Primary care in the United States is on the brink of collapse. Primary care providers suffer existential burnout, are the lowest compensated among all medical specialties, and there is a crisis-level shortage of primary care physicians, especially in health professional shortage areas. Despite strong evidence linking primary care (unlike any other medical specialty) to a better quality of life, longer life expectancy, better patient experience, and lower total cost of care, primary care has remained undervalued and under-resourced for decades, marginalized by an industry dominated by expensive subspecialty care, lucrative procedures, and a dysfunctional third-party payer system which has rendered the patient a commodity.
Yet we already have a recipe to fix primary care – and the broken U.S. health care system. The key ingredient is found in the direct primary care (DPC) model in which primary care providers (PCPs) and patients walk away from the fee-for-transaction third-party insurance payment system in favor of a monthly membership fee. This monthly fee, typically paid either by the patient or an employer, is much like a gym membership or a magazine subscription. The reason it works is that it gives practices predictable, upfront cash flow without the hassle of insurance-driven red tape and reporting requirements, while patients get unlimited access, more time with their doctor, and more convenient care. PCPs in a DPC tend to commit to continuous, longitudinal relationships with far fewer patients than in traditional payment models, ensuring same-day or next-day access for their patients and a much lower administrative burden for the PCP.
Critics of the DPC model argue that with each PCP carrying only 600 patients, the U.S. primary care shortage is made worse. One needs to understand why this argument is flawed and what is causing the shortage. When we examine those reasons and consider how they have resulted in primary care specialties being an inhospitable career choice, we understand what DPC has to offer as a solution to the shortage rather than a threat to it. DPC PCPs are perhaps the happiest physicians in all of medicine. They have better work-life balance, lower stress, a restored sense of purpose, and almost zero burnout. DPC physicians have reclaimed their joy in practice. To wit, adding too many patients to an overwhelmed PCP will never be the solution to the PCP shortage – it will further aggravate the crisis. Enticement into a meaningful career field, in which physicians and patients reap the benefits of a trusting and therapeutic relationship, is the better bet.
What’s still missing, however, is for primary care to be paid fairly for the value it brings. In the DPC model, when the burden to finance the care falls to the patient alone, affordability may present an obstacle. More recently, employers and innovative health plans have built their benefit plans around direct primary care, which relieves the patient of this out-of-pocket cost. If the case studies are accurate in citing a 20 percent reduction in the total cost of care driven by a DPC PCP, payers stand to save an average of $2,500 per beneficiary per year. This far exceeds the average cost of DPC membership ($900 per year) and indicates that DPC practices could be in a position to negotiate significantly higher rates. Paying primary care their fair share for the value they create, and bringing their compensation in line with subspecialty colleagues in doing so, is another crucial key to unlocking the primary care shortage.
We stand at an inflection point – one where we have an opportunity to lean into the DPC model and away from a legacy health insurance system, which has been extravagantly lucrative for those in power in the industry, but of limited benefit to society. The crippling and decimation of American primary care has benefitted hospitals, heart surgeons, and health plans alike but has driven infant mortality rates up and life expectancy down in a country that spends double on health care compared to peer nations. We cannot afford to continue repeating past mistakes – it is time for a change.
The subspecialty-heavy, hospital-driven, bloated and underperforming U.S. health care system needs robust, high-functioning primary care. The evidence for more primary care is clear. How we achieve the goal remains poorly defined. DPC has shown us a way if only we’d take it.
Sara Pastoor is a family physician.
