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The solution to a crumbling primary care foundation is direct primary care

In a report published by the Commonwealth Fund and released in August 2021, the performance of the U.S. health care system was compared to that of other high-income countries. The results were stunning: despite investing far more of its gross domestic product in health care, the U.S. ranks dead last overall and last on access to care, administrative efficiency, health equity, and health care outcomes. Four key features were characteristic of the top-performing countries and distinguished those countries from the U.S. One of those four features was that they invest in primary care.

The primary care that most patients (and primary care clinicians) experience today is rushed, fragmented, disorganized, delayed, diluted, and ineffective. A widely accepted factor is that the fee-for-service payment model of U.S. health care is at the root of this bloated, dysfunctional, poor-performing delivery system, and it has been particularly toxic to the delivery of high-value primary care. Yet, there is good evidence that primary care can restore our communities’ health, close gaps in health equity, and drive down wasteful and preventable health care spending. So how do we get from here to there – considering an under-resourced, under-performing primary care system, crippled by the wrong payment model and overwhelmed by a scarcity of primary care physicians?

Enter the direct primary care (DPC) movement in primary care. In this model, primary care providers (PCPs) step away from fee-for-service insurance billing, which brings with it an administrative burden, increased financial overhead, and an emphasis on transactions and procedures at the expense of powerful clinical relationships between PCPs and their patients. In the DPC model, PCPs are paid a consistent fee through a retainer (or membership) program, often paid either by the patient or by a self-funded employer looking to innovate on their health benefits design. This prospective payment design, both financially and operationally, liberates the PCP to spend more time on patient care, provide same-day/next-day access, deliver comprehensive care, and coordinate care across the complex health care spectrum. At the nucleus of this model and its success is the PCP-patient relationship.

Started in 2007, the DPC model has slowly been growing in prevalence, now estimated to comprise 6 to 10 percent of total primary care delivery across the U.S. Both PCPs and patients in this model report unprecedented satisfaction with the care experience (98 percent for both). In case studies, expensive services like ER utilization, hospital admissions, and subspecialty care are all decreased with a reduction in the total cost of care of 19-20 percent. Appointment times are longer (30+ minutes), there is liberal use of virtual care, and PCPs typically care for only ~600 patients total, unlike traditional FFS PCPs, who may carry thousands on their patient panels. Moreover, the model restores physician autonomy and makes room for unprecedented innovation in care delivery, laser-focused on what patients actually need.

In fact, the DPC model may be the purest form of primary care known and the most patient-centered form of health care we have. Without insurance rules, complex billing and reimbursement processes, or other regulatory burdens, PCPs are liberated to practice their craft as they see fit. But beyond this freedom, they are also incentivized to do what’s best for the patient because the patient’s success is central to the business’s success. With the incentives aligned and the freedom to do what’s best for patients both clinically and financially, patients win – not because of the heroic efforts of primary care teams and their patients to overcome obstacles, bureaucracy, and dysfunctional systems, but by design.

Sara Pastoor is a family physician.


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