Halle Tecco recently wrote a piece about direct primary care. Seeing people outside the DPC world write about the model usually comes with some excitement mixed with trepidation. Increased interest in DPC gives great external validation to the model. However, most people who write about it run into the usual misconceptions and misunderstandings. Since Halle’s article has taken off and gained a good amount of attention, this article seeks to clarify some points and correct others for those who want a more complete understanding of DPC.

Preventive care like vaccines are also generally included

For the vast majority, vaccines are not included. Independent, physician owned practices are often too small to handle vaccines. This has been a top issue many in the community have been trying to solve for a few years. The few practices that do in house vaccines, there is a charge- at cost usually.

hybrid DPC model, they charge a monthly membership fee in addition to billing insurance for services

For the sake of clarity and all future discussion, concierge, DPC, and hybrid practice needs consistent definition.

Membership alone = DPC
Membership + insurance = concierge
Membership for some + Insurance for others = hybrid practice

The most common example of hybrid practice is a DPC who bills Medicare due to existing federal regulation.

hybrid DPC organizations, One Medical

Another reason for the clarification in definition is so people stop thinking One Medical is DPC in any way or form; at least their core business. They acquired PeakMed, an employer focused DPC, a few years ago, just prior to their own acquisition by Amazon. DPC is still likely a minuscule part of One Medical’s portfolio. Their core business remains a concierge model (Membership + insurance).

Many hybrid DPC models accept insurance for labs, imaging, and specialists

Yet another place where labels matter, despite the authors dislike for them. The DPCs do not accept insurance at all for their services, and this doesn’t matter whether it is a pure DPC or hybrid DPC. Patients are welcome to use their insurance for everything outside of the primary care services. In general, things like labs, imaging, and specialists are not usually covered by a DPC membership, but the practices do find the best price and help with navigation. Many times patients find the negotiated prices more reasonable than their insurance price, especially if they have a high deductible plan.

What the math looks like for DPC practices

This section was a bit simplistic, perhaps on purpose. Other factors to consider are: collections (99% in DPC vs 50% in FFS), overhead (much lower in DPC), and size of practice (doesn’t matter for DPC, but insurance contracts are MUCH worse for small, independent FFS practices).

Some patients combine DPC with high-deductible or catastrophic health plans.

Known simply as insurance in any other industry.

Exacerbating the PCP shortage

Perhaps the most legitimate concern around the model. Some debate exists about the actual effects of the model on the system as a whole. DPC is the most promising option to help fix the pipeline issue. Also, it allows for innovation to solve for some inefficiencies necessitated by FFS primary care such as having to have in person visits for everything. More conversation needs to occur around this issue, not just as it pertains to DPC, but for primary care and family medicine overall.

It’s also unclear how DPC would work for those with chronic illnesses requiring regular specialist visits– which is, unfortunately, nearly half of Americans.

Most of these patients may not need so many specialists. Currently, FFS systems are referring out too much, for example, to cardiology for hypertension, endocrine for diabetes, and psych for depression. All these can be done in one PCP office. Hospital systems like to control primary care so they can refer into more lucrative specialties. Plus the use of e-consults, commonly implemented by DPC practices, further reduces referrals.

Some DPC practices specialize in chronic disease management

Especially the ones trained in family medicine and internal medicine AKA 99%+ of DPC practices. There’s a weird phenomenon happening in the health tech space where people are separating chronic care management from primary care as if primary care wasn’t 90+% chronic care management.

Lastly, a 2018 JAMA commentary highlighted the potential for perverse incentives, suggesting that DPC could incentivize doctors to focus on attracting healthy patients who require minimal care.

This terribly informed and misguided JAMA article was properly rebutted in 2018.

Increased regulation and transparency in DPC

We’re already the most transparent model in healthcare. Everyone wants to regulate a good thing into oblivion. There are enough people in the DPC community plugged into the political scene to make sure this never happens.

Direct primary care startups you should know

This list is pretty random. Perhaps a better heading is “DPC Ecosystem startups,” categorized into DPC support, DPC provider, DPC tech, etc.

Can we really cut out the middle man (insurance)?

In primary care, yes. For catastrophic stuff that actually make sense for insurance to help out, no. And that’s the point. Stop using car insurance to pay for your oil changes.

For a more complete understanding check out the articles below

DPC Landscape
Best Practices