Is direct primary care part of the solution or part of the problem?

Unlike other wealthy countries, the United States has a low ratio of primary care physicians relative to medical specialists. Currently, only one in three physicians practice primary care, and only one in six medical graduates chooses primary care. When you consider that primary care visits account for 55 percent of the 1 billion physician office visits each year, and that the Patient Protection and Affordable Care Act (ACA) could generate an additional 25 million primary care visits annually, one begins to see an already stressed system being pushed to the brink.

One way to measure the adequacy of primary care access is by availability of obtaining a doctor's appointment when ill. Although we traditionally have criticized other countries for their long queues in receiving care, there is emerging evidence that long waits for primary care is becoming the norm in the U.S. According to a 2013 study by the Commonwealth Fund, 26 percent of 2,000 Americans surveyed said they waited six days or more for a doctor's appointment when they were sick or needed care. This is just barely better than Canada (33 percent) and much worse than Britain (16 percent).

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Physicians feel the pinch in time and money in this primary care bottleneck. A primary care physician with a panel of 2,000 patients would need to spend an estimated 17.4 hours per day in order to provide recommended acute, chronic and preventive care to their patients. In terms of physician work per hour, Medicare pays almost four times as much for a screening colonoscopy as it does for a complicated primary care office visit. This combination of patient demand alongside a reimbursement system that undervalues primary care care has led some physicians to seek a different kind of practice style. Enter "direct primary care."

Direct primary care (DPC) — also known as "retainer medicine" — has grown rapidly over the last decade; 25 percent in the last year alone. Presently, there are approximately 4,400 direct primary care physicians nationwide, up from fewer than 150 in 2005. Generally speaking, DPC practices do not take health insurance but, in exchange for a direct cash payment of $100 or less per month, offer enhanced access to primary care services. Because DPC physicians reduce their patient panel size by half or more, they often offer same-day appointments, longer office visits, email communication and on-site X-rays. But the direct primary care model is not comprehensive coverage, and although many DPC practices recommend that members obtain a high-deductible wraparound policy to cover hospitalization and catastrophic events, many patients who choose direct primary care are uninsured and use it as their only source of health coverage.

Supporters of DPC believe there are multiple system efficiencies in the model: Burdensome insurance approvals and paperwork are eliminated upfront and chronic condition costs are tempered in the long-term as emergency department, hospitalization and specialist visits decline. The American Academy of Family Physicians endorses the DPC model, but others worry that DPC marginalizes the larger health system as physicians pull out of provider networks linked to insurance. Opponents argue that DPC gives a false sense of security when purchased as stand-alone health coverage and that the low-income uninsured would be better served by purchasing coverage in the ACA exchanges where affordable, comprehensive policies are available.

Interestingly, the ACA allows DPC practices to offer coverage in the health insurance exchanges when combined with a wraparound catastrophic insurance policy provided by a qualified health plan (QHP). The QHP is used for hospitalization, specialty care and other more costly services. To date, there are no DPC practices operating in the federally facilitated exchanges, but the first DPC offering paired with a QHP will be available in the Washington state exchange in January 2015.

So, is direct primary care part of the solution facing the growing lack of access to primary care in today's health system or is it part of the problem? By allowing physicians to see fewer patients, DPC no doubt exacerbates wait times for those seeking care in non-DPC practices. However, because of the potential for more time with patients and higher revenues, DPC may offer an incentive for primary care physicians to stay in practice longer and perhaps even make primary care more attractive to young physicians choosing a career path. And, with 10 percent of doctors planning to change to some form of direct-pay in the next three years, DPC might offer an alternative to the 6 million uninsured individuals living in states that have not expanded Medicaid and who make too little money to qualify for ACA exchange subsidies. Direct primary care is not a perfect solution to the coverage and access problems in healthcare today, but in combination with wraparound catastrophic insurance protection, it may be one incremental step toward an overall better system.

Engelhard is the director of the Health Policy Program at the University of Virginia School of Medicine's Department of Public Health Sciences.

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