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Tuesday Jan 03, 2017

Direct Primary Care Is a Sensible Workforce Solution

Direct primary care (DPC) is widely acknowledged as a trending payment model that creates transactional efficiencies and reduces administrative burdens for primary care physicians. Unfortunately, a few myths have started to appear in the media about this model that must be dispelled.

The anxiety-provoking concern goes something like this: If traditional family medicine practices convert to DPC, that will exacerbate our primary care workforce shortage. Let's examine the mechanics of a free market labor economy to see why DPC is actually an ideal strategy to provide our nation a robust family medicine physician workforce in the long run. The workforce myth is rooted in the untested hypothesis that horrible workforce shortages will occur if panel sizes shrink below 2,300 patients per family physician. My sensibilities tell me physician burnout is a much greater threat to workforce shortages than smaller panel sizes.

No one is satisfied with the 10- to 15-minute office visit -- not patients, not payers and certainly not physicians. There is no equation that allows for longer appointment times without a reduction in panel size. For example, if you want to limit yourself to only one hour per patient per year, to include all phone calls, emails and face-to-face visits with each individual patient, then you can have a panel of 2,080 people and still have a normal workweek. But if we make a modest increase -- let's say to two hours per patient per year -- then a family physician can only have a panel of roughly 1,000 patients (and that's before vacation and holidays). The normal workforce economics that naturally occur in the unregulated DPC environment mean that physicians gravitate to a panel size of 900 simply because that's what is sustainable for healthy physician-patient relationships.

The second myth is that with panel sizes of 900 patients, there is no way we can possibly come up with enough family physicians to provide primary care for everyone.

First, let me point out that there are a significant number of family medicine-trained physicians who don't practice traditional ambulatory family medicine anymore because they burned out during the past decade in the crushing fee-for-service environment. Under the DPC model, there is the potential that those who have left direct, continuing patient care to become medical directors, insurance reviewers, floating locums, early retirees, etc., could be drawn back to do what they became physicians for in the first place. And a satisfied, fairly compensated family physician workforce would become a magnet to draw new graduates into family medicine in record numbers.

Our nation's workforce needs have not, and simply cannot, be met by the current "push" strategy.

What we have always needed is a "pull" strategy that starts with grassroots payment reform, divorced from fee-for-service, whereby family physicians experience a sustainably compensated "fair trade" primary care economy.

With increased demand by students for residencies that will prepare them to become DPC physicians, the academic environment will adapt, just as it did in the past when medical students were first drawn to higher-paying specialty jobs. We cannot push a string, but we can pull medical students into robust, fairly compensated DPC models of health care delivery.

The math shows that with panel size reductions, we would need to double the family physician workforce. The best time to have started doing that was years ago, but the fee-for-service model would never have allowed us to accomplish that kind of growth. The second-best time to double the workforce is now, and DPC economics is the pull strategy necessary to create such dynamics for graduate medical education.

The third myth is that DPC is capitated insurance. This is pure bunk. DPC physicians do not take on underwriting or actuarial risk for the types of acute disease that subspecialists normally treat, nor for catastrophic or hospital care. They do, however, take business risk and must set the price point of their monthly subscription charge at a level that ensures revenues exceed expenditures to realize a normal business margin. As of June 2016, 16 states had laws on the books saying DPC is not insurance.

A fourth myth is that DPC will exacerbate disparities in health care. If underserved populations, including Medicaid, do not have enough access to DPC, it's certainly not because DPC physicians are refusing to see them. Instead, organized medicine must fight to quash the regulatory and bureaucratic discrimination that is preventing the purchasing of DPC services.

Washington state's Medicaid program -- Apple Health -- has already started paying for some Medicaid beneficiaries to use the DPC model. We need the rest of the nation to follow the lead of Washington in this regard.

Finally, businesses are starting to report double-digit savings when they convert to DPC for their workforce. Qliance, Nextera Healthcare, and Iora Health are among those that have published cost-savings data. Recently, Nextera Healthcare helped employer DigitalGlobe in Colorado achieve a 25 percent reduction in its health care spending. The message to our nation could not be clearer: Stop spending more on health care. Convert to DPC and save.

You can learn more by joining the AAFP's Direct Primary Care Member Interest Group. And registration is now open for the AAFP's DPC workshop, which will be held March 11 in Atlanta.

John Bender, M.D., M.B.A., is a member of the AAFP Board of Directors

Comments:

Does anyone on the Board have the least bit of understanding that it is not fee-for-service but the disastrous policies pushed by the AAFP - MU, PQRS, NCQA PCMH, P4P and now the truly abominable MACRA - that is driving family physicians to DPC?

Just something to think about . . .

Posted by R Stuart on January 03, 2017 at 01:18 PM CST #

Dr. Bender,
Thank you and thank you again for this well-written, pointed, factual editorial dispelling some of the 'objections' to DPC. I find tremendous hope in a sustainable patient care model that returns autonomy, mutual regard and TIME to the physician-patient relationship.

In a time where the important work we do as family physicians is diluted by third parties, convoluted relationships and typing...endless amounts of typing... Physicians who want to remain dedicated primary care physicians *have* to find another way.

DPC is one path forward. I, personally, am excited to hear that you, an MD, AAFP Board Member, understands this so well.

Thank you!

Julie Gunther, MD, FAAFP

Posted by Dr. Julie Gunther on January 03, 2017 at 09:43 PM CST #

It's nice to see this from an AAFP board member. In recent years, I hesitate and debate whether to continue to send dues money to a specialty organization that supports PCMH, pay for performance, the ABFM monopoly and its MOC demands, and now MACRA. Only AAFP's recent moves to support DPC have kept me from putting that money to better use.
Dr Bender, please encourage the AAFP to put out AAFP branded patient and employer focused explanations of how DPC works and why it is ethical, sustainable, etc. That would help the growing numbers of family physicians converting or starting new, independent DPC practices.
Thanks,
Brian Pierce MD
Rockport, Maine

Posted by Brian Pierce MD on January 04, 2017 at 07:00 AM CST #

Thank you for this article! I would add that the physician shortage is exacerbated by the amount of time we spend on administrative tasks. The DPC model creates a more efficient practice model, where patients don't necessarily have to be seen for every sniffle. Therefore, we can handle a fairly substantial panel of patients while offering exponentially better access and better care. I'm so thankful that AAFP embraced this model, because I might not have made the change were it not for emails I received about this innovative model. Had I not switched to DPC, I would have quit clinical medicine--my calling.

Posted by Molly Rutherford, MD on January 04, 2017 at 09:34 AM CST #

Thank you for this very sensible explanation of a myth of DPC. I personally would be seeing zero patients right now if it weren't for DPC. Because of my practice, I love what I do and will keep practicing for a good long time.

Posted by Robin Dickinson on January 04, 2017 at 03:36 PM CST #

Excellent, well-written and well-informed article on DPC medicine. I am also glad to see the AAFP as well as my state AFP chapter promote this model of care. Thank you Dr. Bender.

I am personally thankful to forerunners in DPC medicine like Josh Umbehr, MD, in Wichita, KS, for paving the way and making it easy for the rest of us to set-up this model of care and succeed financially, avoid burnout, and offer outstanding patient care.

I look forward to seeing more and more DPC family medicine practices open up across the nation! A great website for patients and physicians alike to help spread the message and encourage growth of this model is www.iwantdirectcare.com.

Thanks again, Dr. Bender, for the excellent DPC overview!

Deborah G Chisholm, MD
Le Roy, IL

Posted by Deborah G Chisholm, MD on January 04, 2017 at 10:23 PM CST #

The United States remains 23rd of 26 developed nations in generalists and less than 50th where most Americans reside. A substantial portion of what exists where care is most needed is a testament to family medicine graduates and past family medicine leadership. Continued failure since 1980, the entire last generation of health care workforce, is the result of failures in political, health, and family medicine leadership.

The United States continues to require broadest generalists that remain broadest generalists over their careers after training. FM residency grads have been stellar in this role as were the generalists before them. No others distribute reliably. No others have Family medicine have resisted the payment design for decades with retention in primary care across the decades after graduation. Over 95% of active graduates have remained in family medicine positions in the past. Even this has eroded in recent years as more family physicians depart small practices, independent practice, rural practice, and primary care to emergency care (12%), urgent care (4%), hospitalist care (4%), other specialties (< 5%), part time, other careers, and retirement (Graham, Masterfile). The steady declines in FM grads found in family practice positions should point to the need for substantial payment changes – changes lacking since the 1980s.

FM completely lost out on the 2010 reforms as none of the reforms resulted in necessary and sustained increased payments to primary care, or decreased the cost of delivery of primary care, or improved retention in primary care, or decreased the cost of primary care turnover, or increased the productivity of team members. Burnout has reached an all time high. Collapses in primary care internal medicine, mental health (now 50% delivered by primary care and even greater proportions where most Americans lack access), in public health, and in basic surgical services have placed additional burdens upon remaining care where needed – where family physicians are most essential.

In the places where most family physicians are found, there is worse to come. In these places the population is increasing faster along with elderly populations and the most complex and least healthy populations. These are also the places where health, education, and economics have most failed. Local resources to facilitate better health outcomes are also being compromised – a nasty consequence of state and federal budgets diverted increasingly to health care.

Family physicians along with rural health providers, small towns, primary care practices, mental health, and the half of the nation less organized and most “outside” have been ignored.

As noted, FM associations not been able to stop delivery costs and increasing regulation that clearly results in declines in productivity, burnout, and worsening of the financial design. Tragically FM associations have even promoted value based efforts that clearly have added new hundreds of billions each year to overall health care costs without improving outcomes - the opposite of value.

Lacking an understanding of the needs of most Americans, the nation’s political and health leaders have lost touch with health access, most Americans, and the family physicians that care most for them. Family medicine leadership is more important than ever in restoring the connections, collaborations, and partnerships that are required to lead the nation to better health, health care, and health outcomes.

FM docs contribute the most across the lowest physician concentration counties with 40% of the population. FM dominates workforce where over half of the nation is found – the half that recently expressed discontent with the establishment and with policies that fail to meet their needs. Where the elderly, poor, Veterans, lower income, rural, and underserved populations are found along with concentrations of lowest paying health care plans, family physicians remain as others depart.

FM leadership has missed opportunities to illustrate the incredible work of family physicians despite the incredibly flawed financial design. Where health care is most falling apart, family physicians are even more important as seen in one of the most rapidly increasing populations in the US – the population in counties without a hospital. The last hospitals in counties are closing at a rate of 1 – 2 per month. The closures involve counties with higher levels of population and overall the counties without a hospital are outpacing other counties in population growth and increases in higher demand populations.

Access is an area most important to family physicians, but access failures are becoming worse. Tens of thousands of Americans are dying from access issues and family medicine leaders do nothing to hold foundations such as Commonwealth accountable for their access mission. Instead, Commonwealth continues to promote the distortion of health insurance coverage as access rather than the proper focus on the lack of workforce, generalists, permanent generalists, and family physicians specifically.

Leadership in FM should remain focused upon the incredible efforts of family physicians, upon access to care, upon deficits of workforce and access facing most Americans, upon true reforms involving substantial payment increases for primary care, and upon the true determinants of health.

FM was restored because FM leaders were successful in convincing Americans of the need for family physicians. Family medicine leaders successfully navigated state and national barriers to accomplish this change. Substantial opposition in medical education had to be overcome. FM funding had to be protected from deans. Family medicine residency programs needed to actually get the funding that was too often diverted by hospitals to other purposes.

FM should once again align itself with the populations that it serves to team up for better health care outcomes. FM should oppose the current misguided focus upon costly and ineffective clinical or digital clinical manipulations. FM teaming up with most Americans and those who truly care for most Americans should return the focus to the personal and community factors that most influence health outcomes.

Current FM leadership is fortunate to have had the incredible legacy of a generation of past family physicians who have been consistent in most needed care. They have also been fortunate to have the example of past family medicine leaders, who rebuilt family medicine despite significant opposition. The lessons learned by the builders still instruct the current leaders.

After exclusion from medical education, formal family medicine was restored by caring family physicians via two specific areas of focus. First, they continued to care for their patients where care was most needed. Their stellar example was the model for generations to come. Second, they cared enough about the country to sacrifice even more to bring forward what the nation needed most in health care workforce – family medicine.

That their success was all too brief is a testament to the decades of life that they spent to restore family medicine and to the lack of access focus by the nation and especially by the new FM leaders.

The time of great success lasted only the first decade of family medicine, a final decade of activity for many restorers. The one time increase to 3000 annual graduates by 1980 remains the one stellar and most specific contribution to health access in the history of the US.

It took hard work by family docs state to state and nationwide to get formal family medicine training established – despite the poor cooperation and even opposition of academia. The original FM leadership never forgot the hard work that it took to practice and also build family medicine.

The 1969 to 1980 growth of family medicine residency graduates was a testament to their hard work as well as a national payment design that supported primary care, family physicians, and care where needed. The original design for Medicare and Medicaid similarly took decades of hard work and worked together with FM to address what the nation most needed and most lacked for most Americans.

The initial decade of FM grads distributed at an unprecedented level above population based distribution with 30% found in rural practice - more evidence of the need for a collaborative relationship between practices and payers for the purpose of access.

FM still maintains 25 – 30 family physicians per 100,000 across the wide range of populations. Even where payment fails most where Medicaid, high deductible, Veteran, and Medicare populations are concentrated, family physicians continue to serve. Where hospitals have closed or do not exist, FM docs are most important. Expansions of the plans least supportive for local family physicians, Medicaid and high deductible plans, should not have been expected to change access. We cannot afford to cling to financial designs or reforms that have failed to address the most basic requirement to rebuild primary care – funding that remains significantly and consistently above the cost of delivering the care.

Posted by Robert C. Bowman, M.D. on January 05, 2017 at 05:54 AM CST #

Since 1980 the critical support for what family physicians do has melted. Not surprisingly family medicine has remained at 3000 annual grads and other key areas have melted in the areas most associated with FM. These include health access, primary care, rural health, care where needed, and the support of the patients and populations cared for by family physicians.

It is the support of the populations and their communities that most shapes health outcomes through changes of behaviors, environments, situations, and social determinants. Improvements in outcomes have been prevented by the last 50 years of health care designs – designs that have added trillions to health care costs for little change in outcomes for the opposite of value. Even worse these increased trillions have depleted spending where communities need economic development, housing, nutrition, public health, police, fire, child development, education, job training and other areas more specific to improving health, education, economic, and societal outcomes.

People, places, and populations in need of care do not need innovation, certification, or increased practice costs of delivery. Team members need to be focused on their local work to delivery the care and build the community. They are the ones that advance basic access to care and accomplish the advanced primary care functions. These are functions only possible with substantially more funding, better support of team members and communities, less regulatory costs, and fewer distractions.

It is perhaps most troubling that family medicine leaders do not understand that it is the people and community factors that most shape outcomes. Or perhaps more accurately, we see promotions of this concept by various health care leaders, but they fail to integrate this into their thinking or their strategies.

A true understanding of the factors that most shape outcomes also leads to understanding regarding the folly of medical error focus 1999 to the present with little hope for changing the real factors that shape outcomes and substantially increased costs. The Primary Care Medical Home effort also fails due to the same reasons. In addition these dollars are shipped out of the local community for software, consultants, and externals. The dollars are shipped away from the support of team members, local jobs, and local economics. Again and again the real determinants of health outcomes are compromised for efforts that at best are a minimal influence.

Family medicine should lead the nation in areas such as better understanding of resident work hours limitations as having no impact upon care outcomes as seen in the best quality before and after studies, but having major importance in establishing better mental and physical health for residents and the physicians that they become.

Even worse has been support for the payment designs that fail in evidence basis, that fail most for small practices, and that compromise most family physicians and most Americans.

Pay for performance and derivatives (quality metrics, measurements, digitalization, value based care) have been demonstrated to be costly, distracting, and discriminatory schemes. The builders did not tolerate costly, distracting, or discriminatory and neither should current leaders.

Over a dozen studies specifically indicate compromises in payments via pay for performance for those who care for the most complex patients – older, poorer, less educated, less health literate, more chronic illnesses, more smoking, more diabetes, more obesity, lesser health status, more preventable outcomes, and more premature deaths. These are all seen and much more across the 2621 lowest physician concentration counties where 36% of active family physicians are found serving 40% of the nation and higher concentrations (42 – 47%) of all of the above. Highest readmission penalties go to rural hospitals (9%) and hospitals in lowest physician concentration counties as compared to urban at only 3%. Providers in the counties with concentrations of the factors most related to lesser health outcomes do consistently have the greatest penalties.

Schemes that lack evidence basis, that lack the full backing of the scheme consultant (RAND), and that discriminate against providers caring for the Americans most left behind should not be supported. Schemes that discriminate against family physicians and hospitals where most needed should be vigorously opposed. Leadership should understand what most impacts family physicians current and future.

Rather than leading academia and designers to the understanding of the real determinants of health, FM leaders promote models of payment and training interventions that distract the nation from real solutions. FM leaders have tolerated numerous claims of being a primary care solution from those who often did not even enter primary care after primary care training. FM leaders have placed support behind Teaching CHCs. In a previous life I supported such efforts, but now see them as distractions from real solutions. Specific training is important, but it is more important to understand that there can be no training that results in a resolution for health access where needed – until payment has been addressed substantially and specifically. Fifteen years of watching 88 counties of need in Nebraska indicated name changes but no workforce or access changes. A stellar design raised FM to 40% of workforce where needed, a level far above the average of 24%, but still did not result in more – only in different.

Those who continue to promote payment plans and training interventions that are not true solutions for health access or for family physicians – are actually delaying the real solutions. This is something that the builders of family medicine managed to avoid and the leaders that follow them must avoid this also.

There are important lessons to learn that have not been learned by FM leaders. We still attempt the 1970s primary care schools, rural pipelines, family medicine interest groups, departments in every medical school, residencies in every state, Teaching CHCs, and other efforts that have always required payment support and still do. Some of us worked 30 years to facilitate such efforts, only to realize that the success is really about the payment design - not anything training interventions can accomplish.

Family medicine still wastes substantial time and effort promoting academics, training, and innovations. FM leaders fail to realize that the only area that matters to accomplish all of these areas and more is the firm foundation of a solid payment design that fits the half of family physicians serving where the nation most needs care.

This what is needed to empower family physicians, to produce more family physicians, to retain family physicians in FM, and to accomplish the higher functions of primary care (not regulation, not certification, and not higher cost of delivery and more impairment of team members).

We cannot afford the diversion of doing much more to get slightly more and must avoid doing much more to get less.

Posted by Robert C. Bowman, M.D. on January 05, 2017 at 05:57 AM CST #

Dear Dr. Stuart,

Thank you for taking the time to read the article and for your feedback, greatly appreciated.

The direct primary care movement predates MACRA. At its heart, the DPC movement has been a response to fee-for-service. Fee-for-service has been toxic to primary care and family medicine physicians in markets where we have seen take-it-or-leave it contracts, narrow networks, the payment disparity of the RUC (RVS Update Committee), and generally no payment for many of the chores of complex care management and high quality care coordination.

Again, thank you for your comments; we value them greatly.

-John Bender, MD, MBA, FAAFP

Posted by John Bender, M.D., M.B.A., FAAP on January 05, 2017 at 07:28 PM CST #

I would like to echo many of the comments above in appreciation of Dr. Bender's thoughtful article lauding DPC. I converted from a traditional family practice to a DPC model in October of last year (with the deeply appreciated support from Josh Umbehr and Julie Gunther!!) and I have never regretted the decision. I immediately regained joy in practice and was instantly reminded why I became a doctor in the first place. I was planning to leave the practice of medicine in the prime of my career because seemingly everything Hippocrates stood for was lost from modern medicine. I was pressured by insurers to knowingly harm my patients in the name of their profits and I could not see any way to continue to ethically serve in such a toxic environment. Then I found "my people" in the DPC movement and my faith and my practice were restored. Burnout is the furthest thing from my mind now and I can honestly say that the family practice work force has at least one additional doc than would have been the case without the mecca of DPC!

Posted by Cher Jacobsen MD on January 05, 2017 at 08:06 PM CST #

I can't believe this article appeared on the AAFP website! I hope Dr. Bender has some influence at the AAFP such that they start acting in the best interest of its members and not as an advocacy group for government payment schemes.

Posted by James Krantz on January 06, 2017 at 08:05 AM CST #

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