D

irect primary care is yet another in a long line of ideas to help reinvigorate primary care for both doctors and patients. Some view it as a panacea, others as snake oil. I’m not sure what it is, but I know it’s not a transformative innovation for making primary care more relevant, responsive, and affordable on a large scale.

In a nutshell, direct primary care is a model for delivering primary care, and only primary care. The doctor charges each patient a monthly fee, generally ranging from $50 to $200, in return for timely, convenient access to him or her and a buffet-like menu of mostly basic primary care services. The amount of the monthly fee is presumably set in relation to the scope of services covered, though every practice may do it differently.

For services that aren’t covered under the fee, like more extensive management of a chronic disease, the patient’s insurance — if he or she has it — must be billed to pay for the service or, in some cases, the physician or practice will charge the patient extra fees to cover those services.

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Direct primary care appeals to a growing number of doctors. Many are burned out and dissatisfied working in traditional primary care practices, where the administrative hassles are high and they do not get to spend enough time with their patients. Many want to return to a time when the doctor-patient relationship was more central to the delivery of primary care. Many want greater predictability and control in their work lives.

Direct primary care might be a better model for some of them — if they can still earn enough while not taking on too many patients. It also sounds appealing for patients, at least at first glance when you go online and see some of the inviting websites of direct primary care physicians.

As someone who studies doctors and how they work, I see problems with direct primary care for providers, patients, and the U.S. health care system. Here are several of them.

Lack of scalability. From a numbers standpoint, direct primary care is self-limiting in how many patients it can serve. According to the fine print from places like the American Academy of Family Physicians, which supports direct primary care, a doctor working under a retainer-based arrangement cannot treat as many patients as physicians working in traditional primary care practices.

This makes sense. To sell yourself — not others like a nurse practitioner, nurse, or another doctor you might not know — as being available in a timely manner and to guarantee a highly personalized relationship implies that the number of patients a direct primary care physician can reasonably care for goes way down, in some estimates to only one-third or one-quarter the number a traditional primary care doctor can care for. That does not define a transformative innovation in a country that has serious primary care access problems.

Having more patients on retainer means less time available for each one and less ability to react quickly to those who contact the doctor. That can make a direct primary care physician’s life miserable pretty quickly. Contracting with too many sicker or needier patients can also be problematic for direct primary care doctors, as these patients require more contact and care management.

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It would be useful to see data from existing direct primary care physicians and larger direct primary care practices on the case mix of their retainer-based patients. They likely include a disproportionately high percentage of healthier, “worried well” individuals.

Incentives to limit care. Another problem in the direct primary care model is the built-in incentive to limit care. The direct primary care physician or practice functions as an insurer by using the fees from their patients to pay for the services they provide. The pushback from direct primary care advocates here is, “Traditional primary care practice also has an incentive to limit care due to the ways they are paid by contracts with outside insurers.” That’s true. But replacing one conflict of interest with another isn’t necessarily an improvement, and the direct primary care potential conflict of interest here is significant.

Direct primary care doctors or practices assume 100 percent of the financial risk for services included under the retainer for each patient, often including lab work and various screenings. While insurance companies spread their financial risk across large numbers of patients and many different doctors and practices, the direct primary care doctor or practice can spread it only over a limited number of patients. That imposes significant pressure to keep service utilization, care management activity, and direct contact per patient lower to maximize the profit margin.

Patient expense. The direct primary care model can get expensive for patients, making it a model that caters to the affluent and potentially worsens inequities in the primary care delivery system in terms of the care that different individuals receive.

When I examined a retainer-based direct primary care practice near where I live in the Boston area, I found that the monthly retainer covered only a limited menu of basic primary care services and number of contacts with the doctor. Anything else required me to get services paid for through other health insurance I might have, and in the process be subject to paying copays and deductibles to get those services reimbursed.

Most people opting for direct primary care will want — and need — to have additional insurance for things the direct primary care practice does not cover. That means it is quite possible that participating in direct primary care could make some patients pay more out of pocket for their care due to the added costs of the monthly retainer fee on top of normal insurance costs. In addition, a direct primary care physician or practice, by choosing to participate in fewer insurance plans, can end up as a more expensive out-of-network provider for patients to use.

There is also the possibility that patients’ paying $1,500 a year in retainer fees for better access to their doctor will feel the need to access him or her more, which may produce unnecessary service utilization and increase out-of-pocket costs.

More work for patients. The direct primary care model places greater responsibility on patients to know their medical insurance inside and out. They must also become the liaison between their direct primary care physician or practice and their insurance plans.

A big part of the allure for direct primary care doctors or practices is that they can dispense with the hassles of dealing with insurance companies on their patients’ behalf, thus not having to spend their own dollars employing personnel for billing or claims processing. This can considerably reduce their fixed overhead. The flip side is that direct primary care shifts a lot of the insurance paperwork and administrative burden onto the patient. I understand why direct primary care doctors and practices like that. I don’t understand why patients paying $1,500 a year out of pocket for retainer fees would want to take that on.

In the very best case, direct primary care could make some doctors and patients feel more connected to each other, and might even help produce a better care experience. But given significant problems with the model, I don’t expect to see direct primary care taking on a significant number of patients across the country any time soon.

This boutique form of primary care, likely to be found in affluent suburban and urban areas or where employers are looking for practices to more aggressively oversee their employees’ health care, is a model that in many ways seeks to carve itself out from the larger health care delivery system.

There’s a bit of smoke and mirrors here, as direct primary care tries to convince patients that the rest of the health care system, like hospitals and specialty physicians, doesn’t really exist. But it does. And as long as many patients have to deal with the rest of that system on a consistent basis as they acquire more serious conditions and have constant needs throughout their lives for complex diagnostic and treatment care, direct primary care will be of limited help.

Timothy J. Hoff, Ph.D., is professor of management, health care systems, and health policy at Northeastern University in Boston; a visiting associate fellow and visiting scholar at the University of Oxford; and the author of “Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health” (Oxford University Press, September 2017).

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  • I am assuming DPC and concierge medicine are the same? I have not met one doc practicing concierge medicine in some form who is not happier doing so. And most are making close to the same money they were making while slaving under the current system. Most patients who participate only have to use insurance for what they would need insurance for anyway: labs, imaging, seeing a specialist. And the point about a patient having to know their insurance in and out being a negative is ridiculous. They should understand their insurance anyway. I really think more and more physicians will be moving in this direction as they get past the first few years post residency. So many things just take the joy out of us doing our very risky profession.

    • No, DPC and concierge medicine are not the same thing. They are somewhat similar and concierge medicine came first. In the concierge model, The Physician has a retainer fee that they charge on a monthly or annual basis and they also accept insurance. DPC clinics, in contrast, do not accept insurance at all and generally have a much lower fee than a concierge doctor. DPC is Affordable for most middle-class and up patients and even some lower-income patients. DPC is like a gym membership, you pay a monthly fee, typically 50 to $100 per month depending upon age only. It also commonly includes access to prescription medications at wholesale cost which is typically cheaper than co-pays. Concierge medicine typically really is for wealthy individuals whereas DPC clinics are not at all geared towards a high-income segment. It also does not offer quite the level of access that concierge offer is, cuz he has practice is typically have smaller numbers of patients in their panel and provide things such as 24 access directly to the doctor the other personal cell phone which is often not the case of DPC clinics which typically see around 600 patients per dr.

    • No, DPC and concierge are different concepts, directed at a different demographic, involving a different set of services, billing practices and philosophy. The only thing they have in common is a periodic fee.
      As for insurance, people do not need to understand the complexity of their health plan. They should purchase actual insurance; the kind that kicks in when a large and unexpected expense hits.

  • “Limited benefits” is the wrong phrase and demonstrates that the author has not thoughtfully considered the issues in primary care. Direct Primary Care fulfills the ultimate benefit to the patient as it establishes a meaningful long term relationship with a physician. For a physician, it empowers them to work with their patients to keep them healthy rather than work for a fee-for-treatment health plan. Collectively, it allows the patient and physician to interact using technology based on their needs/interests to improve their communications so it is both more effective and efficient rather than governed by the rules set by a health plan. The health plan sees the patient and the physician as data sources and do not know either individual. For the employer, they no longer will b e asked to spend on healthcare “gap” filling services like population health and onsite clinics as the DPC doctor will offer these historical primary care services. They are not offered today because they are not in the health plan’s fee-for-treatment lists. The health plans seem to like the gaps left in their fee-for-treatment schedules as they generate incremental revenue opportunities by replacing personalized primary care delivery with depersonalized tele-center based efforts that increase their own revenues. It is the long term personal relationship that changes everything.

  • Cleary an uninformed perspective from someone who is administering and financially gaining from the current failing system. Any writer needs to do his or her research on the subject: D minus.
    About a third of my patients cannot afford any other access to healthcare and have been priced out of insurance coverage. We care for about 90% of all their needs and help them navigate a confusing and dysfunctional industry. There is no where else in medicine today that you can find that true, direct value.

  • Just another one of those Industry funded terms, designed to deceive. It hearkens back to the Good Old Days, when Physician took chickens and firewood for their services. Back when people died from infection, and Syphilis was rampant.

    • I fail to see the connection between a new model of business practice and health-care delivery and the era of syphilis and people dying from treatable bacterial infections. DPC clinics practice the same modern medicine as anyone else. It is just another practice model which seems to be growing in popularity and for good reason.

    • Actually, most of us stand against the rest of the industry. It is not likely that every industry within the larger sector wouldn’t have conflicts on how they generate their revenue. DPC doesn’t think the insurance middle-man delivers value and has made like de miserable for both patients and doctors.

    • Did you read all of the comments here lambasting the author for this worthless piece of shill “journalism?” These are not very real pitfalls. Author is clearly an apologist for the failing traditional healthcare system.

  • What is wrong with putting the health care dollar back at the point of service? Can you show me a traditional health care plan that brings anything of value to the point of service that reflects the 20 plus percent of the health care dollar they consume.
    When the government frees up the use of medical savings accounts for DPC funding we will see patients and physicians make a choice. DPC physicians will adopt the best computerized systems providing better access and care outcomes. Patients will make wiser decisions with their health care dollar. A yearly push of a reporting button on a certified EMR will confirm what is evident in patient/doctors choice of DPC .
    DPC is a no brainer for me. “Would I rather see less patients and effectively take care of more medical problems, or see more patients and poorly take care of less medical problems”?
    Even the good professor does not need an answer to this question.

  • I really wish those who have no clue about DPC would stop writing about it. In any case, this is all about fear. What would this “brilliant” professor pontificate about if an answer to the primary care issues was available? DPC is comprehensive, affordable and both patients and doctors love it. There has to be a catch, right? Nope.

  • Misunderstood article by a non-physician PhD administrator type. Clearly not well informed regarding DPC models.

    Lack of scalability: True, as more doctors move to DPC the PCP shortage will worsen. The counter argument is that as medical students see DPC providers loving their careers while traditional fee for service physicians continue to suffer, more will choose primary care specialties. It’s not our fault that the fee for service industry creates misery and burnout, and we can’t be blamed for leaving such a system. The author is an administrator by training. Administrators are who ruined the primary care experience for doctors and patients; how about if he finds a way to improve the system instead of blaming us for finally leaving this abusive relationship.

    Incentives to limit care: I’m not sure where the author gets this idea. DPC attracts patients by offering services. We are incentivised to provide good care because if we don’t patients would leave and our business would fail. As for ordering labs, most DPC clinics bill the patient the cost of those labs – – the wholesale cost, not a profit center like it is for the traditional system. A CBC is usually around $5-6 from a DPC clinic vs $50-60 from the traditional model. Since the DPC physician isn’t paying for it, there is no incentive not to order the test, and since the cost is low, the patient typically doesn’t mind paying the cost.

    Patient expense: This depends entirely on the patient and the DPC clinic. Many DPCs offer at-cost medications which in many cases is cheaper than even co-pays, so for some patients on multiple medications the savings on medications can itself pay for the DPC membership fees. Still others have terrible insurance that covers nothing until they spend thousands out of pocket. These patients are often better served financially by a wrap around insurance policy plus a DPC membership. Still other patients do indeed spend more money to be a DPC member but they are happy to pay the fee to have better service, more time when needed, more convenience, etc. The traditional model, for example, discourages providing medical advice or management over the phone because it isn’t billable. DPC doctors don’t worry about billing requirements so if the patient wants to discuss their anti-depressant and maybe make some changes, we can do that without making them come into the office and wait in the lobby for 30 minutes to have a 5-10 minute appointment. Of course if they want to come in they can.

    More work for the patient: shouldn’t people know what their insurance covers? It sounds like you are suggesting it is best for patient to stay in the traditional model and continue to be confused by medical bills and insurance “benefit” statements. The DPC model is not confusing, in fact it very clearly lays out what you get and what it costs. The patient is sometimes left to find their own wrap around policy, although some DPCs help patients with that by partnering with insurance agencies, or if they still have regular insurance then nothing changes for the patient other than the simplification of the primary care portion of their care.

    Readers, do your own research. The author either didn’t, or is a shill for the traditional model.

  • These services are already available in Mexico, and cost a lot less. Most minor illnesses and injuries can be easily treated in Mexico , with no waiting. Te Doctors are a lot more pleasant and not subject to up selling, and Gag Orders like here in the U.S

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