"Direct primary care" not the answer for our health system. Beware "Project 2025"!

My last post (June 27, 2024) was about the shortage of primary care physicians (as well as NPs), and the reasons why. To save you the time of (re?)reading it, here is the bottom line: It’s the money, stupid! Primary care physicians – and NPs – get paid a lot less than those working in subspecialties, for what is indeed very hard work, encompassing breadth (everything), depth (everything), and time. I also suggested that there was a relatively simple way to address the income disparity between primary care and subspecialty practice: having Medicare revise the criteria for payment, which affects not just Medicare but also the rest of us as most insurance companies base their reimbursement rates on Medicare’s.

There have been other suggestions on how to “help” primary care. One of them, which has been seen in many places across the country for years, involves having people pay extra money (usually in an annual or monthly fee) to their primary care doctors to supplement their income and to make them more available to their patients. This phenomenon has many names -- “concierge care”, “boutique care”, “direct primary care” -- depending both on the way it is structured (and the amount of the additional fee) and how the user wants to spin it – are they portraying it as good or bad?

One place where it is portrayed as good is in the Project 2025 document issued in April by the Heritage Foundation and its allies, Project 2025 Mandate for Leadership: The Conservative Promise. This document outlines an ambitious, far-reaching, and horrifying vision for the future of the federal government once “conservatives” take the White House back. It systematically goes through every federal function, and many agencies, detailing what should be eliminated or scaled back (mostly) or expanded (rarely, mainly tax cuts for the rich). It manifests a vision of America where the corporations and the richest individuals are even richer and more powerful than they are now and the “poorest” (meaning not just the poor but working people and the majority of those who consider themselves “middle class”) are even worse off.

How does this relate to primary care? One of their (many) plans for healthcare in this country, discussed in the Health Justice Monitor, is to “Remove barriers to direct primary care”. That the Heritage Foundation is for it should in itself be a warning. They like it because it is “free enterprise” and comes from a libertarian approach that basically maintains that it is good to sell (to people who can afford it) those basic things that everyone should have as a right. Also, like most (all?) things endorsed by these “conservatives” (who mainly wish to conserve privilege) it ignores the negative impact on those folks who cannot afford to buy it.

This is not to say that everything about direct primary care as it exists currently is bad. I know many doctors who chose it because it allows them to make a living, yes, but mostly because it permits them to more fully and completely practice the kind of medicine that they trained to do because they wanted to do it, manifesting the 4 C’s of primary care – comprehensive (more or less), first contact, caring, and continuous over time. Most of them had previous jobs where they worked for big health systems (and, increasingly, private equity companies) in which they were continuously pressured to work faster, see more patients for fewer minutes, and generate more income for their employers – a concept” familiar to manufacturing jobs called “speed up” that comes from literally increasing the rate of speed of an assembly line. By charging a (modest, in many cases – this is not about true concierge care where the charges can be $10,000/year or more) fee, they are able, they believe, to take care of most of their patients’ problems, do it compassionately, see them for long enough to do so, and be available to them when they need it. These are all good things, and like most of the doctors I know who are doing this, most of the people I know who go to them as patients appreciate it and think it is beneficial.

So, what is the problem? Well, obviously, it is not available to everyone, to those who can’t afford an extra fee, and already have a problem with their insurance premiums, deductibles, and co-pays. Note that when Project 2025 says “DPC has faced many challenges from government policymakers, including overly exuberant attempts at regulation and misclassification,” the solution they propose is to ensure that the payments for it are not paid by insurance or health savings accounts. That many, most, people can’t afford DPC is the big objection to it, but there are also other problems. DPC hearkens back to the days of the old GP, where for a small fee (or a chicken) avuncular Marcus Welby could take care of all of your problems (of course, old Marcus somehow managed to stay in practice with only one patient a week). But medicine is not like that anymore. While I am a huge advocate for primary care, for family medicine, for comprehensive practice, providing all the benefits that modern medicine has available often requires more than the one primary care doctor can do. It may require specialists, both knowledge-based and surgical. It may require imaging (x-rays, CT, MRI, PET). It often requires laboratory tests and medicines. It requires other people and other resources.

Moreover, as reported in (among many places) a succinct and accurately titled Medscape Medical News article, July 2, 2024, “Better Access for a Few Patients Disrupts Care for Many”. With so few doctors (and NPs) entering primary care, the impact of those entering DPC further decreases the number of providers for those who cannot afford it. Adam Leive, one of the authors of the article on which this report is based (“On resource allocation in health care: The case of concierge medicine” J Health Economics, July 2023) is quoted as saying “Concierge medicine potentially leads to disproportionately richer people being able to pay for the scarce resource of physician time and crowding out people who have lower incomes and are sicker". This is the key point. The Medscape article also adds that ‘Leive's research showed no decrease in mortality for concierge patients compared with similar patients who saw non-concierge physicians, suggesting concierge care may not notably improve some health outcomes.’

Let’s get this straight. The Heritage Foundation’s support for DPC, and indeed elite concierge care, is because they are right-wingers whose agenda is all about further privileging the privileged and ignoring the needy. The large insurance and private equity companies who sponsor versions of DPC are doing it to make money. The primary care doctors who are engaged in it are (mostly) trying to make a living and provide quality care in miserable healthcare system (although not yet as miserable as the one Project 2025 envisions). These doctors are basically engaged in a “work-around” that does help some people, if not everyone, to have better access if not health outcomes.

But we don’t need a “work around”. What we need is a well-designed, single payer, comprehensive, cover everything, no co-pay or deductible, no necessary services that are not covered, health system. Improved and expanded Medicare for All!