My answer to direct primary care evangelists

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One thing I’ve  learned is that physicians who have gone into direct primary care (DPC) practices are passionate about their decision: they not only believe that DPC is better for their patients and their own professional and career satisfaction; many  assert it is the answer to just about everything ailing primary care.  There is an evangelical fervor among some DPC advocates to spread the word and convert other primary care physicians to their cause.

It’s no surprise to me, then, that many of have expressed frustration—to put it mildly—that ACP has decided not to endorse or promote DPCs. Instead, our 2015 position paper, for which I was the lead author on behalf of the College’s Medical Practice and Quality Committee, aims to provide a balanced and evidence-based assessment of the potential impact on patients of practices that have one or more of the following 3 features:

They charge monthly per patient retainer or subscription fees.

They do not participate in insurance contracts

They have reduced their patient panel sizes well below the norm. 

The American Academy of Family Physicians says that “Generally, DPC physicians have a panel of between 600 and 800 patients. In typical FFS settings, the patient panels tend to range from between 2,000 and 2,500 per family physician.”

One of the challenges ACP found in assessing the impact of direct primary care is only one variation of practices that charge retainer fees, do not participate in insurance, and/or have smaller patient panels.  For example, practices often described as “concierge” practices often charge much higher monthly per patient retainer fees than most DPCs say they charge.  (Many DPC proponents fiercely object to being labeled as concierge practices). 

Yet ACP found little in the literature that defines the accepted range of monthly fees charged by DPC compared to “concierge” practices—Medical Economics magazine says they typically range from $50 t0 $150 per month, citing AAFP.   A study in the Journal of the Board of Family Medicine (JBFM), which was published after ACP had completed the literature search for our paper, reported that “Practices that used the phrase DPC on average charged a lower fee than practices that used the term concierge to describe their model: $77.38 compared with $182.76, respectively. Of 116 practices with available price information, 28 (24%) charged a per-visit fee, and the average per visit charge among this group was $15.59 (range, $5 to $35). Thirty-six of these 116 practices charged a one-time initial enrollment fee, and the average enrollment fee among this group was $78.39 (range, $29 to $300).” 

The wide variations in the monthly fees charged begs the question:  at what point, does the monthly fees charged by DPC practices make them concierge? 

Our paper found examples of DPCs that provide low cost and accessible services to all types of patients, including Medicaid patients.  Yet we also observed that there is a potential that less well-off patients, who can’t afford to go without insurance or pay a monthly fee, might be disadvantaged.  Guided by our Committee on Ethics and Professionalism, we accordingly urged physicians who are considering DPC, concierge or other practice arrangements that have one or more of the features described above to consider steps, like waiving or lowering monthly fees for patients who can’t afford them, to mitigate any potential impact on undeserved patients.  Perhaps most importantly, we called for more research on the potential impacts of such models. 

This reasoned position, neither endorsing or opposing DPCs,  instead calling for more research and consideration by physicians who enter into such practices of steps that could mitigate any adverse impact on poorer patients, has been misinterpreted by some DPC advocates as ACP being opposed to  DPCs.  This is not the case.  Our paper clearly states that physicians should have a choice of entering into practice arrangements that provide ethical and accessible care to their patients, which can include DPCs that meet the ethical considerations laid out in paper.

In a recent letter published in the Annals of Internal Medicine, I responded to a letter from Dr. Martin Donahoe that was highly critical of what he called “luxury care clinics,” especially in academic medicine.  I cautioned against painting too broad a brush in characterizing the motivations of physicians who charge monthly retainer fees and have downsized their patient panels:

“I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spending time with patients.  Many say that they charge low monthly fees so that they can be accessible to moderate- and low-income patients at less out-of-pocket cost to patients than many high-deductible insurance plans offer. I caution against painting with too broad a stroke in assessing the motivations of physicians in practices that charge retainer fees or limit the numbers of patients they see and about the effect that such features have on poorer patients. Rather, we need more unbiased research and evidence—while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is nondiscriminatory based on a patient’s income, gender and gender identity, sexual orientation, race, or ethnicity, regardless of the type of practice—concierge or not.” 

I am heartened that Dr. Bob Centor, chair-emeriti of the ACP Board of Regents and a long-standing proponent of direct primary care, blogged that my Annals letter was “a very thoughtful rebuttal” to Dr. Donahoe’s broad condemnation, noting that “ACP has an excellent position paper on direct primary care,” referring to our 2015 paper.

Yet some DPC evangelists remain satisfied with the College’s position that we need more research on the impact of DPCs  on quality, access and cost, especially for underserved populations.  One DPC evangelist—a DPC physician himself, and one of the co-author of the AJFM study cited above—called the analysis by ACP, our Medical Practice and Quality Committee and our Ethics, Professionalism and Human Rights Committee “ignorant”—even though his own ABFM study concluded that “Most DPC practices are young and small and thus lack sufficient quality and cost data to assess outcomes thus lack sufficient quality and cost data to assess outcomes.”  Calling one’s colleagues in another primary care field “ignorant” is a sure fire way to win people over!

Finally, it needs to be acknowledged that there is a significant crossover between DPC advocates and anti-Obamacare physicians.  Just do a Google search of “direct primary care as an alternative to Obamacare” and you’ll find dozens of commentary about why DPC is a “free market” alternative to the Affordable Care Act’s insurance regulations, alternative payment models, and other features.  ACP, which strongly supports the ACA’s benefit requirements, subsidies, and consumer protections, would have difficulty embracing a movement that many of its own advocates assert is intentionally designed to subvert the ACA.  DPC, on the other hand, could be a reasonable option that exists as already permitted by the ACA, as long as it doesn’t weaken the law’s consumer protections.

So this is how I see things.  It is fine for DPC advocates to promote the benefits of this model.  It is fine that many physicians are considering going into a DPC, motivated by their desire to  desire to spend more time with their patients, although I would encourage them to consider the steps recommended in our paper to mitigate any adverse impact on poorer patients.   It is fine—in fact, imperative—that there be more research on the impact of DPCs on quality, cost, and access.  However, the evangelical strain of the DCP movement that seeks to convert ACP, and everyone else, to endorsing the movement—your either for or against them—is not going to result in the respectful, evidence-based dialogue that is needed. 

Today’s question: what is your opinion of Direct Primary Care?