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.
