Family Practice Management
Is Direct Primary Care the Solution to Our Health Care Crisis?
By Edmond S. Weisbart, MD, CPE, FAAFP
Direct primary care (DPC), a reformulation of concierge medicine, has intrinsic appeal to overburdened physicians. Its advocates promise a competitive income at a fraction of the volume of patient responsibilities, and they claim it as a patient-friendly, consumer-driven strategy that can meet the needs of patients across the economic spectrum.
However, there are potential downsides to DPC, which this article will discuss.
1. DPCs exacerbate the growing physician shortage.
Retainer practices such as DPC practices commonly close their panels when they reach about 900 patients, which is much lower than the typical practice panel size of around 2,300 patients.
2. DPCs are essentially unregulated insurance, capitating physicians and removing vital patient protections.
Paying a monthly fee for a specific range of services is one definition of an insurance model. Despite that, DPCs often fall outside of insurance regulation.
3. DPC relies on an erosion of medical benefits.
Much of a patient's health care requires services beyond primary care. High-deductible health plans can expose patients to full retail pricing for these additional services and medications unless their plans have negotiated discounted rates. These health care costs can quickly become a hardship for many patients.
4. DPCs exacerbate disparities in care.
Although the evidence is still emerging, DPCs may be choosing to locate in areas most able to financially support the model. Studies have suggested that DPC physicians have smaller proportions of African-American, Hispanic, and Medicaid patients and see smaller proportions of people with diabetes.
The wrong solution to a real problem
U.S. physicians are among the least satisfied in the modern world.5 Much of this dissatisfaction is related to the amount of time spent on non-clinical administrative functions, particularly tasks related to insurance companies. Physicians' desire to reduce frustrating administrative work is understandable, but DPC is not the solution. Physicians considering a transition to DPC need to consider the impact on physician shortages, disparities in health care, and patient access to health care services outside the DPC.
Comment by Don McCanne
What problem is being addressed by the establishment of direct primary care practices (DPC)? The administrative hassle in dealing with a multitude of payers is replaced with a single retainer fee paid by the patients. That benefits physicians by reducing overhead expenses and freeing up time for a more relaxed clinical work environment.
Patients enrolled in DPC practices benefit from improved accessibility and more personal attention for their routine primary care needs. DPC physicians are not included in insurer provider networks thus their patients pay not only the retainer fee but they are also responsible for the full deductible of their catastrophic plans. Thus DPC practices cater to the carriage trade whereas less affluent individuals find the arrangement to be truly unaffordable should they develop problems requiring specialized care or hospitalization.
Do physicians have an obligation beyond the patients in their own practices? Should they be supporting policies to ensure that adequate affordable care is available to all members of the community at large? DPC reduces both access and affordability. In spite of implementation of ACA we still have intolerable disparities in care, and DPC will only exacerbate those disparities.
DPC is designed to allow physicians to retreat to their cosy practices while escaping from their moral obligation to meet the health care needs of the community at large. They are supported by their wealthy clients, or customers, or patrons, or whatever they're called.
If these physicians really supported the positions they held when interviewed by the medical school admissions committees, instead of fleeing to DPC practices, they would be advocating for reform that would bring essential, affordable care to everyone - an improved Medicare for all. It is painful to listen to their curt dismissal of reform that would bring health care justice to all.