Thursday, February 6, 2020

Inspire future family physicians by teaching them about direct primary care

My last post ended with a cliffhanger. After discussing the America Needs More Family Doctors collaborative, which aims to double the percentage of U.S. medical students who enter family medicine by 2030, I mentioned that one nontraditional practice is attracting medical students "in droves." Yes, it's the title of today's post. This week, I gave a talk on international health systems in Georgetown's 4th year / resident Health Policy Elective during which I pointedly observed that several health systems whose outcomes are superior to those in the U.S. (Canada, Germany, the United Kingdom, and Japan) all have a roughly 1:1 ratio of primary care to subspecialist physicians, as opposed to the more than 2:1 ratio of subspecialists to primary care in the U.S. A sharp student rose to ask if the income disparities between primary care and subspecialists are as large in these countries as in the U.S. Great question! They're not. And, I added, doctors in these countries also don't finish medical school with anywhere near the degree of educational debt that most U.S. graduates have.

But it isn't only dollars and cents that discourage medical students from considering primary care. In a recent qualitative study of 26 primary care physicians, nurse practitioners, and physician assistants with a mean of two decades of clinical experience, Dr. Sumit Agarwal and colleagues explored "factors contributing to burnout and low professional fulfillment." They introduced the apt term professional dissonance, or "discomfort from working in a system that seems to hold values counter to their values as clinicians." For example, many doctors chose primary care to utilize critical thinking skills to diagnose patients with undifferentiated problems, but the system values checking boxes to meet metrics such as immunization or screening rates. Family physicians want to care for and form long-term relationships with patients, but the system instead values volume as "productivity" and treats patients as widgets on an assembly line.

An analysis of claims data from a national private health insurer from 2008-2016 suggested that despite the expansion of insurance coverage due to the Affordable Care Act, adults have become less likely to visit primary care offices or have a usual source of primary care. Although it's possible that Dr. Google has reduced the need for acute visits for self-limited conditions, and that telehealth services may also be replacing some portion of office visits, the authors and an editorialist worried that patients are being "priced out" of primary care by rising deductibles and cost-sharing. Another study found that patients who responded to the Behavioral Risk Factor Surveillance System telephone survey in 2017 were substantially more likely to be unable to see a physician for several chronic medical conditions due to cost compared to 1998, even though they were more likely to be insured.

To not only survive, but thrive, primary care needs to be organized and paid differently. I am skeptical that the CMS Primary Cares Initiatives, though promising, will be the answer for most physicians. Though prospective payments may give practices more flexibility to provide virtual or asynchronous care, rather than doing away with checkboxes, it doubles down on them as a poor surrogate for measuring care quality. On the other hand, direct primary care, which slashes administrative costs that are strangling health care budgets and steadily sapping the morale of non-administrators, is changing the health system from the ground up and restoring critical elements of the doctor-patient relationship. A year's membership in a DPC practice can generally be had for about one month of Presidential candidate Andrew Yang's Freedom Dividend, making it accessible not only to the middle and upper classes, but to patients who are can't afford traditional primary care. Medical schools should prioritize exposing more students to this new primary care model for us to have any hope of attracting one-quarter of them into family medicine.