You’ve heard the story before: a young man or woman with idyllic dreams of practicing primary care goes off to medical school, only to have their dreams crushed by the realities of 7-minute visits, “production goals,” and unstable reimbursement — you’ve heard of the Medicare sustainable growth rate, or SGR, right? Every time you turn around, there is someone talking about primary care physician burnout or complaining about practicing on a hamster wheel.
I left a career I loved as a US Marine to pursue medicine, and I didn’t do it naïvely. I knew full well the realities of modern practice, but I took a leap of faith that I would find a way to practice medicine that would be fulfilling and allow me to be there for my family. Although I loved the idea of building meaningful relationships with patients and families, the downsides of primary care just seemed too daunting, so I thought I would go into emergency medicine.
That all changed when I read about Access Healthcare, the practice founded by Dr. Brian Forrest in Apex, NC. A friend had sent me a magazine article that featured Dr. Forrest’s practice, and I was blown away. Forrest had figured out a way to provide care to the uninsured and underserved, spend enough time with his patients to build meaningful relationships, excel in quality outcomes, maintain a good quality of life, and make a decent living to boot. It all sounded too good to be true but after getting to know him and eventually doing my Family Medicine clerkship in his practice, I can say that this is truly a transformative model of care.
Direct primary care (DPC) is a model of delivery that hearkens back to the glory days of the family doctor. In DPC, the physician’s sole focus is on the patient. Patients have easy access to their physician through open scheduling and often, email, cell phone, or Skype — methods discouraged by current reimbursement mechanisms. Visits are unrushed, and patients get the time they need, whether it’s 10 minutes or an hour. The physician-patient relationship is the foundation, and instead of one-way communication, patient and doctor develop plans of care together that are targeted towards the patient’s own values.
DPC works by extracting the third-party payer from the equation. Third-party involvement in primary care adds an enormous burden of cost and time — a burden that doesn’t add to, but actually detracts from, the quality of care. When that burden is removed, the savings are dramatic, and the whole physician paradigm shifts from chasing reimbursement to providing the best care possible. In DPC, the patients pay the physician directly for service through an affordable subscription or transparent a-la-carte pricing. Just imagine if your car insurance was responsible for changing your oil. We’d go from a service that practically anyone can afford, to one that hardly anyone could afford, with the result being fewer people getting necessary maintenance, leading to engine damage, breakdowns, and exorbitant repair bills. Sound familiar?
The Affordable Care Act (ACA) includes a provision that allows for direct primary care services to be coupled with a wrap-around insurance policy and sold on the health care exchanges. Such a product has already been developed in Washington state and is available on their exchange. There are efforts to provide care to Medicaid patients in this model as well. DPC addresses the triple aim of improved quality, lower cost, and improved patient experience in an incredible way and can be delivered to any patient population. If you care about finding a way to deliver care to the underserved, then you have to be excited about DPC.
The ACA, with its expansion of access to care, heightens already existing concerns about the dwindling primary care workforce, but many of the proposed solutions out there don’t address the reasons that students shun primary care, including rushed visits, production goals, constricted scope of practice, and shrinking reimbursements. DPC addresses all of these issues in spades, and once students realize there is a viable option out there, they will be turning to primary care and family medicine in droves.
Direct primary care makes me incredibly optimistic about the future. I will avoid the hamster wheel and provide the kind of care I envisioned, while building deep, rich connections with my patients. I will be offering a level of care previously only available to the rich that almost anyone can afford. I will be taking meaningful steps towards true, primary-care driven and patient-centered health reform, and I won’t have to wait for the “system” to figure it out. I will be able to provide the majority of care my patients require instead of having time only for refills and referrals. In short, I will be part of the solution, both for my patients and for the system as a whole.