Direct Primary Care: A Primer

According to the AAFP:

The direct primary care (DPC) model gives family physicians a meaningful alternative to fee-for-service insurance billing, typically by charging patients a monthly, quarterly, or annual fee (i.e., a retainer) that covers all or most primary care services including clinical, laboratory, and consultative services, and care coordination and comprehensive care management. Because some services are not covered by a retainer, DPC practices often suggest that patients acquire a high-deductible wraparound policy to cover emergencies.

Advocates of the DPC model believe that it provides much needed relief to physicians by reducing the complexity of their practices, reducing their panel sizes and giving them the ability to get back to the practice of medicine. They also cite numerous benefits to patients including longer appointments, 24x7 access, same-day appointments and reduced costs on ancillary services. Combined with a high-deductible wraparound plan, DPC provides patients with the closest thing to a true consumer experience in healthcare while maintaining protections against catastrophic events. DPC fees range from $30 to $150 per member per month.

DPC shares traits with concierge care, but the two terms aren’t synonymous. In the Concierge Care model patients do pay a retainer for direct access to the physician, but their insurance company is still billed in the traditional fee-for-service model. DPC practices rely solely on the patient retainers and do not accept insurance. There are pros and cons for each. With Concierge Medicine they still deal with the overhead of accepting insurance, but enjoy multiple revenue streams. With DPC, there’s only one revenue stream (patient retainers), but the practice enjoys a major administrative simplification by not having to deal with 3rd party payer requirements. Many practices are beginning to experiment with hybrid models as a way to experiment with the new models without taking on the full risk and allowing them to retain their existing, insurance-based customers.

What about those that can’t afford to pay a monthly retainer?

One of the common objections to DPC is that many people can’t afford to pay for a monthly retainer. DPC physician W. Ryan Neuhofel argues that the model actually reduces financial friction to getting primary care services and lowers ancillary costs. In one example Dr. Neuhofel was able to provide a prescription for $8.12 that used to cost his patient $100/month through insurance. In another example, he managed a forearm fracture with an uninsured patient for $45. Dr. Neuhofel goes on to explain that 3rd party payers are beginning to help offset the retainer itself. For example:

  • Qliance in Washington is caring for members of a private Medicaid managed care plan.
  • Iora Health is providing care to Medicare Part D members in Phoenix.
  • Turntable Health in Las Vegas is available to all members of the exchange-subsidized Nevada Health Co-op.
  • Many employers and unions have also opted to support quality primary care using DPC across the country.

Another argument on this front is that DPC might give a false sense of security when purchased as stand-alone health coverage. It’s true that in this scenario patients would not be protected from catastrophe, but the ACA does allow for DPC practices to offer coverage in the health insurance exchanges when combined with a wraparound catastrophic insurance policy provided by a qualified health plan (QHP).

Does DPC contribute to the doctor shortage?

Another common argument is that DPC will worsen the doctor shortage. On the surface, the argument seems to have merit. If we are looking at a doctor shortage of up to 30,000 primary care doctors by 2025, then all things being equal a doctor going from a panel of 2,500 or more patients to under 1,000 will increase the shortage. That said, the shortage is driven by our current reimbursement system and the perverse incentives it creates. In reality, if the market allows for primary doctors to run profitable practices with smaller panels of happier patients, then more people will want to become primary care physicians (and fewer will want to retire early).

Why would a doctor consider moving to DPC?

Given that primary care physicians spend 40% of their practice revenue dealing with billing issues, are constantly chasing the next incentive program and are forced to manage huge patient panels with ever-shorter appointments, its no wonder the DPC model is gaining traction. It’s an opportunity to cut the cord on many of the things that are driving their dissatisfaction. One physician comment on this Forbes post spells it out clearly:

Since adopting the Direct Primary Care model for my internal medicine and pediatrics practice in Carrboro, NC, last year, I am happier then I have ever been. I come to work each day knowing that I am working for people who say “I value YOU, Dr Annis,” in a very tangible way. That direct accountability between us, that trust, makes me jump out of bed ready to embrace my work. If every primary care doctor could feel this way, there would be no primary physician shortage and no physician suicide crisis. — Cory Annis, MD

What are the challenges?

Physicians will face many challenges when converting to DPC. First, you’re moving away from what you know. The direct-to-consumer model requires a new approach to things like marketing and customer service that not all physicians are prepared for. Second, you may need to part ways with a large portion of you existing, insurance based customers. Many of the providers who make this shift will fail and be forced to revert back to traditional models.


On Wednesday, 4/20 the Business of Healthcare Show will expand on this post.

First at 12:00 PM EST the #hcbiz tweet chat will ask the following questions:

Q1: What are the benefits of DPC for the physicians? Patients? Others?

Q2: What are the drawbacks of DPC for the physicians? Patients? Others?

Q3: What are the major challenges faced by physicians when making the transition to DPC?

Then at 12:30 PM EST we’ll continue the conversation on the #hcbiz blab with me, Shahid Shah, John Chamberlain and Dr. Randall Oates. Subscribe here!

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