Showing posts with label direct primary care. Show all posts
Showing posts with label direct primary care. Show all posts

Tuesday, July 9, 2024

"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 medicineJ 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!

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.

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