dermatologist to remove a basic skin lesion. She knew how to do it. Her schedule didn't have room. The patient got another appointment, another doctor, and another bill. In her words, she was "overwhelmed, burned out and wavering on leaving clinical medicine."
Then she went home to Columbus, Indiana, and opened her own direct primary care practice. A monthly membership. No insurance billing. New patients get 90 minutes. Follow-ups get 60. The shortest visit on her calendar is 30.
Last month, at its 177th annual convention, the Indiana State Medical Association elected her president-elect. In September 2027 she becomes its 180th president.
Sit with that. The state medical association is not a fringe club. It is the house of organized medicine. And it just picked a doctor who walked out of the quota system and built something smaller, slower, and better.
Her own association's policy manual is already waiting for her. 4 resolutions name direct primary care. 2 of the asks have landed. Indiana took direct care agreements out of insurance regulation in 2017. Washington let HSA dollars pay direct care fees starting in 2026. The one still on the list is a pilot letting Medicaid patients and state employees use direct primary care, to see if it lowers state spending.
That is the right test. Run it.
I am not anti-insurance. Keep a policy for the wreck. I am anti a system that burns out a family doctor with 30 years in her hometown and calls it productivity. Direct care didn't just keep Dr. Lovins in medicine. It handed her the podium.
The 180th president of Indiana's doctors will be one who got out of the quota business. That isn't a symbol. It's a direction.
Source: www.ismanet.org/ISMA/About_Us/News/Dr_Lovins_chosen_as_next_ISMA_president.aspx and www.aafp.org/about/blog/lovins-dpc