Unexpected Praise for Direct Pay Practices from
Dr. Vonnegut – A Book Review

Occasionally there are things that happen that reinforce the decisions I’ve made in my career, and this was one of those times! A friend recently gave me the book The Heart of Caring: a life in pediatrics by Mark Vonnegut, MD. Dr. Vonnegut is a pediatrician and happens to be the son of famous American author Kurt Vonnegut. Dr. Vonnegut’s book took me on an entertaining and insightful journey, ranging from very short and hilarious tales of his interactions with his pediatric patients and their parents, to longer chapters where he laments both the disappearance of private practice primary care offices and the loss of physician control in the healthcare system. Given that I own Noreta Family Medicine, an independent Direct Primary Care office, I often felt the urge to stand up and shout “Yes! He gets it!” I read this book on a few airplanes though, so I refrained…

My enthusiasm for this book started at the beginning. To be more specific, it started before the beginning, as I was hooked by the time I finished the introduction! In the intro, Dr. Vonnegut recalls working in a pediatric primary care office early in his career (in the 1970s-80s) where he charged his patients $20 for each visit. He states, “we provided accessible, affordable, very high-quality care and we made a living at it.” He says that many people think there was something wrong with that way of practicing because primary care offices have changed their billing practices so dramatically since then. (Nowadays, instead of directly charging a patient before they leave the office, most primary care offices file a health insurance claim and the patient may not receive a bill, and the office may not be paid for months or years!). Dr. Vonnegut uses many examples in this book to refute the public’s perception, including the following personally meaningful reflection. “Back when patients paid cash, they had more power. Medical care cost a fraction of what it does now. And doctors had a much better time. We worked harder and there was no burnout.” Honestly, it sounds like he is describing a modern-day Direct Primary Care office!

It was very interesting to read these observations written by a physician who has seen primary care change from the simple days of directly charging patients into a complex insurance-ruled world that almost no one understands. While I don’t have first-hand knowledge of what things were like in the “old days”, I am very thankful to have taken a class on the history of the American Healthcare System while in college at Notre Dame. That class was the most influential in shaping my professional philosophy as a physician. We learned about when insurance was introduced into the healthcare system, first with Medicare, then with HMOs. Dr. Vonnegut discusses how HMOs failed to achieve the goal of decreasing the cost of care and improving health. Prior authorizations and co-pays also failed to achieve the same goal. He discusses how insurance companies have caused overhead to DOUBLE in medical practices, and sometimes tell good doctors they are inadequate for not playing by their rules. Who went to medical school again? There were just so many insightful comments in this book!

In summary, I would recommend this book to all physicians, especially younger physicians, residents or medical students who may not know the history of the healthcare system in the US. Of course, I particularly recommend physicians who are thinking about or are currently practicing Direct Primary Care to read this book as it gives unexpected props to direct pay medical offices! I also believe many in the general public who have a curiosity about the medical field would find this book entertaining and informative as well.