A response to a clumsy critique of DPC in JAMA

I was surprised to see Direct Primary Care grace the pages of JAMA for the second time in just a few months. In the July 12, 2018 issue of JAMA, Adashi, et. al opined about DPC in “Direct Primary Care One Step Forward, Two Steps Back”. As opposed to the balanced perspective provided in May, this viewpoint added nothing productive to the discussion about the burgeoning DPC movement. Unfortunately, it was also full of misunderstandings, misrepresentations, and contradictions.

I do want to give them some credit as their paper starts off with a fair description of broad healthcare goals. The importance of primary care and its ability to serve patients through “the 4 C’s (contact, continuity, comprehensiveness, and coordination)” is obvious; as well as the need to achieve “triple aim” in improving our healthcare system-- although the quadruple aim is needed in an age where many PCPs themselves are greatly suffering.

Their description of the DPC model and its purported benefits in paragraphs 2-3 is also accurate.

From there, things go off the rails.

“no study, to our knowledge, has produced data to support anecdotal claims by individual [DPC] practices.”

This is true. Like any defined model of primary care, there are not great large-scale, randomized trials to prove an improved quality of care or better patient outcomes. For logistical reasons, such objective testing of a model through hundreds or thousands of clinics without formal association is extremely difficult. Even when billions of dollars have been invested in pushing more formally defined models like PCMH, their impact is questionable and almost universally unimpressive. The same is true for Alternative Payment Models such as CPC.

Even if such studies were feasible, the demand of such from a young, grassroots model (with almost zero outside funding or mandates) is an unreasonable line of critique.

Despite saying there is limited data on DPC, the authors quickly turn to theorize and speculating on current DPC practices and patients...

Foremost, DPC practices lack specific mechanisms to counteract adverse selection that threatens equity in access to care. 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. Practices directly benefit when targeting healthier patients and declining coverage to the ill.

There is a lot to unpack here, but I can only assume the authors view all health care, including individual practices, through the prism of “insurance” and its related regulations. A DPC practice, practically and legally, is not insurance; nor is it a replacement for insurance or public assistance.

Let us consider the “adverse selection” the authors fear is occurring (or will occur?) in DPC practices. The authors clearly believe that a significant number of practicing PCPs will intentionally engage in the proverbial cherry picking of healthy patients while “declining” to care for sick people.

First, I find such a perspective completely out of touch and offensive to the entire primary care community. While businesses are far from immune to financial considerations, the PCPs I have known through my training and career are almost universally compassionate and mission-driven to care for all people who seek their care. I doubt my experience is unique but maybe Dr. Adashi has a different experience with PCPs in his career. 

Perhaps, PCPs choosing the DPC model are different somehow? As they noted upfront, the authors have no data to back-up almost any claim. But, it doesn’t stop them from disparaging the ethics and professionalism of over 1000 physicians. I wonder if the authors have met a single DPC physician; at least, then they would then have an anecdote on which to base this perspective.

I don’t have data about the ethics of DPC physician but have personally met hundreds of them. I have found them to be the exact opposite of what the authors fear. These doctors are largely driven by a desire to care for patients whom the status quo is failing.

Individual professionalism and ethics aside, do economic forces lead to healthier patients self-selecting to a DPC practice?

Let's consider this:

The number of factors that lead a patient to choose their PCP is numerous and not exclusive to the DPC model. Like any PCP practice, new patients are acquired through a variety of sources. Ultimately, patients voluntarily choose their PCP based on their preferences. Most DPC practices are community-based and independent and have no way to collectively bargain for a healthier group of patients beyond the inherent demographics of their community-- again, true of any practice.

Anecdotally, patients who choose my DPC practice do so for a variety of reasons. My personal group of patients is fairly diverse but closer to demographics of FQHC than that of suburban private practice. The value proposition for chronically ill patients-- needing frequent visits and savings on ancillary services (labs, meds, etc.)-- is obviously higher. Given this, the bias for patients seeking care in the DPC model would lean towards sicker patients; not towards healthy people who don’t expect to have great medical needs. Most DPC docs I know report high numbers of patients with chronic illness and unresolved problems. There is some practice level data on this and larger efforts to study demographics and health status of DPC patients are underway. 

In theory, some patients-- such as those with HMOs-- may be steered away from DPC practices, but this is the system, not the PCP, making demands of the patients to see a particular network PCP. 

"A willingness to pay" is a difficult thing to measure, but obviously some patients will have limited financial means; a huge percentage of my DPC patients would fit this description. There are lots of ways we could support lower-income people, including those on Medicaid, ability to choose a DPC practice. Many states are considering doing just that. If structured appropriately, I would suggest patients would welcome such an option.  

Indeed, limited existing data suggest that concierge practices, which admittedly are similar to but not the same as DPC models, are less likely than non-retainer practices to serve Medicaid, Hispanic, and African American populations, as well as people with diabetes.

“LImited data….which are admittedly similar but not the same”??!? They should’ve just stopped there. But, they go on to reference an ACP opinion piece which cites a 2005 study (prior to the existence of DPC) of the demographic concierge internal medicine patients.  By any academic standard, this is dishonest.

DPC fails to address fundamental market inefficiencies and facilitates a substantial gap in catastrophic coverage. By relying on high-deductible wraparound coverage to supplement primary care services, patients bear a steep cost-sharing burden. Even though a large majority of health care needs can be met in a primary care setting, even limited episodes of care outside of a DPC practice could be financially devastating for DPC patients.

From a primary care level, DPC addresses a huge number of “market inefficiencies”, including administrative costs which are widely accepted as a problem in American medicine.

I am not sure what they mean by “facilitates a substantial gap in catastrophic coverage”, but again, a DPC practice is not insurance and not attempting to fill that role. DPC did not create or encourage high deductible health insurance plans. So, it’s odd to say we are “relying upon it” or that we don’t recognize this problem. If anything, DPC practices are helping patients with high deductibles from piling up large bills in the standard medical system. It’s one of our main selling points to patients in fact!

Furthermore, DPC circumvents the quality metrics and incentive structures designed to improve population health and reduce national health care expenditures. DPC practices once held accountable through value-based payment systems have no obligation to report or measure quality metrics.

This is making one huge, false presumption here: Such incentive programs are actually working! There is a mountain of evidence that quality metrics have been misguided and pay-for-performance programs are failing miserably. I wrote extensively about the fundamental flaws in applying a carrots-and-sticks approach to primary care in this AAFP Fresh Perspectives blog.

Why should we apply such unproven pressures to DPC practices? 

By reducing patient panels by nearly two-thirds, without a commensurate decrease in revenue, DPC makes an implicit assertion that the health care system is better served by more primary care.

There is some debate about the size of current PCP panels, but also DPC doesn’t have a universal fixed panel size, and certainly panel size doesn't define the model.

Indeed, most DPC practices will have many fewer patients than a traditionally PCP. Inherently, this allows for more time with each patient (longer visits) and an enhanced accessibility (remote communications, same-day visits, etc.). So, in a sense, this is “more” primary care. But, more importantly, higher quality primary care that can serve more of a patient’s needs-- leading to fewer ER visits, specialists, hospitals, and ultimately less overall costs. 

Although current research does not validate the claim that primary care is a panacea for the problems with the US health care system, there is evidence that health outcomes improve when patients have access to a usual source of care and in areas with a higher number of primary care physicians per capita.

Yes, panacea’s are hard to find in complex systems.

Yes, primary care (of almost any type) is the one type of healthcare that has proven to improve outcomes. So, why are the authors so skeptical that better, or higher quality primary care cannot really help that much?

This suggests that capitated payment models in primary care have historically failed because there were no concurrent efforts to correct system-wide resource allocation differences between spending on primary care and spending on other medical care.

No, it doesn’t. Capitation models (third-party managing payments to providers) have been flawed in a number of ways. Historically, they have vastly undervalued the importance of primary care, and the time needed to perform it well-- low payments requiring PCPs to have large panel sizes. Also, capitation schemes including networks and opacity are vastly different than a patient managing their own dollars in a transparent and portable fashion.  

Though flawed in design and execution, the fundamental argument of DPC is tenable:

Translation: “Unsound in principle and reality, but fundamentally reasonable.”

They go on to say...

“comprehensive care must be compensated with comprehensive payment. DPC shifts payment from encounter-based reimbursement to comprehensive global payments, giving physicians flexibility in determining the most appropriate mix of patient services and care coordination. And then, “global capitated payments—should be applied.”

What to make of this? The authors believe a simple  “global” (e.g. bundled) fee for primary care should be used instead of fee-for-service payments, but that a patient should not (? could not) be in charge of organizing such a relationship with a primary care practice. Ultimately, the authors are fundamentally opposed to a person or family directly managing their own health care or health care dollars at any level.

Apparently, the authors trust that the powers-that-be will finally realize the massive errors of their past ways. After forty-plus years of those entities getting it wrong, I have to admit that the authors’ optimism is admirable.

In the closing paragraph, they say...

“DPC is not a scalable model” and “is not the answer to the problem.”

In reality, DPC is already “scaling”, or rather replicating, all over the nation-- now nearing 900 practices in just about every type of community imaginable. There are now a handful of DPC conferences every year that continue to grow in attendence. The DPC Alliance launched just a few months ago and already has 300 members.

So, despite Dr. Adashi, et. al, skepticism, more and more physicians and patients are showing that DPC is the solution to many of their problems.

W. Ryan Neuhofel, DO, MPH
President, DPC Alliance