The only thing more fundamental to Direct Primary Care than the monthly fee is the direct relationship, both medically and financially, between the patient and physician. While payment structure defines the model, refusal to allow in middlemen rallies the movement. Removing insurance from the mix has allowed DPC physicians to run successful businesses in a setting where fewer and fewer physicians work for themselves, much less own their own practices. Many DPC offices are completely run by the physician themselves and the majority of practices have no more than a handful of staff. Usually, the larger a practice, the more staff it has due to an increase in tasks and the physician focusing their time on seeing patients and leading the practice. Growth of any practice follows this natural evolution, and the same principle which draws more people to a single practice as it grows, also applies on a larger scale to the community as a whole. As the DPC model grows, specialization necessitates more players in the game, which raises the questions of who gets to join the community and on what terms.
Thinking outside the insurance box- dropping the assumption that health insurance pays for all things healthcare- was a marketing struggle for early DPC physicians. Even now potential patients will ask unabashedly why they should pay for primary care services which are already “included” in the insurance plan. Hundreds of DPC practices around the country have succeeded in answering the question and have filled their panels with individual patients; and for the most part, individual patients have driven the early growth of the DPC movement. However, the individual patient market has limitations as it only captures two groups of the entire population:
- Those with insurance who have access to primary care but want to and can pay extra for the value of direct primary care
- Those who can only afford DPC as all other options to healthcare access are too expensive.
These two groups exist paradoxically at either end of socioeconomic status, a testament to the versatility of the DPC model.
Understanding the coverage of most Americans allows for better recognition of where ongoing efforts are aimed in recruiting more patients to DPC. About half of the US population has insurance coverage provided by their employer. Fifteen percent are covered by Medicare and and a fifth are covered by Medicaid. Since these populations have their health coverage provided by an entity, they will subsequently expect their healthcare to come from the entity. Approaching these populations without engaging their insurance-providing entity proves difficulty for various reasons. Employees expect health benefits to come from their employers, so they often don’t see a need to pay for DPC services themselves. Most Medicare recipients do not feel they should have to pay more for health benefits which they spent their whole life paying into. Medicaid patients generally can’t afford the monthly fee. Fully reaching this 85% of the population requires engagement with the respective insurance providing entities, thereby introducing the first third party member- the payor.
Insurance and government as a payor for the last decade or so has come with “quality” metrics, another reason many physicians find themselves fleeing to DPC. Time has unfortunately allowed data collection and metrics to root into the culture of healthcare. While most DPC physicians usually eschew any sort of reporting or data collection, the critics will always have a leg to stand on if no objective evidence proves the superiority of DPC over FFS. Perhaps the biggest issues with the current FFS metrics are the lack of relevance to actual patient care, the administrative burdens on the physician in reporting the measures, and the coupling of reimbursement with these faulty measures.
DPC’s monthly fee has fully separated reimbursement from any sort of third party performance grading; and because of the separation, DPC can lead the charge in changing how value in primary care is measured. Already people are looking at alternative, better ways to evaluate primary care, such as the Person-Centered Primary Care Measure (PCPCM). Certain companies exist to help collect and process data. While EMRs can do some rudimentary analysis, this is not the main function of EMRs and they also vary widely from one to another whereas objective analysis needs standardization. In order to spearhead the change for defining value in primary care while reducing administrative data collection tasks, the next third party arrives- data collection and analytics.
Innovation which exists in a bubble will inevitably pop and disappear forever. Luckily, DPC has already begun to change the landscape around it. Labs, imaging, pathology, specialists, and ancillary services are examples of major areas where the direct pay model has already begun to disrupt in big ways. From these primary care associated services come many potential third parties, though a little more indirect than the aforementioned two. In fact, if all services outside the direct physician-patient relationship are considered third-party, then even the Direct Primary Care Alliance, an organization by DPC physicians for DPC physicians, would be considered a third party intruder.
By convention, the “third party” usually applies to the payor, but because the DPC community has removed itself from insurance and has thrived on keeping things simple, a culture has grown where various outsiders are considered third parties and viewed negatively. Some of the more common groups who have tried to enter the DPC space and have been immediately blacklisted by the community include certain brokers, non physicians who try to create “networks”, and most non-physician individuals or groups who promise to help grow DPC or make DPC physicians more money somehow. Up to this point, these outsiders have been filtered out through community shaming via Facebook or other social media. As the community grows and turnover happens, with older physicians spending less time on the forums and newer people taking the reins, a set definition or guidelines for acceptable third parties should be set for posterity. Based on the fundamental principles of DPC, working with a third party can only happen if all the following criteria are met:
- Adds value at least in direct proportion of added cost
- Value added serves an essential purpose
- Payment structure does not interfere in the direct relationship between patient and physician or with physician autonomy
- Aligns with the general philosophy of DPC and associated values.
Specialization has always come with bringing in more individuals to promote growth and efficiency. But like a person who’s spent a life consuming fast food, our current healthcare system has grown large out of convenience and perverse financial incentives with deleterious results. To contrast the unhealthy growth of our current system, the growth of DPC its surrounding ecosystem needs to occur in a way which does not compromise its core values or introduce perverse incentives. To stay fully insular leads to stunted or fully stalled progression, but to accept all offers can lead to quick perversion of the original principles and a loss of direction for the future. Building the infrastructure around the core doctor patient relationship will require careful consideration of new potential players in the DPC space.
