Response to opinion in Annals of Internal Medicine

The DPC Alliance, the leading body of physicians practicing in a Direct Primary Care setting, recognizes that there is significant confusion and misinformation regarding the impact that the DPC model is having in health care delivery transformation. This was again demonstrated recently in an Annals of Internal Medicine’s “Fresh Look” blog post by Dr. Brian Block.

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Dr. Block’s opinion drew upon dated information and unsupported personal impressions instead of the realities of the growing DPC movement. For example, the study referenced by Dr. Block (and others before him) to characterize the DPC model as unintentionally discriminatory and prohibiting patient access was published in 2005 (before the DPC model even existed!). Also, that study comprised entirely of “concierge” (self-identified) practices which is not Direct Primary Care as it’s widely defined and practiced.

The reality is that hundreds of DPC physicians report their patient populations are not the “healthy & wealthy” suspected by Dr. Block; far from it. We recognize these anecdotes are not a substitute for objective data, but much better than conjecture from people who have zero data and personal experience with DPC practices. To help get more objective information about DPC patients, the DPC Alliance is working with academic researchers to put together a survey of patient demographics and health status… stay tuned for that.

With respect to the new Medicare payment program… In 2018, the Alliance issued comment on the initial “Request for Information” for a potential Medicare “direct provider contracting” project. Our perspective on Medicare’s role in supporting patients in choosing Direct Primary Care has not changed.

For a more real-world impression of what DPC looks like in the trenches please check Dr. Rob Lamberts’ (Internal medicine/Pediatrics physician and DPC pioneer) experience:

Comments from Dr. Rob Lamberts of Martinez, GA:

Let me comment as a fellow internist and having practice in a traditional fee-for-service for 18 years, then a DPC practice for the past 6.

First, it’s a false assumption that it’s either 1000-3000 patients or downsizing to 500-900.  I was in fairly significant burn-out when I left my practice in 2012, and would likely have found an alternative situation to my fee-for-service practice.  There was NO WAY I could practice in an environment that forced me to give substandard care and terrible customer service to my patients.  The current system seems to select against doctors who are patient-centered, and my practice was diving into a money-over-patient mentality that I could not tolerate, so I left.  DPC saved me, allowing me to give high-quality care to 800 patients. I do not believe I was giving anywhere near my current quality of care to any of my 2000+ patients in my old practice.  Is it truly better to give substandard care to a higher number than it is to give excellent care to less?  I don’t think so.  Additionally, we are adding 4 new DPC providers in our area, ALL of whom are coming from either an urgent care or hospitalist setting.  They are leaving because of the ability in DPC to give care like we always wanted to give and they feel abused in urgent care where they see 50+ patients per day. There are lots of providers like them who are coming back to real primary care from outside of that system and bucking the trend away from primary care, instead adding to the providers available to patients.

Second, the policy statement cited was from 4 years ago (2015), a time when DPC was much smaller and less developed than it currently is (it has roughly doubled in that time).  The development of tools to extend the reach of DPC (as it, as you say, is a model that favors innovators) and the movement itself has organized to improve itself, forming bodies like the DPC Alliance and others.

Third, the population of my practice includes approximately 20% Medicare (I am med/peds) and has a significantly lower median income than my old practice.  I am caring for uninsured and many who are disenfranchised by the money-centered care that dominates our system.  I also have about 10% Medicaid patients in my population.  My practice is far more diverse, far less WASP than my old suburban FFS practice.

So, is there any chance DPC doctors will embrace these Medicare proposals?  Why? Would a freed prisoner want to go back to the jail because they got some nicer furniture? My life is better.  My care is MUCH better.  My patients are happier.  I am caring for more of the poor than I ever did in my money-centered practice.  Business are beginning to bang on my door because of the benefit we can be to their employees.  We are beginning to engage some larger businesses, pairing DPC with level-funded self-insured plans that will save them large amounts of money while improving care for their employees and decreasing absenteeism.  Is this pie-in-the sky?  It is being done all over the country now (perhaps not in 2015, though).

DPC is an innovation.  It is not perfect, and there are ways it can be improved to increase its outreach.  But it is a breath of life into primary care which was dying under the obscene burden put on it by blind government agencies and money-hungry insurance companies.  I am baffled by ACP’s continued tepid approach to the first good news primary care doctors have gotten in a VERY long time.

We hope this information clears up any confusion for Dr. Block. But, if questions remain, the Alliance has hundreds of physician-members around the nation who are happy to provide an actual fresh look at innovative primary care.

Joe Grundy
Executive Director, DPC Alliance