Direct Primary Care
By innovating to a DPC model, primary care physicians offer a membership-based prospective payment model as an alternative to fee-for-service insurance billing. Instead of taking insurance, physicians charge patients a retainer that covers all or most primary care services, including clinical, laboratory and consultative services as well as care coordination and comprehensive care management.
Promise
No more insurance
The direct primary care promises physicians to step off the fee for service “hamster wheel”. Improved care is enabled by increasing access and visit lengths while decreasing patient panel size and the administrative burden of trying to get reimbursed. Most importantly it offers the time and freedom to actually fully care for their patients while attaining a sustainable practice to life balance. It restores professional satisfaction and optimizes the primary care experience.
Peril
Inertia, can't make the leap
Physicians often describe their decision to move into DPC practices as a jump or a leap based on the benefit of practicing on their own terms outweighing the risks of trying something new. The main perceived risk was financial. They feared moving into unknown territory with initially less cash flow and not knowing the duration it would take to get their membership to a practice-sustaining level.
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Voices
I get up every day and really like what I do.
I’m able to give people information that’s customized to their healthcare needs. People come to see me because they like me personally and I’m connecting with them.
Now I am using a lot of technology to stay in contact with patients – text messaging and patient portal to connect and make it easier to provide good care.
I had thousands in this community that said they thought I was their doctor, but I was really covering for others and seeing them.
I want to get other providers or NP’s that work with me, that share my level of personal connection with patients.
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It’s (DPC) just a dream job compared to FFS and filling out insurance forms and all that kind of thing.
There’s an opportunity to turn this into something that actually could be a system fix with comprehensive care, coordinated care, accessibility of services, quality and safety, all that kind of stuff.
We wanted to be able to perform better population health management and then also risk stratification of the panel and then target the people who needed care proactively.
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Success Factors
DPC Works
This lab provides ten proof points that DPC works to eliminate burnout, improves professional satisfaction and the family medicine experience. The results and conclusions are loud and clear. The
DPC prospective payment model allows physicians to lower the size of their patient panels and their
overhead both in time and money. This allows them to spend all the time they want and need with their
patients and on their care. DPC offers a compelling alternative to the predominant fee-for-service
practice, particularly for family physicians who are experiencing burnout. DPC is an example of the
likely essential innovation of prospective, value-based care.
Why don’t more family physicians adopt DPC?
Although DPC has been around for well over a decade, the AAFP DPC Survey shows 6% of family physicians have adopted DPC. The adoption as measured in the AAFP Annual Survey has grown in a
modest linear fashion from 2014 at < 1% per year. Our assumption is that adoption is still mainly found in early adopters and that it has not “crossed the chasm” to the early majority – it has not yet gone mainstream. Our hypothesis is that the stalled adoption is the combination of perceived risks and low awareness of proven well-paved adoption paths. Here are the questions that need to be addressed:
• What is slowing the early majority from adopting DPC?
• How do we diffuse DPC from early adopters to the mainstream early majority?
• How do FP’s who are burning out learn about and adopt DPC?
• How do FP’s who are in training learn about and adopt DPC?
• How can FP’s lower their cashflow risk when moving to DPC?
• How can FP’s lower their membership growth risk when moving to DPC?
Perceived Risk
The participants often describe their decisions to move into DPC practices as a jump or a leap based
on the benefit of practicing on their own terms outweighing the risks of trying something new. The main
perceived risk was financial. They feared moving into unknown territory with initially less cash flow and
not knowing the duration it would take to get their membership to a practice-sustaining level.
Participants were uncertain how many of their existing patients would come over to a membership
model and feared they might lose too many of them to develop a financially sustainable DPC practice.
Yet they moved to a DPC model despite these obstacles either because of sheer desperation and/or
guidance from colleagues who had successfully made the change to DPC.
Hybrid DPC/FFS Practice: Mitigation and Migration
If physicians are hesitant to “make the leap” and shift completely off of FFS and insurance, is there a
way they can keep FFS patients while they develop their DPC membership? Does this help mitigate
their risk? Does this help them either migrate to a full DPC practice or to a balanced sustainable hybrid
practice? Can this be done at a physician level, or must it be done at a practice level where a physician
is practicing either FFS or DPC?
DPC and VBC: Personalized and Population Health
These DPC doctors believe that they are providing better quality care. How can (or must) they prove
their quality and lower cost of care? Can (or should) DPC practices develop scalable population health
value-based revenue opportunities with employers, private payers or Medicaid and Medicare? Can
they participate in pay for performance and risk-based contracting? Are there new payment models
that are compelling to self-insured employers who have already embraced DPC?
What can be done to help more family physicians adopt DPC?
The first step in helping physicians is to identify those family physicians who stand to benefit most
substantially from adopting the DPC model and where they practice. We believe these family
physicians fall into 4 general groups:
• Primary care physicians experiencing FFS burnout (Maslach Burnout Inventory > Level 3)
• Primary care physicians experiencing with some FFS burnout and considering retirement
• Employed FFS physicians wanting independence
• Residents and medical students looking for deep relationships with their patients
Join vs Start a DPC Practice
The second step is to engage these family physicians and educate them on the most proven and well
paved paths to DPC. We believe early majority adoption may be supported more by opportunities
initially to join DPC organizations or networks rather than to start or convert a practice. We hypothesize
that these are the existing potential paths to DPC practice listed in order of perceived risk from (lower to
higher risk):
1. Join corporate DPC as an employee
2. Join a DPC network as an affiliate
3. Convert your practice to DPC
4. Start your own new DPC practice
How can these paths be optimized to lower risks and open up more opportunities for mainstream
adoption by the early majority? The lab intends to study mainstream family physicians who have been
successful on each of these paths, developing case studies and best practices.
Caring for the Uninsured and Underinsured
The anecdotal finding that these DPC practices offer significantly more care to the uninsured and the
underinsured is very intriguing. DPCs may offer more care to where it is needed most. FFS practices
have such small margins, large panels, and set fee schedules that there is little room to fit in the
uninsured or underinsured. But DPC allows the physician the flexibility to adjust their care to meet their
community’s needs. Is the membership retainer model more affordable and effective in caring for these
patients, particularly those with chronic diseases? Could employers (at scale) offer an affordable
monthly membership for basic primary care bundled with a high deductible plan? Could DPC provide
the uninsured better primary care and preventive services much more affordably than their current
options: urgent care, ER or even FQHCs?
DPC Innovations
To be successful in direct primary care, physicians can transform through a set of innovations.
Shift from FFS to a membership
prospective payment model.
Unified Communications
Expanding
Scope of Care
Use increase time to provide more comprehensive care and services.