Does direct primary care improve quality measures?

Part of a series.

In earlier posts, I have described direct primary care (DPC) in its various forms called membership, retainer and concierge. There are some concerns with DPC. Does more doctor-patient time really mean better quality care? Does it really mean lower total costs? It seems logical that closer care means better care, fewer referrals to specialists and fewer hospitalizations. Most DPC physicians will tell you this is the case but there are few studies to actually document results. Here are two based on data from a large DPC organization.

MDVIP, which has about 700 affiliated PCPs in 42 states and the District of Columbia. MDVIP is a national company that assists PCPs transition to a form of direct primary care model which puts an emphasis on wellness and lifestyle factors in addition to expanded primary care. MDVIP was founded by physicians in 2000, purchased by Procter and Gamble in 2009 and sold to Summit Partners in 2014.

In their model the PCP affiliates with but is not an employee of MDVIP. The PCP still bills the insurance carrier for visits but also requires a $1,500 to $2,200 annual fee for expanded services. He or she limits the practice to a maximum of 600 patients and generally follows the approach described previously for direct pay practices (same or next day appointments for whatever length necessary, 24/7 cell phone access, etc.)  The PCP includes a very extensive 1½ to two hour preventive medicine annual exam preceded a week before with vision, hearing and pulmonary function tests, an electrocardiogram if appropriate, a survey of dietary habits, psychosocial issues and a large battery of blood and urine tests.

As with most doctors that go with direct primary care, those that affiliate with MDVIP are usually far advanced in their careers and find they are getting burned out by “the treadmill” and the lack of enjoyment and satisfaction in their current practice arrangement. MDVIP has an extensive methodology to transition a physician from the traditional primary care practice to an MDVIP practice. To counter the argument that patients who choose to not join will be left with no physician, MDVIP will not accept a doctor into its program unless it is clear that there are sufficient other PCPs in the area. Although the average PCP converting has 2,500+ patients in his or her panel, it does not turn out to be first come, first served to reach the limit of 600 patients. Instead, usually only about 300 to 350 actually sign up in the first year with more coming on board via word of mouth over time.

PCPs who switch to direct primary care, in general, state that they now can delve into the psychosocial issues that are underlying many trips to the doctor. For example, one MDVIP doctor told of a patient with many difficult to control chronic conditions over the years. Now, nearing the end of the lengthened annual evaluation and, having developed a much closer relationship than ever before with his patient, he asked, “Is there anything else we should discuss?” “Well, yes, I was raped in the concentration camp. I never told anyone before just now.”

With that startling revelation, the doctor was able to finally understand the basis for many of her symptoms and illness problems and was able to rethink the best approaches to her care. He felt that this came about only because he had been able to develop trust as a result of deep nonjudgmental listening rather than rushing the process as he had to do in the past.

MDVIP is large enough, with 215,000 patient members, that it has been able to do some retrospective evaluations of whether direct primary care with limited patient numbers actually improves quality and reduces total healthcare costs. Patients in MDVIP practices studied have had a substantial drop in hospitalizations including a 79% decline for Medicare enrollees as compared to similar patients in regular primary care practices and a 72% reduction for those ages 35 to 64. Elective, non-elective, emergent, urgent, avoidable and unavoidable admissions to the hospital were all lower for the MDVIP members. Hospital readmissions have likewise declined substantially.

Another retrospective review suggests that the MDVIP patients are more likely to have higher quality measures (HEDIS) than are those in regular primary care practices. For example, blood pressure control was better, diabetic HbA1c and cholesterol levels were lower and a higher percentage of patients had mammograms and colonoscopies, as appropriate for sex and age, than national averages.

These are not randomized controlled studies but they do suggest that direct primary care with a reduced patient panel and extensive attention to wellness, prevention and care of those with complex chronic illnesses does result in better health and lower total costs to the system.

Does direct primary care improve quality measures?Stephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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