Direct primary care may be the link to the ‘fourth aim’ of healthcare

As burnout and job dissatisfaction rises among U.S. physicians, many have investigated switching to a Direct Primary Care (DPC) model as a form of relief. The alternative to traditional fee-for-service billing is seen by many as a way to refresh careers and return more of an office visit’s focus to the patient.

In 2015, the average monthly fee for DPC was $77.38, this compares to $182.76 for concierge medical practices, according to The Journal of the American Board of Family Medicine. This typically covers unrestricted next day or same day appointments, prolonged visits, direct communication via text, email, phone, virtual visits, and access to greatly discounted ancillaries such as in-house generic medications, labs, and imaging.

Recent reports published by Forbes indicate that DPC increases access and comprehensive medical care, and reduces overall cost when compared to a consumer-driven health plan and traditional insurance plans.

The model certainly provides hope for an improved patient experience, however any formal evaluation of a DPC practitioner’s experience within this model is limited.

In the U.S., clinician burnout and poor job satisfaction has become endemic. Enough so that a fourth aim of healthcare has taken hold-clinician and staff satisfaction; first discussed in a 2014 volume of The Annals of Family Medicine.

The “professional morale, practice patterns, career plans, and perspectives” of U.S. physicians were recently examined by The Physicians Foundation with help from Merritt-Hawkins in the 2016 Survey of American Physicians. The survey reported that amongst primary care physicians, 49.5 percent rate their morale and view on the current state of the medical profession as somewhat or very negative, 47.5 percent often or always experience feelings of burn-out, and 46 percent said they would not recommend medicine as a career to their children or other young people.

Looking deeper into the survey, possible explanations for these responses arise: 78.9 percent of primary care physicians identified patient relationships as a top source of job satisfaction but only 11.1 percent reported having the time needed with patients to provide the highest standards of care. Meanwhile, 51.4 percent reported time with patients as “always” or “often” limited. The top three factors identified as “least satisfying” about medical practice were erosion of clinical autonomy, regulatory/paperwork burdens, and inefficient EHR design.

In a recent article published in Medical Economics, a physician stated the multiple issues with EHRs is “magnify(ing) a shortage of primary care doctors….across the country.”

DPC vs. PCP attitudes

DPC has been touted as a healthcare delivery model that provides physicians with greater clinical autonomy, more time with patients, relief from the paperwork burdens associated with insurance-based practices, and headaches associated with billing-focused EHR systems.

The 2016 Survey of American Physicians did not examine DPC physicians as an aggregate. Therefore, the Moral and Practice Patterns of DPC Providers consisting of an online survey sent out to practicing DPC physicians in September 2017, was to see how these physicians’ responses compared to the responses of primary care physicians in the 2016 survey.

The Moral and Practice Patterns of DPC Providersis a first-look attempt to highlight the attitudes and outlooks of DPC physicians. Survey responses (n=72) were based on self-reported data and responses were not limited to one as that would have required a longer sign-in process respondents were not crosschecked to ensure that they were practicing DPC physicians. Data was not protected from researchers by a third party.

Doctors responded from 39 states; 76.4 percent reported themselves as family physicians, 13.9 percent as general internal medicine; and 72.2 percent were female, 27.8 percent were male. The average age was 43.5.

Notably, 9.7 percent reported often experiencing feelings of burnout and no respondents reported always experiencing feelings of burnout. This is down from 30.6 percent (often) and 16.9 percent (always) of primary care physicians in the 2016 Survey of American Physicians.

Nearly 14 percent said in the DPC survey that the negatives outweigh the positives and they would not choose to do medicine over again, compared to 27.4 percent from the 2016 survey. Nearly 67 percent report that they “would recommend medicine to their children and other young people” compared to 54 percent in the 2016 survey.

Perhaps as an explanation for these differences is that only 26.4 percent of DPC clinicians reported spending greater than 10 hours per week on “non-clinical (paperwork) duties” versus 48 percent of primary care providers in the 2016 survey. Nearly 46 percent of this survey’s respondents report working zero to five hours per week on these duties versus 21.3 percent of the 2016 survey respondents.

Charting current, future thoughts on DPC

Seventy-nine percent of the DPC survey’s respondents reported “generally having all the time needed with patients to provide the highest standards of care” contrasting with only 11.1 percent of primary care practitioners feeling this way in the 2016 Merritt Hawkins survey. As a possible explanation, only 26.4 percent reported spending greater than 10 hours per week on “non-clinical (paperwork) duties” versus 48 percent of primary care providers in the 2016 survey.

An “additional comments” section was offered with the survey, which provides further insight into the thoughts, feelings, and experiences of the DPC practitioners. The following comment captures a common theme:

“I think overall, the state of medicine is in terrible shape. I think Direct Primary Care is one way to help save our profession. I have only been doing DPC for six months so I am still recovering from the previous 16 years of the fee-for-service nightmare. I could not recommend medicine to anybody in the current state of the profession but I definitely would recommend direct primary care.”

[For more comments from the survey, click here for a slideshow.]

In a follow-up survey, after a presentation of the Moral and Practice Patterns of Direct Primary Care Physicians, 23 4^th-year medical school students from the USF/Morsani College of Medicine responded to questions regarding their thoughts on direct primary care and their experience within the current healthcare system.

The data showed 47.8 percent heard about DPC prior to the presentation and 43.5 percent have considered DPC or practicing outside of the insurance-based reimbursement system. A high percentage (77.3 percent) reported a perceived a concerning level of poor job satisfaction in the medical field and 47.8 percent stated an impact on specialty and career decisions.

Based on the Moral and Practice Patterns of Direct Primary Care Physicians survey data, DPC demonstrates as a means of achieving the “fourth aim” of healthcare-improved clinician and staff work life. This aim may provide a foundation from which to rebuild family medicine and possibly other areas of medicine.

The information gathered by this study about physicians-in addition to existing information on DPC cost, quality, and access metrics-points to DPC as primary care model that should be strongly considered by patients, current and future primary care physicians, as well as state and federal lawmakers as they draft legislation to promote and protect the growth of the only innovative healthcare model to develop in the past decade.

As the owner of a DPC practice in Pennsylvania, Corba offers the following perspective:

“Primary care is the foundation of medicine and without a functioning workforce of primary care physicians, not only will the U.S. healthcare system falter, but more importantly, the patients will suffer,” Corba says. “Direct Primary Care answers the call for improved access, cost and management of care by removing the administrative burdens of third parties from the office and exam rooms. It is clear from this survey that the intrusion of third parties has eroded the foundation of what primary care is supposed to provide to our patients which is destroying the heart and soul of primary care physicians. DPC is disrupting the status quo; it preserves the sanctity between patients and physicians." 

Kimberly Legg Corba, DO, is a board certified family physician, a Direct Primary Care physician, and the owner of Green Hills Direct Family Care in Allentown, Pa. She is also the author of The Manual of Policies and Procedures for Direct Primary Care. Corba was the supervising attending physician for this study.

Michael Watson, MD, a 4^th-year Medical Student, at time of writing, enrolled in the University of South Florida’s Morsani College of Medicine; he completed 3^rd and 4^th year rotations at Lehigh Valley Health Network in Allentown, Pa., and is now completing a transitional internship year with the United States Air Force at San Antonio Military Medical Center in San Antonio, Texas. Watson completed this survey as part of his MS4 Capstone Project.