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Tuesday Jun 21, 2016

AAFP Showing Strong Support for DPC

Innovations in primary care continue to flourish in various markets across the country. One such innovation, which is mentioned often in the comment section of this blog, is direct primary care. What once was a novel idea in primary care delivery is rapidly becoming a highly sought after practice design for many family physicians.  

The AAFP strongly supports innovations in primary care delivery and payment models that embody the core elements of the patient-centered medical home (PCMH) and place a priority on the patient-physician relationship. We also strongly support the reduction, if not elimination, of the complex administrative burden placed on family physicians through prior authorizations, appropriate use, and other such measures aligned with payment and compliance. We believe that the DPC model is an advanced primary care delivery and payment model that meets these criteria.  

The DPC model embodies the core principles of the PCMH and is, at its core, patient centric. The model, through its payment structure, eliminates much of the administrative burden associated with modern primary care practice, which in return allows the physician to focus more time on direct patient care.  

It is noteworthy that the DPC model is becoming widely accepted as a primary care delivery model that promotes patient-centered care. Although some suggest that it is a "return to traditional primary care," I would argue otherwise. It is a progressive delivery and payment model, built on the traditional primary care patient-centric model that places the patient as the focal point of the practice, but it also is a model that uses a team-based approach, advanced technology and data to deliver timely and quality care. The DPC community deserves a lot of credit for its efforts to demonstrate to public and private payers that the DPC model drives improvements in quality at a lower per capita cost, and people are starting to notice.

The AAFP has taken some criticism from the DPC community for not being an advocate for the model, but this is not the case. The AAFP first engaged with the DPC community in 2012, during the earliest days of the movement. I will admit that we were not the first person on the dance floor, but we have worked hard behind the scenes to make certain that the band keeps playing.  

We have focused our efforts in two places; education and advocacy. Our education efforts feature a content resource page and a comprehensive toolkit that serves as a step-by-step guide on how to open a DPC practice.  

We also have conducted a series of educational seminars around the country that have provided interested physicians the tools and resources they need to transition their practices to the DPC model.  

Finally, in 2015, we partnered with the American College of Osteopathic Family Physicians and the Family Medicine Education Consortium to host the Direct Primary Care Summit. The 2016 Direct Primary Care Summit will be held July 8-10 in Kansas City, Mo. If you are a DPC practice or simply interested in exploring the opportunity, I would urge you to attend this event. We are confident that you will find this meeting both educational and energizing.  

Our DPC advocacy efforts originated during the debate and consideration of the Patient Protection and Affordable Care Act (ACA). The ACA established DPC as a qualified health plan for the purposes of meeting the individual mandate established by the law. Although this was an important first step, which established a path forward for the DPC model, much work remains to ensure that patient contributions to a DPC practice are recognized as qualified medical expenses. The AAFP initiated our advocacy on this objective in 2013 when the AAFP formally recognized DPC as an advanced primary care delivery and payment model.

We accomplished this through the adoption of a position that reads, in part, "The American Academy of Family Physicians supports the physician and patient choice to, respectively, provide and receive health care in any ethical health care delivery system model, including the DPC practice setting."

During the past few years we have worked closely with our state chapters and other interested organizations such as the Direct Primary Care Coalition (DPCC) to advance legislation that would recognize payments made by patients to DPC practices as a qualified medical expense. For the DPC model to flourish, it is important that we ensure such recognition. I am pleased to report to you that there has been progress made. Sixteen states have enacted legislation in the past few years: Arizona, Idaho, Kansas, Louisiana, Michigan, Mississippi, Missouri, Nebraska, Oklahoma, Oregon, Tennessee, Texas, Utah, Washington, West Virginia, and Wyoming. Montana and Virginia passed legislation this year, but pending bills were vetoed by their respective Governors.

The AAFP also is actively supporting the Primary Care Enhancement Act (S. 1989). This legislation clarifies that DPC is a medical service and not a health plan under section 223 (c) of the Internal Revenue Code relating to Health Savings Accounts (HSAs). The legislation correctly defines DPC services as qualified health expenses under section 213 (d) of the tax code. The bill also creates a new payment pathway for DPC as an alternative payment model (APM) in Medicare and with dual eligible. This would allow CMS to pay practices an affordable flat fee for primary care services offered by a DPC medical home. The legislation includes a waiver to allow qualified physicians who have opted out of Medicare to participate in the program at any time. It also allows for Medicare Advantage plans to pair with DPC practices as primary care partners in an ACO-like structure.  

To learn more about the DPC model, please consult our DPC FAQ. I also encourage you to join our DPC member interest group, which provides an opportunity for you to connect with other DPC family physicians.

Hi, My Name Is …
Congratulations to David Barbe, M.D., M.H.A., for being elected president-elect of the AMA. Barbe, a family physician from Mountain Grove, Mo., will become president of the AMA in June 2017. Family medicine has strong representation on the AMA Board. In addition to Barbe, there are four other family physicians serving on the AMA Board of Trustees.

A special hat tip to Barbe for quoting the incomparable poet Marshall Bruce Mathers III in his acceptance speech to the AMA House of Delegates: "Anything is possible as long as you keep working at it and don't back down."


It's good to see AAFP taking a strong stand in favor of DPC. We definitely need more legislative support.

I think some of the upset may be the somewhat vague view the AAFP has of DPC... That the specifics of PCMH don't apply to most DPC or solo practices. Some of us are micropractices, which provides what I believe is better than team based care. :)

Thank you for being very clear that you are supportive of DPC and ready to do more.

My special request is to consider other formats of understanding and meeting this interest.

Big conferences we have to travel to are nice but I'm mentoring a number of physicians who are also mothers of young children and are going into DPC because it allows them to be home more with their kids and have a flexible schedule. We find each other through places like Facebook and support each other in odd moments when our kids are asleep. Sadly, AAFP probably has no idea we exist because you are more likely to find us on Facebook than the official DPC MIG. But we're out here doing our part to change the world.

My own observation is that the physicians I meet outside of the MIG are less likely to have any business experience or training, more likely to be less than ten years in practice, and more likely to want to help out marginalized patients in various ways.

While the entrepreneurial aspects of DPC are important, I think a greater focus on the altruistic opportunities would provide a more well-rounded view of what we're doing. At a recent get together of local DPC docs, I definitely noticed that we are along a spectrum from typical entrepreneur to social entrepreneur. I'm at the latter end.

Anyhow, it's good to know you see us innovators out here!

Posted by Robin Dickinson on June 21, 2016 at 11:29 AM CDT #

It's great to have the support and backing of the AAFP, as one of the "deterrents" to moving in the DPC direction for me has been fear of state or federal regulation preventing freedom to practice this way. For example in Massachusetts, we are required to have "competency" in electronic medical records to even get a license (however ill-defined that is!). I am worried that my future DPC practice will be regulated in some unfair and unsustainable way by other entities.

I truly believe that DPC is the highest quality, highest safety and accountability, and highest satisfying practice of medicine for both patients and physicians. It also happens to be extremely economical.

Posted by Michele C Parker on June 21, 2016 at 12:16 PM CDT #

"The AAFP has taken some criticism from the DPC community for not being an advocate for the model, but this is not the case. The AAFP first engaged with the DPC community in 2012, during the earliest days of the movement."

From my perspective this is patently false, albeit a matter of perspective.

From my experience, AAFP expended too much energy jumping on the PCMH/ACA/P4P bandwagon, while suppressing alternative ideas from the grass-roots of the Academy. I recall joining with many like-minded individuals advocating for direct-primary care, patient-centric service, idealized medical practices (IMP's), and the like from 2004-2010. There was almost no support.

It is great to have the Academy back on board! I appreciate all the new emphasis of DPC. But please don't take a victory lap without acknowledging the shortcomings of the past. It's always a good time to take an interest in new innovations and ideas from within. And it is always a bad idea to try too hard to direct or suppress the conversation from the grass-roots of the organization!

Posted by Bob Forester on June 21, 2016 at 12:31 PM CDT #

This is great news but Im hoping this was a typo: "The ACA established DPC as a qualified health plan for the purposes of meeting the individual mandate established by the law". This is completely untrue and is the issue we are dealing with on the state level and the federal level with HSA money being used for the monthly fee. The IRS feels that if you have a HDHP/HSA and DPC you have "2 health plans" and can't use one to pay for the other even though the DPC clause in the ACA clearly states that DPC is NOT a health plan but a legitimate way to obtain primary care as long as wrapped with some type of ACA approve insurance plan. I call it the double edged sword for DPC. We are approved as a PCMH but the ACA prevents true wrap around insurance policies from existing. I hope this post does not confuse people even more.

Posted by Jeffrey S Gold MD on June 23, 2016 at 10:01 AM CDT #

Thanks for your support for DPC.

Please add some patient orientated, AAFP branded webpages and social media sites that explain and endorse DPC.

Even at this point, many members of the public and other physicians still confuse DPC with expensive concierge practices or doubt the value of DPC to cost conscious patients and employers. While we all keep working on that via marketing and countless conversations, having AAFP branded information geared toward patients and employers that we can link online or share on social media would be very helpful for both current DPC and the many family physicians who will transition after attending AAFP sponsored training. Your current DPC policy statement and physician oriented pages aren't that suitable for this.

As DPC grows and we get pushback from hospitals and other competing interests in state legislatures, this would help us with advocacy there as well.


Posted by Brian Pierce on June 26, 2016 at 08:48 AM CDT #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.