Why I Like the Direct Primary Care & Advanced Primary Care Models

I have written blogs on the value of primary care physicians and the need to move them to center stage, but as I deep dive more into this issue, my concern and disappointment become enhanced.

The primary care physician role has continued to be devalued in many venues, including:

• When they are employed by hospital systems that narrowly define their role as a gatekeeper to all the specialties.
• When they are employed by for-profit entities that look at them only from the lens of “return on investment.”
• When they are in private practice but do not have the resources and staff to provide the needed comprehensive primary care for their patients.

Obviously, there are always exceptions to these scenarios where the primary care physician is indeed valued and can exercise the holistic skills that set them apart from all the other physician specialties.

As noted in many of my prior publications, as we transition to a world of risk/value-based healthcare and overall population health, the role of the primary care physician needs to take center stage.?The role of the primary care physician should not be subservient to the other specialties.?

In fact, the role of the primary care physician should be more like the?“conductor”?of the orchestra.?Conductors?need not know how to play each instrument, but they know enough to bring them all together to make beautiful music. Likewise, the primary care physician can help?orchestrate?the care from the other providers to bring forth a better health status for the patient.

Ideally, the primary care physician should be:

• The trusted patient advisor and advocate.
• As a trusted patient advisor and advocate, playing a key role in engaging patients in their own health.
• Playing a key role in a risk/value-based world that financially rewards providers, including hospitals, for keeping patients healthy.
• Capitalizing on their holistic role by linking clinical, behavioral/mental health, and chronic disease management in a team-based approach to better serve their patients.
• Not limited by “fee for service” payer restrictions that potentially restrict innovative approaches to patient education, provision of services, and wellness programs,
• Able to deliver services, consultative advice, etc., through any means that is acceptable and convenient to the patient (virtual, text, secure emails).
• Able to provide deeper analytics, population health management, and reporting to help employers reduce the total cost of healthcare while improving health outcomes.
• Playing a key role in reducing costs to the patient and the entire system due to appropriate utilization and provider effectiveness.
• Orchestrating care coordination, value-based referrals, a powerful informatics platform, and guiding patients through stages of change, including while in the inpatient hospital setting.
• Able to provide longer and more frequent patient appointments to facilitate hands-on provider-team interactions, which will result in better diagnosis and treatment plans.
• The hub of up-to-date patient information to manage more care out of their primary care office. A key ingredient to unleashing the real power of the primary care physician is timely and appropriate data. The primary care physician cannot be a real advocate for the patient without the necessary data from the other caregivers.
• Able to develop a strong relationship with community-based organizations that provide nutrition counseling, transportation, and other services addressing the social determinants of health that can impact patients' lives and outcomes. Establishing this type of community support network for vulnerable populations is essential if we want to improve health equity and attain the goals of value-based care.

Primary care physicians who are employed by hospital systems that view their role as gatekeepers to their specialists, or who are employed by for-profit organizations that narrowly focus on return on investment, or who work in under-resourced independent practices do not address many of the above key roles for this important specialty.

Primary care physicians can exercise this role as conductor and patient advocate and achieve most, if not all, the above goals of primary physicians through the Direct Primary Care (DPC) / Advanced Primary Care (APC) models.

What Is Direct Primary Care/Advanced Primary Care?

Direct Primary Care (DPC) / Advanced Primary Care (APC) is an alternative care and payment model that eliminates fee-for-service payments and third-party billing. Instead, patients pay their primary care providers a flat annual or monthly fee for routine services, such as quarterly exams and routine lab testing, as well as enhanced services, such as telehealth and home-based visits.

Since the DPC/APC financial model is not dependent on patients coming into the clinic since it is not fee-for-service, that opens the universe of possibilities when it comes to care delivery. The primary care physician can utilize virtual visits, secure emails and texting, interactive education, wellness programs, etc., in addition to in-office encounters. All of that is easier to implement because you do not have to figure out how to monetize it. It is all covered under the membership.

APC, as explained to me, looks a lot like the patient-centered medical home which relies on a team approach to care.?APC builds on the foundation of DPC and, because of increased resources, can provide deeper analytics, population health management, and reporting to help organizations reduce healthcare costs beyond primary care services while improving health outcomes.

When patients are being sent around to different doctors or facilities, it is easy to see how vital information can slip through the cracks. That loss of data and context for patient care means valuable time and resources are wasted, potentially endangering the patient’s health in the process.

In the APC model or DPC model, with sufficient resources, patient records are kept more complete and up to date because more care is managed out of their primary care office, and care coordination eliminates gaps in information when specialist care is necessary.

DPC/APC From a Physician Perspective

The feedback that I have received from physicians who utilized the DPC/APC model is incredibly positive.

The per member per month (PMPM) flat fee?model that is utilized by DPC/APC aligns provider-patient incentives, meaning the primary care physician can focus on “wellness” and can utilize?any means to get there without being hindered by FFS. The primary care physician under this model can follow-up via whatever means is most convenient to the patient. This increases compliance and follow up. In addition, the practice/provider can save up to 40% in overhead costs by not having to bill through insurance or hire coders

The DPC/APC models’ resiliency was also highlighted during the COVID pandemic, as these practices entered well-positioned with stable revenue streams due to flexible membership models of care and flexible care delivery tools such as telehealth.

DPC/APC Providing Another Option for Medical Students and Residents

As discussed in my blog titled “Physicians, Your Future Is In Your Hands,” physicians have options, and they can control their own future.?This is especially true for primary care physicians.?

Being a primary care provider in the DPC/APC model potentially provides a more enjoyable and rewarding experience that could cause a resurgence in the interest of students in primary care. This could help to alleviate the current shortage of primary care physicians organically.

DPC/APC Alliance With Self-Insured Employers and Healthcare Consultants (Referrals, Value-Based Benefit Designs, Data Analytics)

The DPC/APC model can lower the risk for self-insured employers due to the significant reduction of downstream hospital medical claims and can improve long-term health outcomes due to enhanced exposure of the primary care team.

Lower employee absenteeism due to illness (acute or chronic) and travel times to doctor visits, as well as increased productivity of employees, are additional benefits of the DPC/APC alliance with self-insured employers.

Enlightened consultant and brokers are partnering with self-insured employers, and third-party administrators are inserting DPC/APC practices into value-based benefit designs, which also utilizes bundled payments and centers of excellence models.

Smaller employers?can partner with “near-site” DPCs/APCs who service multiple employer groups.

If employees and their dependents have streamlined access to primary care and are incentivized because it is “free,” it makes high-value care the first point of contact.

DPC/APC Impact on Patients

There can be considerable cost savings for patients, particularly if they have no insurance coverage or a High Deductible Health Plan (HDHP).

The most significant benefit is that the care received is personalized, and the patient develops a strong relationship with their primary care physician.

There is less spending on urgent care, costly lab and x-rays, and prescriptions, and there is 24/7 access to their physician through a secure communication platform.

Patients also get long appointment times (30-60 minutes), same-day or next-day appointments, little to no waiting in the office, and enhanced virtual care possibilities.

Does the DPC/APC Model Reduce Healthcare Costs and Provide Better Patient Outcomes?

DPC/APC practices can produce better outcomes because primary care providers can spend more time with patients. This allows them to ask more questions, engage in discussions about conditions and treatments, and conduct basic testing in the office or even in a patient's home.

The more familiar a physician is with a patient – including understanding the social determinants that may impact that patient's life and health – the greater the chances of a better outcome.

Additional services like embedded health coaching work in tandem with the primary care team by giving patients helpful, practical tools and support for changing their behavior, minimizing the effect of social factors impacting their health, and meeting their personal goals. Health coaches are an integral part of the care team, trained in understanding how to move people through the stages of change.

Legislative and Regulatory Obstacles Negatively Impacting the DPC Model, Which Would Mostly Apply to the APC Model

As noted in this policy paper published by the Heritage Foundation, policymakers should enable doctors to continue to build on the initial successes of the direct primary care model by removing legislative and regulatory obstacles at the state and federal levels that negatively impact the model.

The Executive Branch should:

• Finalize a rule to clarify that DPC’s fixed fee for the promise of care constitutes payment for medical care, not for health insurance.
• Make clear that DPC is also not “insurance” or a second “health plan” in the context of health savings account rules.?
• Create a pilot program in Medicare for DPC.?

Congress should:

• Codify that DPC arrangements?are?not?a health plan
• Permit DPC?physicians greater flexibility to participate in Medicare?than is permitted under current law.?

States should:

• Ensure that DPC physicians can refer patients for specialist care.?
• Confirm that DPC?is?not?insurance.”

The Future of DPC/APCs

Commercial payers need to recognize the value of collaborating with DPC/APC practices. These?disruptive organizations are also sending a message to traditional insurance companies that do not value the role of the primary care physician in the value equation.

By sharing information and analytics and realigning downstream reimbursement to include both medical and non-medical services, DPC/APC providers can activate a powerful community-based network of care for their patients.

DPC/APC practices that align with self-insured employers have the greatest opportunities for financial success, and their impact on the overall cost of care will be much greater.

Small employers that historically have experienced the greatest increases in healthcare costs can benefit from a DPC/APC collaboration to an even greater degree. Consortiums of small employers within a community could benefit by teaming together and contracting with DPC/APC practices.

Rural Healthcare - The New Frontier for DPC/APC Practices

I recently wrote a series of articles on the challenges and opportunities relating to rural healthcare; this series included: Rural Healthcare Challenges, Key Initiatives That Could Positively Impact Rural Healthcare, and Collaborative Initiatives Play a Key Role in Addressing Rural Healthcare Challenges. There is a shortage of primary care providers and specialists in rural areas. Rural hospitals are closing or cutting services. Residents in rural America are facing health challenges both from a lack of medical services available and also a result of being negatively affected by Social Determinants of Health.

While there is no silver bullet answer to these rural healthcare challenges, the DPC/APC model could play a significant role in positively impacting the quality of life of residents in rural America. DPC/APC practices can align themselves with rural hospitals, Federally Qualified Health Centers (FQHCs), local employers in the community, especially governmental entities such as counties, towns, schools, etc., as well as national organizations such as Walmart and Dollar General who already have a footprint in rural areas.

To further enhance their positive impact on rural residents, DPC/APC practices could also enter collaborative relationships with social service and safety-net organizations in the community.

Conclusion

Even though I am an advocate of increasing the role of primary care physicians, I am not under-valuing the role of specialists and sub-specialty physicians. I am not suggesting that a primary care physician has the expertise of these specialists, nor would any primary care physician make such an assertion. Patient care should be a team approach, and the primary care physician needs to play an increasingly prominent role in our new world of healthcare.

Finally, the DPC/APC model may not be the right fit for some primary care physicians, but it is a viable option that should be explored. Hopefully, the success of the DPC/APC model will incentivize more medical students to select the primary care track. Also, as the DPC/APC model becomes more successful in our communities, it should also incent short-sighted hospitals and for-profit organizations that narrowly focus on return on investments to recognize the value of the primary care physician and allow them to expand their role within their organizations.

Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry—particularly the health insurance, physician and hospital sectors—he’s focused on strategic advising and community outreach.?Follow Tom’s articles on LinkedIn for his latest weekly coverage of the healthcare industry.

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