HealthApril 15, 2020

The pros and cons of direct primary care (DPC)

By: Roxanna Guilford-Blake

How much do you know about direct primary care (DPC)? If your answer is "not much," don't worry. You're in good company. The Medical Group Management Association reports that 74% of the 1,435 healthcare leaders who responded to a 2018 survey didn't even know what DPC was!

Before we weigh the pros and cons, let's get a sense of what we're talking about.

What is direct primary care?

Direct primary care, which you may see abbreviated as DPC, is a subscription-based model for delivering primary care to patients. It's been around for about a decade, but it's only started gaining traction over the last few years. Now it's quickly becoming one of the hottest trends in primary care.

Each practice varies, but here's a snapshot:

  • Each patient pays a membership fee, usually monthly. Think of it as a subscription. (Sometimes an employer offers DPC membership as a benefit and pays the fee.) The fee generally ranges from $55 to $150. A few practices, usually with low subscription rates, add a nominal per-visit fee.
  • DPC practices don't accept insurance, and they don't participate in Medicare, Medicaid or any other government program. Their income comes from the monthly fee.
  • Patients typically receive unlimited scheduled appointments, in person and virtually. The visits are longer, allowing for comprehensive care management. Basics like vaccines are covered. Some, but not all, practices provide simple lab work, with other lab and imaging services available at a steep discount through the practice.
  • DPC practices focus only on primary care, so patients may need additional insurance for emergency or specialty care — most likely a high-deductible health plan.

What it's not: Although both are based on a subscription model, DPC is not the same as concierge medicine. Concierge practices cost considerably more, offer more services and may take insurance in addition to the membership. Concierge care typically appeals to more affluent people.

The advantages of direct primary care

DPC advocates' arguments can be boiled down to this: You can provide better, more personalized care with far fewer administrative hassles. More specifically, physicians who embrace a DPC model could find themselves with:

More control

Because you receive a lump sum — a comprehensive global payment — instead of a piecemeal "fee for service," you have greater flexibility in determining which approaches and services are best for the patient.

More time with patients

With a smaller panel of patients, you can spend more time with each one. The DPC model allows time for conversations that can yield clinical insights for care. "I know all my patients by name. I have time for them," Matthew Abinante, DO, MPH, told The DO, a publication of the American Osteopathic Association. "I probably interact with about 20 patients a day when you factor in the electronic communication."

Less administrative hassle and paperwork

You won't have to deal with insurance paperwork or quality reporting. This was a big deal for Rob Lamberts, MD. He'd often asked himself, "What would medical records look like if their only purpose was patient care?" No documentation to justify billing, no reimbursement codes — just patient information. Now he knows, he writes in a Medical Economics blog post. "I now document for care, leaving out parts of the note (what I refer to as 'computer vomit') that get in the way of patient care."

Reduced clinician burnout

Many doctors are burned out from too much paperwork and too little time with patients. Many want greater predictability and a happier work life. DPC could offer that.

Improved patient care

There's little research comparing the quality of care in a DPC practice to other primary care settings, but DPC physicians seem to think the approach allows them to provide superior service. "Eliminating all the people in the middle between the physician and the patient makes such a huge difference in the quality of care that's delivered, and that isn't lost on patients," Belen Amat, MD, told her colleagues at the Michigan State Medical Society.

The disadvantages of direct primary care

Most of the arguments against DPC focus on financial issues.

Perverse incentives

A 2018 commentary in JAMA offers this disturbing analysis: "DPC presents physicians with an incentive structure built on accepting healthier patients with limited health care needs and a willingness to pay a retainer fee."

Increased costs for patients

Patients still need insurance coverage for specialty and other types of care, which can be costly.

Lack of regulation

Various groups are shaping the definition of and standards for DPC, but there's no official framework. And because DPC does not take Medicare, Medicaid or other government funds, it isn't subject to various cost and quality regulations, such as the Medicare Access and CHIP Reauthorization Act.

The future of primary care

As noted above, the DPC model is one of the most important trends in primary care, and many physicians who adopt it appear to be satisfied. If it does increase physician satisfaction, then it may be a boon to primary care, which is facing a severe shortage. As Tiffanny Blythe, DO, told The DO, "With DPC, we're recruiting a new generation of doctors who wouldn't even consider primary care before."

But what about established doctors who want to move to DPC? It could be scary, Amat warns. "Before you jump into DPC, it feels like you're about to hurl yourself off a cliff, but then you do it and you realize it's really more like hopping off a curb. Making the move is a scary thing to do, but you quickly realize everything is going to be fine. And it ends with you realizing it was totally worth it."

Roxanna Guilford-Blake
Lippincott® Medicine
Lippincott is a leading international medical publisher of professional health information for practitioners, faculty, residents, students, and healthcare institutions with a full suite of essential medical products, from books and journals to digital solutions.
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