Monday, February 22, 2016

Direct primary care enters the mainstream

Burnout among medical professionals has risen sharply, particularly among primary care physicians. A 2014 survey found that more than half of U.S. physicians reported at least one symptom of burnout (depersonalization and/or emotional exhaustion), and nearly as many are dissatisfied with their work-life balance, both worse than a similar survey from 2011. In a recent perspective in the New England Journal of Medicine, primary care internist Suzanne Koven described "the doctor's new dilemma": how to build healing relationships with patients in the face of 15-minute visits and overwhelming electronic documentation burdens:

Do I ask [the patient] what’s really bothering her and risk a time-consuming interaction? Or do I accept what she’s saying at face value and risk missing a chance to truly help her? ... If we ask about the pastry, we fall hopelessly behind in administrative tasks and feel more burned out. If we don’t ask about the pastry, we avoid the kind of intimacy that not only helps the patient, but also nourishes us and keeps us from feeling burned out.

New York Times editorial by Dr. Robert Wachter (author of The Digital Doctor) stated plainly what I and many other family doctors have felt for some time: quality measurement in medicine and the elaborate documentation required to support it has gone too far. "Our businesslike efforts to measure and improve quality are now blocking the altruism, indeed the love, that motivates people to enter the helping professions," Wachter argued. Perhaps the core measures sets announced last week by an alliance of private and public insurers and physician and patient organizations will reduce the measurement burden, but count me as a skeptic.

Larry Bauer, CEO of the Family Medicine Education Consortium, sees direct primary care, or the replacement of insurance intermediaries with a direct financial relationship between patients and primary care physicians, as an exit from "all the administrivia and foolishness" that prevent physicians from serving the unique needs of their patients and communities. It's worth reading through testimonials from physicians in direct primary care practices. My favorite is Dr. Brian Forrest's: "In Direct Primary Care we have pushed all of the things that get between us and our patients out of the exam room. The only thing left in the exam room is the physician/patient relationship and that is at the heart of real quality care and healing relationships."

Compared to just a few years ago, when it was considered a fringe movement with little recognition or support from organized medicine, direct primary care is rapidly moving into the medical mainstream. Direct primary care practices have been featured in NPR/Kaiser Health NewsForbesHealth Affairs, and profiled in the American Academy of Family Physicians' Health Is Primary campaign. Last November, the Journal of the American Board of Family Practice published the first academic study of DPC practice distribution and costs across the nation, and these figures are already out of date.

Courtesy of
Although the American College of Physicians has expressed concerns that the spread of direct primary care could exacerbate primary care shortages (though smaller patient panels) and health disparities (by reducing access for low-income persons), direct primary care physician Alex Lickerman, MD believes that both of these obstacles can be overcome:

Unless a viable solution is found to reverse primary care physician dissatisfaction, a critical shortage is already inevitable. What’s required is a new model that attracts physicians into primary care so we can reduce the number of primary care physicians who want to leave the profession and induce more medical students to enter it. ... Savings to government programs like Medicaid and Medicare could be redirected as subsidies for the poor to enable them to enter into direct primary care, or concierge medicine, medical practices. Qliance, in fact, is already experimenting with this model and finding success, having added 14,000 new Medicaid patients in 2014.

Another potential hurdle, the Affordable Care Act's requirement that most persons who are not eligible for public coverage purchase full-service health insurance, has also been removed with the creation of ACA-compliant plans where part of the monthly premium goes directly to the direct primary care practice.

What about quality? How will we know beyond anecdotes that the DPC model is as good for patients as it is for doctors? The nonprofit Consortium for Southeastern Hypertension Control was recently awarded a $15.8 million practice transformation grant from the Centers for Medicare & Medicaid Services that will, in part, support transitioning 600 traditional primary care practices to the direct primary care model over the next 4 years and evaluating their performance on 14 different quality measures.

My current patients can rest easy; I won't be taking the plunge into direct primary care any time soon. However, I am married to another family physician who is - and whose 2013 guest post about how the DPC model could benefit poor patients remains one of the best-read on this blog, for good reason.