Is Direct Primary Care a Game Changer?

by admin on 07/20/2018 1:02 AM

by Rita Rubin, MA

May 22/29, 2018

Article Information: JAMA. 2018;319(20):2064-2066.3173

Denver family practice physician Lisa Davidson, DO, ran a fee-for-service practice for 8 years, her only staff a physician assistant who was also a social worker. By 2011, her practice had grown to 6000 patients, and her rent was about to soar.

Davidson had had enough. “I wasn’t even making 6 figures, and I was killing myself,” she recalled.

Frustrated, she googled “ideal practice” one sleepless night and came across Atlas MD in Wichita, Kansas. That practice does not accept insurance, although patients still need to have insurance to cover health care beyond the scope of primary care. Instead of co-payments and deductibles, Atlas MD patients pay a monthly “membership fee” that covers all of the primary care their physician provides. But more importantly, this retainer guarantees unhurried, same-day appointments and round-the-clock accessibility to their physician, who would get to know their story “inside and out,” thanks to having to care for only around 500 patients. 

After talking with an Atlas MD physician, Davidson decided to follow suit. She still works with her physician assistant/social worker, but they now care for 600 patients instead of 6000. They each work 3-and–a-half days a week in the office, and Davidson is accessible at all hours, 7 days a week, via her practice’s email portal.

She is one of a small but growing number of primary care physicians who, for both personal and professional reasons, have decided to adopt the “direct primary care” (DPC) model.

Direct primary care is related to but not the same as concierge medicine. Both models charge a membership or retainer fee, but DPC practices’ fees are typically lower, while their panels are larger. The average DPC membership fee is $70 a month, according to Jay Keese, director of the Direct Primary Care Coalition, a lobbying group in Washington, DC, that has 770 member practices in 48 states. The biggest difference, however, is that neither DPC physicians nor their patients file insurance claims for primary care, unlike concierge physicians.

By not taking insurance and limiting their panels to only several hundred patients, DPC physicians say they have more time to practice primary care medicine the way it should be practiced, not the way payers dictate.

“The burnout in the world of doctors is largely fueled by the hectic, crazy overutilization mode that we have created with our finance system,” said Seattle family practice physician and DPC pioneer Garrison Bliss, MD, who adopted the no-insurance, retainer-fee model in 1997, before it even had a name. “There’s this notion that playing along with a corrupt, hopelessly ineffective system is good, that being forced to see 30 people a day is something you should just get over.”

Bliss and other proponents claim DPC can cut health care spending by keeping patients healthier, thus reducing their need for specialty care or hospitalization.

The question is whether DPC is indeed a better mousetrap, both for the health of patients and that of the health care system.

While the American Academy of Family Physicians calls DPC “a meaningful alternative to fee-for-service insurance billing,” the American College of Physicians (ACP) has not yet endorsed the model.

“We are interested in monitoring and understanding what is going on in terms of direct primary care and other practices that are opting for cash only,” said Robert Doherty, the ACP’s senior vice president, governmental affairs and public policy. The problem, Doherty said, is a lack of data to evaluate the effect of DPC on accessibility, cost, and quality, not only for individual patients but for their communities.

But one reason solo practitioners choose DPC is to escape “the world of data” that comes with dealing with coding and billing, Davidson said. Other types of data are more important, she added, noting that she can probably recite the names of all her patients with diabetes along with their hemoglobin A1C levels.

For some physicians, though, that benefit isn’t enough to justify the DPC model. Edmond Weisbart, MD, a St Louis family physician, emphasized the need for outcomes data. “How many flu vaccines did your practice give? That’s the kind of data that I think we need to have.”. . .

Unlike Davidson, Iora Health has to prove its worth to the Medicare Advantage Plans and to employers who pay patients’ membership fees, so it has raised venture capital funds for a system to track outcomes, said company cofounder and CEO Rushika Fernandopulle, MD, MPP.

Based in Cambridge, Massachusetts, Iora has nearly 2 dozen DPC practices that care only for people 65 years or older, as well as a few practices for younger people. Over an 18-month period, a cohort of 1176 Iora Medicare enrollees—who, based on risk models, were 1.5 to 2 times sicker than the average Medicare beneficiary—saw inpatient hospital admissions drop by half and emergency department visits decline by 20%, Fernandopulle said.

Medicare Advantage Plan members don’t have to choose Iora for their primary care, but “if they choose us, they get all this great stuff. We’ll take them to the grocery store. We’ll do free yoga classes,” Fernandopulle said. Each Iora physician works with 3 “health coaches,” who “can do a lot of the stuff that doctors would otherwise be doing,” he said, such as counseling patients about nutrition. Since Iora physicians don’t practice insurance-based fee-for-service medicine, he said, “we can be free. We can do emails and text messages. We can meet the needs of the patient and not just do what someone else will pay for.”. . .

Before she shrunk her practice from 6000 fee-for-service patients to 600 DPC patients, Davidson said, she spent 3 months explaining the change to her patients. In the end, Davidson said, only 300 of her fee-for-service patients stayed when she converted her practice to DPC, although more eventually returned. Today, three-fourths of her patients were part of her fee-for-service practice.

While there aren’t enough primary care physicians to replace fee-for-service with DPC, the latter does have its place, said Guy David, PhD, an associate professor of health care management at the University of Pennsylvania’s Wharton School. “It’s really a good model when you believe in segmentation.”

In other words, he said, healthy young people who see a primary care physician once a year, if that, could stick with a large fee-for-service practice but, as they age and develop a need to see a primary care physician more often, they would receive care from “smaller, more focused practices” that can take more time with them, David said. “That’s not a bad world to be in.”. . .

Fernandopulle estimates that perhaps 4000 to 5000 practices nationwide are at least partly DPC. And yet, Qliance, a pioneering DPC company cofounded in 2007 by Bliss, shut down in May 2017, leading some to question whether the model is viable in the long term. Bliss, who left to open his own practice before the company folded, blames Qliance’s demise on its contract with the Washington Medicaid program. “We became a predominantly Medicaid company overnight,” he said, noting that the company expanded from 6500 patients to 40 000 in only a few months. “Eventually, it became clear: Medicaid doesn’t pay for the things that we do. They pay you more if your patients are sick.”

Whether DPC expands or contracts in the coming years depends on the popularity of high-deductible health plans, David said. “If you have a high-deductible health plan, you’re going to pay out of pocket for primary care anyway.” Direct primary care “just becomes a win-win for patients and providers.” . . .

To read the entire report, go to JAMA:

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