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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(www.dpcare.org).

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(medcitynews.com) -- 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(nexterahealthcare.com). 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

Posted at 08:51AM Jan 03, 2017 by John Bender, M.D., M.B.A.

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