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!

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[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.