Direct primary care: a new system for general practice

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US primary care medicine is a mess. In most of the developed world’s healthcare systems, primary care doctors comprise at least half of the medical workforce. In the US, it is less than one third.1 Primary care brings hard work, low status, and relatively low pay in the US, and graduating medical students, deep in debt, are voting with their feet. In the most recent class, less than half of the available family medicine residency entry positions were filled by US graduates.2 ⇑

Doctors complain that insurance and health plan paperwork is burdensome, reimbursement is low, and thus a large number of patients must be seen daily to provide enough income to keep the practice afloat. The pressure of patient volume leaves doctors frustrated that they are unable to spend an adequate amount of time with each patient. Burn-out is common, further exacerbating the brain drain from primary care.

One widely publicised response to this situation has been for doctors to join so called boutique or concierge medical practices.3 In this model, primary care doctors charge enrolled patients an extra annual fee, usually between $1000 (£640; €795) and $2000, to provide them with an “executive” physical examination and more personal service. In addition to the annual fee, they are billed for all primary care visits and lab tests, as well as specialist, hospital, and emergency care, so patients must maintain their full health insurance. The annual fee buys patients who can afford it increased access (and usually the doctor’s mobile phone number), longer patient visits, and less waiting time. Doctors have more income, more time to spend with patients, and less patient volume. Patients who cannot afford the membership fee are “referred elsewhere” (that is, shown the door).

Concierge medicine has been criticised as being elitist and harmful to the healthcare system overall. It gives patients who already have access to care access to more care, at the expense of those who can’t afford the annual fee. It reduces the number of doctors available and may also lead to unnecessary testing and interventions secondary to the comprehensive physical examination and test battery that comes with the package. It also, of course, does nothing to reduce the time and cost burden of insurance paperwork, either for doctors or patients, since it is overlaid on top of regular insurance coverage.

Another, more egalitarian scheme to deliver and pay for primary care is drawing some interest in the US. It is called direct primary care and it dispenses with insurance altogether.4 Patients pay an age adjusted fee, ranging from $50 to $150 a month, directly to the practice in exchange for unrestricted, comprehensive primary care. They have 24/7 access to the practice and unlimited visits. Basic lab tests and x rays are usually included. The practice takes no insurance and the only administrative burden is billing the monthly fee. Because overheads are low, fewer patients are needed to allow the doctors to make a decent living, which leaves more time for patient visits and counselling. Most direct care practices include other clinicians, such as nurse practitioners and counsellors, who share patients with the doctors.

Proponents say that this model makes sense because insurance should be for expensive, uncommon, and unpredictable problems. Primary care is cheap and predictable, and it should be readily available. Though research data are lacking, the argument is that direct primary care will keep patients healthier and doctors happier, reduce costs, and (ultimately) increase the interest in and supply of primary care doctors.5

Direct primary care patients do, of course, need insurance, but only for uncommon problems: hospitalisation, emergency room visits, and specialty care. This type of plan is fairly affordable if it is purchased with a high patient deductible, say $1000. Patients are then at risk for that amount but are covered against the catastrophic costs of a long hospitalisation.

So far, direct primary care is a tiny movement, with perhaps 100 000 patients enrolled, mainly in three US states: New York, Washington, and California.6 In some states, direct primary care is illegal, because it violates state insurance regulations. Some states have modified their rules to allow direct primary care practices. The federal government also makes direct primary care difficult because it is not compatible with Medicare rules, although there is legislation to create demonstration projects to test direct primary care with Medicare patients. Similarly, the Affordable Care Act will allow qualified direct primary care practices to become part of the health exchanges to go into effect in the next two years.

The modest, predictable expenses of direct primary care appeal to groups such as the young uninsured and to small business owners. They like the lack of paperwork, ease of access, and continuity of care that these practices offer. Doctors in these practices enjoy the continuity of care and decreased patient load, but they are less enthusiastic about 24/7 availability and the self selection of their practices by patients who demand constant attention for trivial matters.

It remains to be seen whether this model will be tested to see if it can offer a real alternative to primary care patients and doctors who are tired of paperwork, high expenses, and difficulty with access and overcrowding. If so, it deserves to be expanded nationwide.