Retort to a limited understanding of DPC in STAT

Recently, the Direct Primary Care (DPC) movement has attracted a lot of attention in the op-ed pages of reputable publications. Given our swelling ranks, I guess the attention was inevitable. A few of these opinion pieces been have filled with misunderstandings about the DPC model, but Timothy Hoff, Ph.D. healthy policy professor at Northeastern University, recently took his critique of DPC model and physicians to another level in STAT News.

As always, DPC physicians are happy to educate people about primary care and the DPC model, so I will respond to Timothy’s concerns directly and point-by-point.

“Some view it (DPC) as a panacea, others as snake oil. I’m not sure what it is...”

I don’t know a single DPC physician who believes that the DPC model is a “panacea” for all of the problems in the health care system; nor does anybody believe DPC is a replacement for health insurance or public assistance.

Snake oil”? I would expect somebody with a Ph.D. working for an academic institution to use less empty and inflammatory rhetoric. Are you suggesting that DPC practices are perpetrating actual fraud? Or are you just reporting other people believe that?

Timothy, you definitely proved you don’t know what what DPC is repeatedly in this ill-informed opinion. Perhaps you should’ve just stopped there, instead of baselessly attacking it?

“direct primary care is a model for delivering primary care, and only primary care.”

And only primary care? Yes, it is right there in the name...Direct Primary Care.

You then state that primary care cannot care for “more extensive management of a chronic disease”. Sir, you have no concept of what primary care physicians do-- DPC model or otherwise-- around this nation on a daily basis. We care for nearly every common chronic disease you could name (and many you couldn't); as well as provide care for a patient's’ symptoms of uncertain origin, acute needs, and psychosocial problems-- often all at the same visit. I realize you didn’t go to medical school, so if you need a comprehensive list of problems and diseases I diagnosis and manage, I’m happy to provide it for your review.

Sadly, your perspective about the limited role of primary care is all too common. I suppose this view has some validity as the American health care system that has undermined our value for many decades. (If you aren’t familiar with why, I'd suggest you read up on the AMA RUC) This low valuation slowly warped the nature of primary care itself. Too often, rushed primary care physicians are forced in to being a referalist, rather than an actual clinician.

The DPC model has many benefits, but most importantly is that it provides an opportunity and environment for PCPs to provide a higher level of care than is possible with 10 minute visits and juggling a panel of 2000 or more patients.

“the physician or practice will charge the patient extra fees to cover those services (chronic disease management).”

I am not sure where you got such information (I know a few DPC doctors in Boston area and you certainly didn't chat with them), but DPC fees nearly universally cover management of chronic disease without “extra fees”.

At least you recognize-- sort of-- the problems primary care physicians face with “burn out” (I prefer the term moral injury), administrative hassles, and lack of time with their patients; leading to poor doctor-patient relationships. And, you admit that DPC might be a better in those respects; as well as appealing to patients.

But, you must believe improving those issues is not significant enough to be a net positive. I guess it’s easy to downplay this since they don’t affect you personally. Although, I would note that unhappy doctors often provide inferior care to patients.

Besides, would you like your personal doctor to be miserable? As long as they are in your insurance network, maybe that is an acceptable trade-off to you?

“From a numbers standpoint, direct primary care is self-limiting in how many patients it can serve.”

I didn’t realize primary care physicians in traditional models could take on unlimited numbers of patients. What is the first question many patients ask upon calling a new doctor's office? "Are you taking new patients?" They ask because many PCPs in traditional models cannot and do not take on new patients. 

The DPC model is not defined by an exact number of patients per physician, but indeed, most will carry a smaller panel size than a traditional, modern PCP.

If you think caring for fewer patients is inherently a bad or unethical decision, can you please provide us with an exact minimum number of patients (e.g. panel of 2387 or 23 visits/day) so that we can be certain to be in professional good standing with your standard?

Besides, are more patients per PCP better? Would you like your personal PCP or specialist of choice to be responsible for 5,000 other people’s care? or 10,000? Or are those volumes just okay if it’s other people's’ doctor?

“They likely include a disproportionately high percentage of healthier, “worried well” individuals.

This is an enormous amount of speculation for a person in an academic position. You provide zero data to support such a presumption. But, let's consider this from an economic incentive perspective:

The number of factors that lead a patient to choose their PCP is numerous and not exclusive to the DPC model. Ultimately, most patients will voluntarily choose their PCP based on personal preferences. Anecdotally, patients choose DPC practices (versus other options for primary care) for a variety of reasons, but namely for reduced out-of-pocket costs, and/or improved access and experience.

Given the flat monthly fee for services, 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.

“direct primary care physician or practice functions as an insurer.”

No, they do not.

DPC practices, functionally and legally (based on 25 state laws), are not “insurance”. The DPC practice agrees to provide a certain set of services (namely the physicians time) to a patient for a fixed monthly fee. While some DPC practices will include services such as EKGs, procedures, less expensive labs, and point-of-care tests, for no additional fees, these costs account for a tiny fraction (< 1%) of a practice’s operating expenses. I doubt you know this Timothy, but band-aids don’t actually cost $50 a piece as is often found in hospital charges. So, appropriately structured, there is no real financial risks to a DPC practice.

If you are worried about practices functioning as insurance, I would take a look at those participating in Accountable Care Organizations (ACO) which are assuming actual financial risks based on total patient health costs.

“The direct primary care model can get expensive for patients, making it a model that caters to the affluent and potentially worsens inequities.”

You have a Ph.D. in health policy, so I’m sure you realize the per capita spending on health care in America is now over $10,000/year. Most of those dollars are sunk in to insurance premiums (often hidden by layers associated with employer-based coverage and taxes), but an increasing number of Americans have high deductibles and "out-of-pocket" (after the premiums) expenses.

In 2017, the average individual plan's deductible was $4,358, and for a family plan it was $7,983. Some large employers are still maintaining low deductible plans (at the expense of lower paychecks for employees) but even those plans are increasingly rare.

If you are keeping tally, many American families now pay $12,000-18,000 (individuals $6,000-12,000) of their own money in a given year prior to their insurance plan picking up a dime of the tab; and they still usually owe 20% of costs after that to some astronomical "out-of-pocket maximum".

But, you may say, "yeah, but at least insurance protects a person from financial ruin." You'd be wrong there too. Studies have shown that 70% of bankruptcies related to medical care debt occur in people with insurance! And many more insured people worry about being able to pay their medical bills. 

In that context, a membership fee of $50-100/mo ($600-1200/yr) for comprehensive, high quality primary care services doesn’t seem so expensive. Many patients who choose DPC are exactly the same people suffering financially under the status quo.

“patients’ paying $1,500 a year in retainer fees”

Perhaps you didn’t have time to research much, but the vast majority of DPC practices are much less expensive than $1500/year. The DPC Alliance has over 200 active practices and over 90% of those practice have fees under $100/mo ($1200/year); two-thirds charge $50-75/mo, but many are less than per person when considering child and family discounts.

“direct primary care model places greater responsibility on patients to know their medical insurance inside and out. They must also become the liaison between their direct primary care physician or practice and their insurance plans….direct primary care shifts a lot of the insurance paperwork and administrative burden onto the patient.”

First, do you have any idea of how much paperwork is traditionally required of patients when they visit a doctor’s office using insurance? Have you ever been? If not, patients are typically flooded with forms upon arrival; every time they go. Subsequent, patients often receive confusing bills and explanation of benefits months after care that even doctors have trouble deciphering. The usual system is hardly devoid of paperwork or administrative burdens for patients!

With respect to DPC, in most cases, a patient chooses DPC in lieu of their options for “in network” primary care services. Patients do not submit DPC fees for reimbursement from an insurance plan. Simply, there is no extra paperwork required if patient opts for DPC.

On the contrary, a DPC clinic is likely the only place that provides patients upfront, easy-to-understand pricing and payment on a wide array of medical services. If a patient does require care outside of the the DPC practice, we can now serve as a stronger advocate for our patients because we are afforded such time. If a patient prefers, they can opt for a network speciality provider when needed as usual-- although many patients will find those things (radiology, medications, etc.) more affordable with a direct pay option. Either way, a DPC physician can be helpful in navigating those options.

“In the very best case, direct primary care could make some doctors and patients feel more connected to each other, and might even help produce a better care experience. But given significant problems with the model, I don’t expect to see direct primary care taking on a significant number of patients across the country any time soon.”

Again, how can you downplay the significance of better relationships and patient experience? If that doesn’t matter, what does?  

“There’s a bit of smoke and mirrors here, as direct primary care tries to convince patients that the rest of the health care system, like hospitals and specialty physicians, doesn’t really exist.”

Huh? I'm not sure if you are being literal here, but...

Compared to our small, quaint clinics, most hospital systems have giant, multimillion facilities, so it’s pretty hard to hide their existence.

“And as long as many patients have to deal with the rest of that system on a consistent basis as they acquire more serious conditions and have constant needs throughout their lives for complex diagnostic and treatment care, direct primary care will be of limited help.”

Timothy, I have seen lots of policy wonks view primary care physicians as less important than their speciality peers, but your disdain is beyond the pale.

Despite your skepticism, the DPC movement is growing in every corner of this country; now over 900 DPC practices, with steady growth year to year. You may not understand why anyone would choose an independent DPC physician over an insurance-managed provider, but frankly, that doesn't matter to our patients. We are showing them the real benefit of high quality, transparent primary care every day.

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