How direct primary care can revolutionize health care [PODCAST]

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The U.S. health care system ranks poorly among high-income countries, but the direct primary care (DPC) model offers a potential solution. In this model, primary care providers are paid a consistent fee through a retainer or membership program, rather than relying on insurance billing. This frees up providers to spend more time with patients and offer comprehensive care. Both patients and providers in the DPC model report high levels of satisfaction and there is evidence of decreased utilization of expensive services and lower overall health care costs. Join us as we speak with Dr. Sara Pastoor about the potential for the DPC model to improve primary care and the health care system in the U.S.

Sara Pastoor is a family physician.

She shares her story and discusses her KevinMD article, “The solution to a crumbling primary care foundation is direct primary care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back on the show Sara Pastoor. She’s a family physician. Her KevinMD article is titled “The solution to a crumbling primary care foundation is direct primary care.” Sara, welcome back to the show.

Sara Pastoor: Hi, nice to see you again. It’s great to be back. Thank you so much for featuring my work. I really appreciate it.

Kevin Pho: We’ll get into the article in a little bit, but for those who didn’t get a chance to listen to our first episode together about eight, nine months ago, just briefly share your story.

Sara Pastoor: I’m a family physician. I spent the first 15 years or so of my career in Army medicine and was leading primary care transformation there, and I did a lot of work with technology and EHR optimization. Then I took a detour into academic medicine and did a lot of the same kind of work there. I’ve also done work in patient safety and credentialing and all kinds of things. And then I went to work for a really innovative, cool primary care company that contracts directly with self-insured employers.

Now I work for an EHR company that focuses on primary care only, called Elation Health, and we really are focused on rescuing primary care in this country. We develop specifically for primary care and are trying to really help high-value primary care. And then my side hustle is that I work in a direct primary care practice in Austin, Texas.

Kevin Pho: So we’re going to talk about your article, which talks about direct primary care, but how did you initially get involved with direct primary care? How did you find out about it?

Sara Pastoor: An Army buddy of mine approached me about an opportunity in Austin, an opportunity to join a behavioral health operation that was looking to expand its capabilities to offer primary care also. What they noticed was that they had a lot of clients who needed primary care, and they were having trouble plugging them into good primary care in the community, and we all know that good primary care is hard to find. They also just felt like they needed to have a good, tight relationship to work collaboratively with primary care.

I’ve had the really good fortune of having worked in integrated practices of primary care and behavioral health my entire career, going back to residency, so it was a really good fit for me. And so he and I decided to join that practice, and we’ve been doing that ever since.

Kevin Pho: Walk us through a typical day. How many patients would you see? What are some common conditions you would treat?

Sara Pastoor: Direct primary care is really cool because we’re not really tied to a day. It’s very patient-centered. My day job is really about the work that I do at Elation, and I flex that day job around what my patients need. So I provide care for my patients when and how they need it, whether it’s virtual care, or if I need to step into the practice to see a patient in person, or if I need to make a house call. However that works, I take care of my patients when and how they need me.

Kevin Pho: All right, and you’re going to talk more about direct primary care in your KevinMD article titled “The solution to a crumbling primary care foundation is direct primary care.” Now tell us, how did this article come together?

Sara Pastoor: Well, I had been reading the Commonwealth Fund article about how poorly our health care system performs relative to other peer nations, and thinking about how the direct primary care model is really the purest form and most patient-centered form of primary care that I know. When you read that article, it really is very stunning to see, from a health system performance standpoint, that when you put us against those other 10 nations, it’s not like we miss it by a hair. Those other 10 nations are clustered together, and then we are the lone country falling far below in performance compared to those other 10. And then when you look at the trend in spending, we are spending more than double what those other countries are spending. So that cost versus health system performance comparison is embarrassing.

One of the key drivers of that is investment in primary care systems. There are other problems, social infrastructure and administrative efficiency and other things that we clearly need to work on, but primary care is a key driver of that. So it’s really interesting to me to think about how much primary care influences how much we spend on health care and the kind of outcomes that we get on health care.

If we spend $4 trillion a year on health care in this country, and if the case studies that we’ve seen about DPC are accurate, and there are new studies starting now that are going to look at this more closely, but the case studies that have been conducted thus far are really remarkable, showing that DPC has the potential to decrease total cost of care for DPC patients by 20 percent. So when you think about that, 20 percent of $4 trillion is $800 billion that we could be saving. People always say, “Well, not everyone can afford DPC,” and that’s true. But when you think about the affordability crisis in this country, that’s a very myopic way to think about affording health care: “I can’t afford primary care.” You could take that $800 billion and use it to pay a $100 per month subscription fee for every single American to give them a DPC primary care doctor and still have $470 billion left over. So I think that we need to rethink this and look at how valuable primary care is to patients, to society, and to the health care system.

We also need to start looking at the measurable outcomes that we’re getting beyond cost of care from DPC. Just looking at high-value primary care in general, not necessarily tied to DPC, we know that it improves life expectancy, infant mortality rates, maternal mortality rates, all kinds of health outcomes, and even patient experience. And primary care physicians who are working in direct primary care practices are the happiest ones that I know. It restores their sense of autonomy and increases their scope of practice and their sense of professional satisfaction. So I think it’s just a really elegant solution to a really intense crisis that we have in health care in this country.

Kevin Pho: So you mentioned other countries, countries in Europe, Canada. They have a significantly bigger investment in primary care in contrast to the United States. So talk more about that. Why is that?

Sara Pastoor: Well, I think part of the problem is that they offer universal coverage, which I know is a hot, controversial issue here, but it shouldn’t be. Universal coverage basically is the way to erase those health inequities and make health care affordable for everyone, and to turn health care into a basic human right instead of the privilege we’ve made it in this country. By investing in health care as a right for every citizen, and then also investing in social infrastructure for children and people who are out in the workforce, that just improves society in general. A rising tide lifts all boats, and it just makes society in general healthier and better off. So we improve productivity that way, we improve the way we function as a society, and that improves the economy. I mean, it just makes sense.

Kevin Pho: So one of the criticisms I often hear about direct primary care is that, in general, direct primary care physicians have smaller patient panels. So if you were to wave a magic wand and convert every primary care doctor to a direct primary care practice, there’s just not going to be enough of them to see all the patients that require being seen. So how do you address that issue?

Sara Pastoor: That is my favorite topic to talk about. That is because we’ve already overwhelmed primary care physicians in this country with too many patients, and that’s one of the main reasons why we have a shortage of primary care in this country. That shortage is largely manufactured by a fee-for-service, transactional payment system that has focused on generating volume of care instead of value of care and focusing on the doctor-patient relationship. So by forcing physicians to just see more patients and have more patients to take care of, we’ve worn them down and worn them out, robbed them of that valuable, sacred relationship, and just turned primary care into a sweatshop.

So no wonder fewer medical students are choosing primary care. It’s become an inhospitable career choice. And no wonder more primary care physicians are choosing to leave the profession sooner, either retiring early or transitioning into an administrative area of medicine, or whatever it is. So when we restore the joy in practice in primary care through the DPC model, then we see what a wonderful career choice primary care can be.

I have many colleagues who have medical students who rotate with them in their DPC practices, who have this eureka moment where they go, “Wow, I never knew that primary care could be like this.” My colleagues will tell you their very own personal stories about how much their lives have changed from when they were working in the fee-for-service model and then transitioned into direct primary care, how much they love their jobs now, and how they were on the brink of just leaving medicine altogether.

So if we want to have more primary care physicians in this country, we’ve got to make primary care an attractive career field. I think that we also need to make a case for paying primary care for the value that they contribute to medicine, and I think we are way underpaying them. Family medicine, internal medicine, and pediatrics are the lowest three paid medical specialties. Out of, I think, 27 or 29, they’re the bottom three. Considering what they contribute, which no other medical specialties can boast, in terms of improving outcomes and decreasing total cost of care, I think we’re way underpaid. But on top of that, just by making it an enjoyable career field, I think we have an opportunity here with DPC to right that ship. If we make it an attractive career field, we will keep more people in it and attract more people to it.

Kevin Pho: If you were in charge of health policy in this country, what are some of the next steps you would take to implement more DPC practices in our primary care system?

Sara Pastoor: I would look for ways to help employers, and find other ways to help subsidize that membership fee, to make sure that the DPC membership fee is affordable for everyone. There is something magical about the patient paying that fee. So if it comes out of a health savings account, it’s my money; it feels like it’s my money that I’m paying you. When the patient’s controlling the money, there is something magical when it feels like my doctor is working for me. So I think if we could find ways to wire it that way, that would be a really nice arrangement. But it needs to be something that we can make affordable for every American.

Kevin Pho: And just for those who aren’t familiar with direct primary care practice fees in general, how much are they?

Sara Pastoor: The national average is $75 per month. There’s a wide range. You can go to Silicon Valley, and some people are charging $1,000 a month for very wealthy CEOs of big companies, but the national average is $75 a month.

And then I would also incentivize recruitment into primary care residency programs, and I would build more around recruiting, like building medical schools around primary care, and redesign both medical school training and medical training around outpatient and community-based learning. The centrality of hospital-based and health-system-based training is a legacy model that really is not serving us anymore today, and it doesn’t teach students what they need to know if they’re going to go out and serve their communities in a primary care setting.

So I think we really need to start writing some policy and investing in new ways to train the primary care workforce, and not just physicians but also other folks in the workforce who are going to be working as part of the primary care team, because the primary care of the future is going to be a multidisciplinary team that is going to work together to keep patients well and out of the hospital: social workers, behavioral health, health coaches, a variety of folks. So we really need to start thinking about primary care in those terms and investing in that kind of primary care.

Kevin Pho: We’re talking to Sara Pastoor. She’s a family physician. Her KevinMD article is titled “The solution to a crumbling primary care foundation is direct primary care.” Sara, what are some of your take-home messages that you want to leave with the KevinMD audience?

Sara Pastoor: I want people to start thinking about primary care in terms of that relationship that is possible. The kind of primary care that many Americans experience today is watered down and has been sort of decimated by a very toxic payment system, and that’s not the kind of primary care that you should expect. You can expect something much better that will be better for you, and give DPC a try. I promise you will love it. My whole family sees a DPC physician, and I’m a DPC physician. I believe in it strongly. It is worth the money. It has paid dividends for us, and it’s just a game changer. It really is.

Kevin Pho: Sara, thank you again for sharing your time and insight, and thanks again for coming back on the show.

Sara Pastoor: Thank you.

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