Experts clash over direct primary care model
Primary care providers face an increasingly challenging landscape that limits their time with patients. A report in Annals of Family Medicine concluded PCPs spend almost 6 hours daily dealing with electronic health records alone. Another study found that PCPs would need 7.4 hours each working day to provide all the preventive services that the U.S. Preventive Services Task Force recommends.
In recent years, a possible solution to help PCPs better manage their time has emerged: direct primary care.
According to the American Academy of Family Physicians, this model consists of “charging patients a monthly, quarterly, or annual fee (ie, a retainer) that covers all or most primary care services including clinical, laboratory, and consultative services, and care coordination and comprehensive care management.”
The model is structured to prioritize the relationship between a patient and their family physician, enabling the physician to spend more time with patients.
There are currently about 800 direct primary care practices in the United States, according to The Chicago Tribune.
Direct primary care supporters told Healio Primary Care that putting patients front and center has alleviated many of their burnout symptoms and administrative burdens. In addition, because physicians practicing in the direct primary care model typically have fewer patients and deal less with insurance companies, they spend less time on EHRs and have fewer administrative burdens than their peers who follow the more traditional care model, like fee-for-service and value-based care.
However, opponents contend that direct primary care jeopardizes patients’ well-being and simply shifts some medical responsibilities onto others.
A ‘practical solution’
Thomas White, MD, a physician in Cherryville, North Carolina, had been practicing medicine for more than 25 years in a fee-for-service setting. He said in an interview that because of the increasing patient load and paperwork, he almost gave up practicing medicine. That changed after he learned about direct primary care.
“I was being pushed to see too many patients. I almost retired from medicine as a result. Instead, I spent a year studying, planning, thinking, talking about the direct primary care model with others and decided, ‘Yeah, this is the kind of doctor I wanted to be.’ So at age 60, rather than walk away from medicine, I found something that will likely enable me to keep practicing for many years to come,” White said.
Since making the switch, White says he typically sees about eight patients a day, down from about 30 when he practiced medicine in the fee-for-service environment.
“Now, it’s just me and the patient and maybe a clipboard in my hand. No electronic health record with boxes to check to ensure I get paid. Appointments are very personal and private, and I no longer feel like there’s an insurance claims employee in the room looking over my shoulder,” he said.
Jennifer Harader, MD, a family physician and direct primary care provider in Topeka, Kansas, told Healio Primary Care that switching to direct primary care was the best career decision she ever made.
“I will never go back to the broken and harmful traditional primary care setting,” Harader said in an interview, more than 3 years after making the switch.
“Previously, I was always answering to my health system. I was answering to the insurance company. I should have been answering to the patient, but he or she became the lowest priority because those other wheels were much squeakier,” she continued.
“With direct primary care, I take all of the other agendas out of the room and just focus on the right thing to do for the patient,” Harader said. “Isn’t that where the focus should be?”
Another direct primary care practitioner, Ryan Neuhofel, DO, MPH, began his practice in Lawrence, Kansas, since finishing his residency 7 years ago.
Although he agreed with White and Harader about direct primary care’s benefits, he cautioned that the model requires a steep learning curve that might never be taught in medical school.
“Physicians are not trained to be entrepreneurs or business owners. You really have to think outside of the box about yourself, your finances, your services, and marketing yourself in your community,” Neuhofel said.
He added that the model, like many small businesses, is not always profitable from the beginning.
“Most of my colleagues just starting direct primary care practices have made very little income in the first year,” he said. “Even once established, many doctors in DPC are not yet making an average salary for a family physician. This can be a huge sacrifice, especially when you consider the financial burden some of us graduate with.”
Despite the financial challenges, he said he would still choose direct primary care if he had to make the decision all over again.
“If you look at all of the points that we lament in the fee-for-service model — that we're rushed with our patients, that our time and services are undervalued, the administrative burden, the paperwork burden, the distractions, lack of transparency, pricing, all of these things — direct primary care solves almost all of them. It's a practical solution for a lot of problems that are well-documented and well-researched,” Neuhofel said.
‘Not a great idea’
Carolyn Engelhard, director of the health policy program in the department of public health sciences at the University of Virginia School of Medicine, said she is sympathetic to the challenges PCPs face, but she argued that the direct primary care model removes clinicians from the overall health care provider pool, thereby stressing already understaffed primary care practices.
She added that patients who cannot afford direct primary care may have worse health outcomes because they wait longer to see their doctor, which in turn could prolong access to medications, tests and other critical services.
“I understand why physicians would want to practice direct primary care,” Engelhard told Healio Primary Care. “But from a system perspective, direct primary care is not a great idea. It fragments health care and sets it backwards, not forwards.”
Reducing the panel size allows physicians to spend more time with patients, but “by going that route, a lot of people in the community will suddenly not have access to health care,” she said. “There is already a primary care physician shortage, and direct primary care exacerbates this problem.”
She added that direct primary care may be shifting administrative burdens to the overall health care system, rather than simply eliminating them from individual practices. For example, if a patient is in direct primary care, his or her medical history may not be on a health information exchange that other health care providers can access, causing physicians and clinical staff to spend more time tracking down the records.
Rather than adopt a direct primary care approach, Engelhard suggested PCPs in the traditional care model utilize team-based care or patient-centered medical home models to eliminate burnout and administrative burdens.
“There is no reason for a PCP to do everything,” she said. “Let a nurse practitioner or physician assistant do routine clinical activities and leave the more complicated situations for yourself.”
In a 2018 opinion piece published in JAMA, clinicians wrote that the direct primary care model is “not the panacea for payment reform” that doctors so desperately need. “Direct primary care is not a scalable model built on fundamental incentive drivers that shape physician and patient behavior to achieve systemic cost savings, promote equity in access, and yield improvement in population health outcomes,” they wrote.
One of the JAMA opinion piece’s authors, Paul George, MD, MHPE, associate professor of family medicine and medical science at Brown University, told Healio Primary Care that he has other concerns, as well.
“Direct primary care advocates will say it is affordable, but in my practice in an underserved community, there is likely not one patient who can afford the costs. So, it in effect sets up a two-tiered system, where those who can afford direct primary care can get care through this model; those who can't afford it, don't. Practices will say they offer scholarships to defray the costs of direct primary care, but this is only 5% to 10% of their overall patient panel,” George said.
One of George’s co-authors, Eli Y. Adashi, MD, MS, CPE, FACOG, and the former dean of medicine and biological sciences at The Warren Alpert Medical School at Brown University, concurred with Engelhard that the model could further shrink an already shrinking physician pool. “Unless we suddenly graduate a plethora of primary care providers who can care for these patients (since there are only 600 patients per direct primary care practice instead of the 2,000)”.
Another direct primary care opponent, Claire McAndrew, director of campaigns and partnerships at Families USA, a nonprofit group that advocates for high-quality, affordable health care for Americans, said she had concerns about confusing messaging around direct primary care.
“We have seen that not all direct primary care physicians take time to explain that direct primary care does not meet the Affordable Care Act requirement of having insurance,” McAndrew said.
“We also want to make sure direct primary care practitioners aren’t only selecting healthy patients, since this could affect the risk models that are used to generate insurance premiums,” she continued. “We want to see a health system that, whether you’re healthy or sick, rich or poor, works for everybody.”
Legality of direct primary care
Barbara J. Zabawa, JD, MPH, clinical assistant professor at the College of Health Sciences at the University of Wisconsin-Milwaukee, told Healio Primary Care she has doubts about direct primary care’s legality in the individual health insurance market.
“If the model does not cover the 10 categories of essential health benefits such as emergency care, mental health care, hospitalization and rehabilitative and habilitation services, required by the Affordable Care Act, it would not likely meet the ACA requirement of having insurance.”
“With regard to the small group market, it is [also] possible that a direct primary care model may fit within a Qualified Small Employer Health Reimbursement Account, which would exempt such plans from certain legal requirements under the Internal Revenue Code and the Public Health Services Act,” Zabawa continued. “Employees of these small employers would need to have minimum essential coverage, however, for the direct primary care plan offered by the small employer to be exempt from those legal requirements.”
She added, “large companies who participate in direct primary care have more flexibility in their health plan design than the individual or small group markets” and therefore are more likely meet the minimum Affordable Care Act standards.
However, Neuhofel told Healio Primary Care that “There is absolutely no question about the legality of direct primary care as a practice model. More than half the states have legislation that clarifies the model as 'not insurance,' but it is completely legal even without those state laws.”
Zabawa said that, “overall, direct primary care holds a lot of promise with achieving better care, better access and lower costs, but further legislative and regulatory work is needed to make direct primary care adoption less risky for employers and the providers who offer those services.” – by Janel Miller
AAFP. Direct primary care. https://www.aafp.org/practice-anagement/payment/dpc.html. Accessed Oct. 4, 2018.
AMA. In a complex environment, physicians have at least 8 paths to choose from. https://wire.ama-assn.org/practice-management/complex-environment-physicians-have-least-8-paths-choose. Accessed Oct. 5, 2018.
Chicago Tribune. More doctors embrace membership fees, shunning health insurance. http://www.chicagotribune.com/business/ct-biz-membership-medicine-20180529-story.html. Accessed Oct. 4, 2018.
Families USA. About Families USA. https://familiesusa.org/about. Accessed Oct. 4, 2018.
Disclosures: No relevant financial disclosures were reported.