The risk of direct care

©Stuart Miles 

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

I am a proponent of direct primary care (DPC). OK … maybe I’m a fan-boy.  It has changed my life so dramatically that it is hard to explain it without sounding like I’m giving a sales pitch. My practice, the quality of my care, and my life have all improved since making the change six years ago. But with such enthusiasm comes a danger: being blinded to the negatives, the risks, and the potential problems of the model, both in the present and future. 

A letter to the editor of Medical Economics recently caught my eye. The author was a primary care doctor who had read my articles on DPC.  While interested in the practice model, he pointed out the potential negatives:

…there is a dark side to the conversion that nobody in the DPC camp ever seems to talk about. While the new practice model might be great for the select group of patients who agree to stay on and pay their monthly fees, what about everyone else? Dr. Lamberts wrote that he averages 8 to 11 patients per day. I wonder how many he was seeing before he made the switch. In my practice, I was routinely seeing 25 to 30 patients per day. Had I jumped on the DPC bandwagon, that would have meant that about 20 patients per day would have been displaced and forced to find a new family doctor.

He goes on to spell out the obvious concern based on this real observation:

I just can’t help but wonder where the thousands of patients who get displaced are supposed to go for care once their family doctors can no longer see them. Urgent Care picks up a lot of the slack for acute care needs (I still see 25 to 30 patients per day) but they don’t handle chronic conditions. Especially as the population ages, there is an ever-growing need for better primary care access. It seems to me that a growing DPC movement will make the access situation even worse.

This is a very valid point that those at the head of the DPC movement need to address and answer up front. Yes, I did consider this when I left my old practice, and it was the largest source of hesitation I had in making the leap.  

Beyond this, there are other even larger concerns that could swallow up the DPC movement and shunt it from being a potential salvation for our system to a flash in the pan. This article will explain the problems that direct care may cause and point toward a potential solution. I do realize that my foresight in this arena is limited, so I may be missing the real problems we will face in the future. But the best chance for this practice model, which has made my life and my care so much better, is to succeed in the long run.

Problem 1: DPC abandons patients

This is what the letter to the editor was saying: I and my DPC colleagues were abandoning patients, leaving care to be picked up by those who hadn’t made the switch.  While I don’t think the number of office visits makes the case strongly, I do think this is a valid concern.  

In truth, the lower number of office visits is a good thing. The reason I see less patients per day is not just because I have lower overall census, but because I don’t limit care to office visits.  While I see between 8-12 patients per day, I actually give care to 20-50 patients each day via text messaging and phone calls. I found that only about 25 percent of my visits in my old practice required an office visit. I don’t have to worry about lost income in my new practice, so I can handle most problems without an office visit.

I actually think that the average primary care doctor’s schedule of 25-35 patients per day is a major indictment of our system. It is not possible to see that many patients (especially with the huge time burden of insurance compliance and unfriendly medical record systems) and still give high-quality care. This is what drove me to burn out: the knowledge that there was no way I could give the care my patients deserved when seeing so many people each day. 

A more serious number, however, is the fact that I reduced my entire patient census from 2000-3000 to 800. How can this work if adopted by all doctors? What will happen to all of the patients if DPC becomes widely adopted? I think the answer will not be as simple as many DPC proponents say. It will likely cause a crisis of access, which I hope will be met by an increased workforce of primary care doctors who no longer see the profession as a booby prize. Primary care has become the domain of the idealist-those willing to give up significant income to do good for people. DPC raises the possibility that primary care won’t be relegated to the realm of self-sacrifice and social good, but turned back into the most fulfilling and important job in the entire system.

Will that happen? Time will tell.

Problem 2: DPC is unregulated

The other, more subtle risk of DPC comes from the blatantly independent nature of most doctors who adopt the practice model.  

This seems like apostacy within a “movement” in medicine that is defined by its libertarian leanings. I am, by definition, anti-insurance company and anti-government in my practice. I accept no payment from either, which is part of what makes the model so great. But while I am dedicated to giving excellent evidence-based care to my patients, what keeps other doctors from wearing the “noble” DPC mantle and not being so dedicated?  

I have seen much discussion about approaches to care within DPC practices that are far from mainline. DPC groups (such as the DPC alliance, of which I am a founding member) are regularly approached by naturopaths for membership. Within our membership are doctors who engage in medical practices I do not endorse, and I’m sure that some of my approaches to care wouldn’t be endorsed by all of my colleagues.

There is nothing keeping a medical provider, regardless of training or practice, from claiming to be DPC. Left to chance, this could dilute the current goodwill enjoyed by the direct care community at this time.  It seems to me that the only real solution to the lack of regulation is a set of criteria and certification by a medical body/society.

Can the DPC movement police itself?  Can a group of vigilantes who are largely defined by what they aren’t become a cohesive and influential mover in our system? These are real questions that the DPC leadership must address, and ones that will be met with much resistance from some of the current members (and leaders) of the DPC movement.  

I certainly hope that DPC is here to stay. But we in the early stages of this movement must look ahead to what our biggest challenges will be. We can’t deny there are negatives, because doing so will play into the hands of those with a vested interest in seeing this movement fail.  

I think that DPC is the best model we have at this time. I believe I give better care than most other doctors out there, and it’s not because I am smarter or more talented; I think it’s because the model encourages me to give good care, not bad (as is the case with regular fee-for-service medicine).  We in leadership need to assure that this good care will be available to everyone in the future. 

Rob Lamberts, MD, is a board-certified internist and pediatrician who runs Dr. Rob Lamberts, LLC, a direct primary care practice in Augusta, Ga. He also recently gave a TED talk on the DPC model. Have questions about DPC? Email medec@ubm.com.