Could direct primary care practices be contributing to the shortage of primary care physicians?

Direct primary care (DPC) is a primary care practice and payment model in which patients pay their physician or practice directly, in the form of periodic payments—typically a flat monthly or annual fee—for a defined set of primary care and medical administrative services. The DPC model looks to replace the traditional fee-for-service model, relying on third-party reimbursement for primary care services.

Since 2019, the Health Resources and Services Administration (HRSA) has designated specific health professional shortage areas (HPSAs), which are, “areas, population groups or facilities within the United States that are experiencing a shortage of health care professionals,” according to an HRSA release. In a report published in The Annals of Family Medicine, researchers set out to determine the overlap between HPSAs and DPC practices in the US, and how the communities served by the practices differed from primary care physicians (PCPs).

A common criticism of DPC, as well as the similar, yet distinct, concierge medicine practice, surrounds the possibility of these models worsening the PCP shortage in the U.S., and thus contributing to greater disparities in access to care. According to the report, concierge medicine practices were not included in this analysis because they tend to skew toward higher-income households for a variety of reasons.

In their analysis, researchers determined that DPC practices were overall less likely to be found in HPSAs, compared to PCPs identified by the National Provider Identifier (NPI). Although DPC practices were less likely to be found in high-priority–need HPSAs, they were more frequently found in rural and partially rural HPSAs.

In total, 44% of DPCs were in HPSAs, with 45% in low-priority–need areas, 47% in medium-priority–need areas and 14% in high-priority–need areas. In contrast, researchers found that 47% of the NPI PCPs were in HPSAs, with 39% in low-priority–need areas, 49% in medium-priority–need areas and 20% were in high-priority–need areas.

Of the 44% of DPC practices in HPSAs, 25% were in rural areas, 22% were in partially rural areas and 53% were in non-rural areas. Among the 47% of PCPs in HPSAs, 19% were in rural areas, 19% were in partially rural areas and 63% were in non-rural areas.

The report offered several observations based on their findings. For one, although there is evidence that DPC practices can be found in non-urban areas, where there is a documented shortage and need for PCPs, DPC practices are not as geographically dispersed as PCPs are across the country, with respect to HPSAs. They also noted that geographic availability is not the sole factor in health care accessibility. Factors including cost, coverage, distance, patient volume and patient comfort could serve as barriers regardless of geographic availability. Further, just because DPC practices are present in high-priority–need HPSAs does not mean that they will serve the target population, especially if they pull from the sector of the population who have access to primary health care in that area, or if the DPC practice’s cost serves as a barrier to entry.

“In conclusion, there remains ample opportunity to grow DPC presence in many HPSAs, especially high-priority HPSAs in urban areas,” the authors of the report wrote. “As others have stated, there is a need to show that expansion of DPC practices into HPSAs will not further marginalize groups that have historically lacked access to primary care.”