Thursday, January 1, 2015

Direct Primary Care, Scope of Practice, and the Health of the People

One of the relatively new and growing movements in family medicine is “direct primary care”, or DPC. The term seems to have a lot of different meanings, depending upon who is talking about it (or, often, it is talked about in very vague terms, as are many things we want to have only thought about in positive ways; if we get too specific people can criticize!). In general, however, it is about primary care doctors taking direct payment from patients for their services rather than getting reimbursed by insurers (including Medicare and Medicaid). This is touted to be a panacea for doctors tired of “bureaucracy” (often referring to the “government”, but certainly at least as painfully insurance companies); of too many forms to fill out and rules to follow and loss of autonomy. The primary care doctor provides the service that s/he is capable of and the patient pays, just like in the old days (maybe barter is included, but don’t know about paying in chickens – on visit to the vet the other day I saw an old sign on the wall advertising a vet’s services, indicating both cash and barter—but no poultry.)

There is a certain attraction to the simplicity of this arrangement. The doctor provides the services that s/he can provide (presumably not including most laboratory tests or medicines or immunizations) for a fee that is collected in cash. The patient can even apply to their insurance company for reimbursement. Voilà! Everyone is happy! The patient gets the service, the doctor does what s/he likes to do, and is freed from bureaucratic regulations and thus can operate his/her business more efficiently and with lower overhead, presumably (this is not always explicit) passing the savings on to the patient. But there are a few concerns.

The first, obviously, involves people who are too poor to pay. This may not concern some of the DPC doctors, but does others, and should concern our society as a whole. We know these people; we see them regularly in our student-run free clinic (except there they do not pay anything). I have pointed out that this need not be a problem; one of the advantages of not taking insurance is that the doctor is free to charge different people different amounts. The Center for Medicare and Medicaid Services (CMS) requires physicians accepting it to not charge anyone less than the amount they charge Medicare (not the amount Medicare actually pays). Not accepting Medicare means a doctor could charge a well-heeled person $100, and another poorer one $25 for the same service. Or $5. Or a chicken. Or nothing. And those people with Medicare (or another insurer) could still submit a request for reimbursement for what they actually paid. Don’t know if they would be reimbursed or not. And it might be tough for the senior who can barely accomplish their basic functions to submit directly to Medicare. It all depends, as I pointed out to a colleague considering such a practice, on how much you want to make. If you are willing to make less, you can charge people less. I have no idea how many of those physicians currently practicing or planning to practice DPC are charging such a sliding scale, or taking all comers, or are willing to earn less. But it is at least theoretically possible to do this.

A second concern is “what is the scope of care provided by the DPC provider?” Sometimes discussions of DPC seem to focus on treating colds, high blood pressure, sprains, etc., all the things that are currently taken care of by the increasingly common Urgent Care Centers in drug stores and big box stores. Many of these things are problems that do not need to see a provider (your mother can tell you to drink plenty of fluids, rest, and eat chicken soup – perhaps a better use for that chicken than paying the doctor!). Otherwise, it is not clear what advantages DPC offers over Urgent Care Centers, except that the latter are often staffed by Nurse Practitioners, not physicians. If you care. If the services being offered are within the scope of practice of the provider, what difference does it make? And the Urgent Care Center will take your insurance, not a small matter when it comes to the cost of immunizations, for example.

Clearly, this DPC model cannot work for problems that need to be cared for in the hospital, or require facilities. The doctor cannot choose to be DPC only for their outpatient practice but be on insurance for inpatient care, so won’t do it. Or probably deliver babies. Or provide any beyond the simplest of office-based procedures. Including the critical ones of providing long-acting reversible contraception (LARC), IUDs and implants, which have very high up-front costs, except for quite well-to-do patients. Again, it is getting hard to see the benefit of DPC over Urgent Care, except, possibly, the provision of continuity of care with the same provider. Unless, of course, you need something that cannot be done in the office. Metaphors abound; one DPC provider is quoted as saying “you don’t use auto insurance to buy your gas; why should you use health insurance to buy primary care?” I leave this question up to you, including whether the metaphor is apt. However, it clearly minimizes the scope of what primary care doctors can do.

This is a potential challenge for family medicine and other primary care providers, especially as family medicine moves into its “Health is Primary: Family Medicine for America’s Health”[1] campaign. For a long time, other specialists have derided PC for only taking care of simple problems. Many, including me, have argued the contrary, that primary care is difficult and complex (see, for example, my 2009 blog post “Uncomplicated Primary Care”, and my recent Graham Center One-Pager “Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties[2]), but quotes like the one above seem to indicate a retrenchment, away from “full-scope” practice. Obviously, like DPC, “full-scope” can be defined in various ways, but usually means things like caring for people in the hospital (another thing I have argued is a strength of US family medicine), delivering babies, caring for children, doing a variety of procedures, and even caring for people in intensive care. At the recent North American Primary Care Group (NAPCRG) meeting, several papers from the American Board of Family Medicine (ABFM) and Graham Center indicated that in most cases greater scope of practice of family physicians led to lower cost. The ABFM developed a 0-30 scale for scope of practice, and found significantly lower costs for patients cared for by FPs with 15-16 scores than those of 12-13 (a relatively small difference in scores). Presumably this is because those with lower scope of practice are referring more to higher-cost specialists. The interesting exception was integrated practices (like Kaiser) where the scores for FPs were low (~11.5) but costs were low, as a result of the other surrounding services available to patients from those integrated systems. These would not be characteristic of small DPC practices.

Finally, there is the concern about “who is health care for?” Much of the interest in DPC among residents, it seems, is to make their own lives less stressed, less busy, less frustrating. Not bad things. But the ultimate and only real measure of whether our society should embrace such a trend is whether it enhances the health of our people. All our people. Rich and poor. Rural and urban. White, Black, Asian, Hispanic. Over 150 years ago, Rudolf Virchow (the Father of Social Medicine) wrote “Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community.… If medicine is really to accomplish its great task, it must intervene in political and social life.”

I hope that we still believe this to be true.

Happy New Year!

[1] Phillips RL, et al., “Health is Primary: Family Medicine for America’s Health”, Ann Fam Med October 2014 vol. 12 no. Suppl 1 S1-S12.
[2] Freeman J, Petterson S, Bazemore A, “Accounting for Complexity: Aligning current payment models with the breadth of care by different specialties”, Am Fam Physician. 2014 Dec 1;90(11):790.


ken thompson said...

Hi Josh
Sounds like fp has discovered the private practice of psychiatry. Roughly 50% of psychiatrist now only take cash- with significant damage to our social contract.
As for the relative complexity of practice- as a psychiatrist working in the non-cash trade all I can say is hmmmm.

Ryan Neuhofel said...

Hi Dr. Freeman,

Thanks for sharing your thoughts on DPC. I actually have bartered for both chickens and eggs!

I share your concerns about the affordability of health care. It was one, of many, reasons why I started my DPC practice. My practice is certainly unique but has a majority of uninsured a patients. I know many DPC docs who have higher than average uninsured % as well. Further, with rising insurance deductibles, I have new patients join because they still cannot afford out-of-pocket expenses for routine care. I wrote a blog post for AAFP on this recently . . .

I don't pretend to have all the solutions to our mess of a health care system, but know that better primary care -- for patients AND PCPs -- must be a part of it.


Matthew said...

Dr. Freeman,
I'm not exactly a DPC shill (though when I move to Africa, I'll be joining a hospital that charges patients for everything), but here are a few thoughts in addition to what Dr. Neuhofel offered:

1. Dr. Marguerite Duane offered some thoughts here (, but the general idea is that patients like to know how much they're paying for something and opaque insurance products with high deductibles don't seem to have as much value for folks at the margins as just paying the doctor directly. Of course single payer would also get rid of the opaque insurance product, but implementing that is not as easy as opening a DPC practice.

2. A DPC provider can do whatever s/he wants and patients are willing to pay for. Theoretically, if you're paying $1500/yr for a catastrophic plan instead of $5000/year for your family's insurance, you could probably afford to pay out of pocket for some immunizations and an IUD if you wanted.

3. Inpatient care is certainly a trickier question-- most "free market" advocates point out that most people only use the hospital for things that would be covered under a catastrophic plan and would pay for it the same way they pay for a new engine if their car breaks.

Jose Villalon said...

Thank you so much for sharing your thoughts about DPC. I have several residents exploring this option as part of their future practice model. It is definitely something that sounds intriguing for practitioners. Unfortunately, it doesn't guaranteed that patients will receive a comprehensive and affordable care. We need to see how it will play out in the coming years.

thank you!


Sara said...

There is a sure fascination in the effortlessness of this course of action. The specialist gives the administrations that s/he can give (apparently excluding most research facility tests or medications or vaccinations) for an expense that is gathered in real money.

Jamie Glover said...

The data coming out shows that patients at DPC practices have a lower average income than at traditional practices and DPC's have a higher uninsured and under-insured rate because the current terrible options are not feasible for these patients. I have worked at at big community health department with local funding for a low income clinic and a low income urgent care, at a private practice, and at a hospital-owned clinic. Now I'm in a DPC. More than half our patients there seem to have fallen through the cracks... not eligible for Medicaid and willing to pay the penalty for not having ACA compliant insurance because the $850 annual penalty is better to them than $850+ MONTHY that insurance would cost for them or their family. DPC seems to be what is allowing these folks to have cheap yet great access to primary care and is enabling them to add much lower cost high-deductible insurance that they actually have a change of affording, way less than the $850+ a month for comprehensive insurance. The patients I have seen at our DPC include landscapers, pest technicians, under-insured moms, long haul truckers. The beauty of DPC is that, it is also attractive to all walks of life because we also see, for example, a cardiothoracic surgeon and a psychiatrist who appreciate the value of this model as well as busy professionals. The model is about access. Insurance was never meant for cheap and simple things. It only makes those things more expensive and more complicated. Insurance is meant for expensive and complicated things. It makes those things more expensive and complicated as well, but for those things like hospitalizations, surgeries and long term care, insurance it worth it. Let me ask you this rhetorical question... would car insurance for oil changes make sense? Would you like to put it on the oil change shop to file a claim for every oil change and other basic services? Would the oil change shop get reimbursed on time? How many more staff would the oil change shop have to hire to file claims and deal with trying to get reimbursement from the car insurances? Could the oil change shop then stay in business? That is what insurance has done to primary care. Insurance is for most of the rest of care, but not for primary care. Most family medicine, pediatrics, general internal medicine and even mental health could be made much more affordable if you take insurance out of the equation. But with insurance being in the primary care equation, now the total cost of care is so high everywhere that those who fall through the gaps of ACA and Medicaid can't afford even an urgent care visit or a follow-up in the traditional model. DPC is actually turning out to be a safety net and is not going after deep pockets as is the concierge model.

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