The emergence of direct primary care (DPC) has the characteristics of a social movement, defined as a “purposive and collective attempt of a number of people to change individuals or societal institutions and structures.”
Moreover, the DPC movement has thus far succeeded largely because it is based on a guiding set of strongly-held principles from which its founders have not wavered. The concept of direct primary care as a reordering of the incentives and priorities of doctors and patients away from those of third-party payers has attracted a large following among physicians and members of the public who laud it as a positive example of disruptive innovation. The genius of the concept lies in its common-sense simplicity, which stands in stark contrast with the confusing complexity of the larger health care system.
As direct primary care gains in popularity, it runs the risk of succumbing to the same pressures that have affected other growing social movements. Namely, the movement risks relinquishing its founding principles in an attempt to accommodate previously held norms within society. While the siren call of more widespread acceptance and recognition of the movement within the mainstream is attractive, I believe it may represent the first challenge to the integrity of the social movement as we have known it.
The most visible example of such a challenge comes in the form of a bill introduced in the U.S. Senate (S. 1989, also known as the Primary Care Enhancement Act). This Bill, which ostensibly works to assert the validity of direct primary care as a payment model that is not classified as insurance, also moves to establish a definition of “qualified direct primary care medical home practice” for the purpose of enrollment of practices in a Medicare primary care demonstration project. In order to qualify for this pilot project, qualified DPC practices must comply with a prescriptive set of operational requirements regarding manner and scope of practice (including such requirements as “availability of ongoing care appointments seven days a week”). The Bill also outlines a series of performance benchmarks — the same quality measures used to measure accountable care organizations in the Medicare Shared Saving Program — which “qualified DPC medical home practices” are required to report if they are to maintain their inclusion in the demonstration project.
The promulgation of this pilot project among direct primary care practices places DPC on the same trajectory as many of the social movements that have gone before. While the inclusion of DPC among the practice types of CMS’ pilot project may seem like a flattering gesture to some at the top of the DPC pyramid, it nonetheless represents the first large-scale move to accommodate to the societal norm of third-party payment for primary care services. The illusory belief that this accommodation is necessary in order to make DPC ‘scalable’ and more widely available undermines the defining characteristic of the movement — the direct financial relationship between doctor and patient.
The topic of DPC’s flirtation with the Medicare pilot project evokes visceral reactions from many in the DPC community. From what I can gather, supporters of S.1989 view it as an exercise in pragmatism that is necessary in order for DPC to grow and move to the next level. Opponents by and large feel betrayed by the acquiescence of the movement to the regulations and requirements of Medicare in return for a larger slice of primary care market share. The discussion about how to negotiate with third-party payers sounds a lot like Yogi Berra’s “déjà vu all over again.”
In my opinion, this is an important time for those in the DPC movement to assert the value of direct primary care with the public by being mindful of the foundational criteria of good primary care, as described by Dr. Barbara Starfield and as conceived by family medicine’s founders, such as Drs. Lynn Carmichael and Gayle Stephens. By definition, effective primary care should be: 1) patients’ point of first contact with the medical system; 2) be longitudinal and person-focused (rather than disease-focused); 3) be comprehensive in nature; and, 4) coordinate care with other services when patient needs go beyond its scope.
When practiced as it was originally envisioned, DPC performs exceptionally well in all four of these areas. By reducing barriers between doctors and patients, DPC ensures access to the primary care physician as the “go-to” person for patients’ health concerns. Its avoidance of third-party entanglements (which are often employer-based and thus easily disrupted by changes in employer) make person-focused and longitudinal care the norm in DPC. Regarding scope of care, practices can expand their scope of practice beyond what is customary in insurance-based models, with the intent of maximizing the practice’s value to patients. One element of this value entails partnering with subspecialty physicians and others for care that is not provided in the primary care practice (coordination of care).
It remains to be seen how the DPC movement will react to its own rapid growth and early success. Will the siren’s call to negotiate some of its principles in return for greater mainstream acceptance be too enticing for DPC leaders to resist? Might DPC organizers succeed in bucking the trend of previous social movements and manage to shepherd the movement’s integration into the larger health care system without abandoning its core principles? Or will the growing tensions within the DPC community produce a schism, with the fractionation of the movement into a “purist direct primary care” wing and a “Medicare per-member-per-month” capitation wing? Regardless of which side of the debate over Senate Bill 1989 they find themselves, participants in the DPC movement would do well to bear in mind the four essential qualities of primary care — first-contact, person-focused, comprehensive, and coordinated — and ask themselves how their vision for the future of DPC squares with these defining elements.
James Breen is a physician.
