A Rebuttal

Kenneth Q
6 min readJul 21, 2018


JAMA published an article on 7/12/18 titled Direct Primary Care: One step forward, Two steps back by Adashi et al. from Brown University. This article presents some of the classic opposition to Direct Primary Care (DPC) and truly highlights the misconceptions people have when thinking about it. https://jamanetwork.com/journals/jama/fullarticle/2688238

To date, uptake has been limited, with only an estimated 13% of primary care physicians adopting some form of direct payment models.

The insinuation here is that the DPC movement is not gaining traction, whereas in actuality, the number of practices has been growing rapidly. There are currently almost 900 practices across the country, double from 2016 and growing at an exponential rate¹.

Individual DPC practices have indicated that practice-level data on outcomes support these claims; however, no study, to our knowledge, has produced data to support anecdotal claims by individual practices.

Here you go: https://www.dpcmh.org/dpc-presentations

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.

Most people in the healthcare sector, especially non physicians, have conditioned themselves to think only in terms of insurance. This idea of cherry picking patients originates from the unintended consequence of capitation, which is where an insurance company pays the doctor a certain $ amount per patient per pay period. The less a doctor uses those dollars on the patient, the more he gets to take home. DPC on the other hand is a non discriminatory free market model. If a patient pays their monthly fee, it doesn’t matter if they’re young and healthy or old and complicated, they will be seen. Having the time to see patients longer also helps remove the drive to hand pick healthy patients. More complicated patients usually means more visits and more visits in the current system means less money under capitation. DPC docs don’t care how often a patient visits per month and each visit can handle so much more than a traditional visit (with no modifier 25 needed!).

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

The article itself earlier differentiates, quite well, the difference between DPC and concierge. To then lump the two together in order to impose a weakness of concierge to DPC in the very area where the difference is the biggest is simply ridiculous and shameful.

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. The success of DPC hinges on the presumption that primary care can yield a net financial advantage for patients by replacing or preventing the utilization of subspecialty, ancillary, and hospital care.

Lots of words here which just says DPC makes healthcare more expensive for the patient. In 2016, the average unsubsidized individual paid $321 per month for their insurance product which gifted them an average deductible of $4,358². With these high deductible plans, virtually nothing is covered before the deductible is met. DPC on the other hand, with its $70 average monthly fee, includes not just the annual visit, but also any sick visits and chronic disease management. Which is more expensive: having comprehensive primary care for $70 a month or paying $321 dollars a month for a “free” annual physical where you can say literally nothing and hope your labs and vitals are normal or else get double billed and end up having to pay for a sick visit out of pocket because you haven’t met your deductible. For generally any insurance, chronic care management is not part of this “free” annual physical. From the primary care side itself in which “a large majority of health care needs can be met,” there are already tremendous savings.

In regards to specialists and ancillary services, having more time and providing better care allows DPC docs to refer less and manage more. When physicians are only given 10 or less minutes to manage complex issues, they are going to refer more, out of necessity. When more time is given and they actually have time to think, you can bet they are going to do more themselves. Besides for the obvious money saving in not having to pay all the different specialists, there is a big time cost saving too by not having to make appointments with, visit, and coordinate 3–4 different specialists.

Yes, sometimes people will need to go to the hospital or some devastating disease will happen. That is the point of having insurance. If the vast majority of patients paid for their primary care directly, which could handle the vast majority of issues, it would leave insurance to help mitigate the risk of having a severe illness or injury, creating a leaner and cheaper system overall.

Furthermore, DPC circumvents the quality metrics and incentive structures designed to improve population health and reduce national health care expenditures.”

False. DPC is currently one of the models being evaluated by CMS in their Transforming Clinical Practice Initiative³. There are also Medicaid pilots happening or about to happen in Kansas, Nebraska, and Michigan.

DPC practices once held accountable through value-based payment systems have no obligation to report or measure quality metrics.

Just wanted to point out here that we have had numerous attempts over the years to “measure quality metrics” and incentivize behavior changes through those metrics. I personally have not heard or seen any obvious systems improvement in the last 20–30 years since the idea of reporting metrics became popular. If anything, all it’s done is burned out thousands of physicians and led them to early retirement. Not saying that measuring outcomes is not important, it is, but there are better ways to do it than linked to payments via insurance or federal government. Jumping through hoops imposed by government or insurance is not a prerequisite for an improved care model.

DPC allows practices to avoid the undertaking of adopting alternative payment models designed specifically to promote high-quality, cost-efficient care.”

Rewrite: DPC is an alternative payment model designed specifically to promote high-quality, cost-efficient care.

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. 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

I’m just going to let this self contradiction sit as is.

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.

DPC looks like capitation but is not. Capitation incentivizes less visits and more referrals while DPC does the opposite. To illustrate the difference in underlying psychology and motivation between DPC and capitation, imagine I make and sell lemonade. If I set a price for the lemonade and a customer pays for my lemonade, I’m going to ensure the customer gets the best lemonade possible and will do everything in my power to ensure quality so the customer keeps coming back. This is DPC. Now, if a big company puts me in a network of lemonade sellers and says they will pay me a certain amount per customer and will assure customers come by putting my name on the in-network list, I’m likely going to create a watered down product that just barely counts as lemonade in order to maximize my payment from the big company since customers are coming anyways and, at the end of the day, its the company that pays me, not the customer. This is capitation. As it relates to primary care, better lemonade means more access and better, more comprehensive treatment, both medical and personal.

Changes to the current fee-for-service reimbursement model are needed, but DPC is not the promised panacea of payment reform…

The entire conclusion is based on looking at our healthcare system through the lens of insurance. The wordage used more than proves it. DPC is a simple idea which requires thinking outside the insurance box: when there is no middle man in primary care, you get more engaged doctors, more satisfied patients, better outcomes, and cheaper healthcare overall.

  1. https://www.dpcfrontier.com/mapper/

2. https://www.cnbc.com/2017/06/23/heres-how-much-the-average-american-spends-on-health-care.html

3. https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/