Fee-For-Service (FFS) is dead! Long Live Direct Primary Care (DPC)! Or not?

Recently, I shared an infographic from @MGMA (The Medical Group Management Association) that indicated that 74% of respondents were unfamiliar with the Direct Primary Care (DPC) model.  Shortly after sharing, @SteveHeet replied to my tweet asking the following:

“Is there a general consensus that DPC reduces the traditional FFS patient panel? If so, with all physician shortages nationwide, how does DPC solve things? Doesn’t it displace remaining patients back into looking for a new PCP in which many FFS practice have closed panels? Mmmm”

I’m not sure I was positioning DPC as a solution to high FFS panel sizes.  The typical FFS physician has ~2,000 patients where the typical DPC physician maintains between 500 and 1,000 patients.  DPC, I don’t think, is intended to siphon off patients from FFS panels.

What I would say is that DPC solves consumer demand for:

  1. More time with their physician.
  2. Easier and more timely access to their physician.

@SteveHeet goes on to inquire about physician shortages and what happens to patients that need a new primary care physician (PCP) when many have closed panels.

I’m not an expert on this topic by any means but I have been following the subject.  According to a report from April 2018, the Association of American Medical Colleges said we could see shortages of up to 120,000 physicians by 2030.  How does DPC potentially solve this problem?  Well, I surveyed an un-statistically relevant number of DPC providers (5) and asked them several questions:

  1. Why are you in this model?
  2. Do you like it?
  3. What do you think will happen with DPC in the future?

Of the whopping five physicians surveyed, three were 20+ year veterans in the field of medicine and two were newly minted, millennial doctors.  The three veterans we will refer to as the “Old Guard” and the other two will henceforth be referred to as the “Young Guns”.

The Old Guard had all be practicing in an FFS model for their entire careers and were burnt out and disillusioned with medicine.  They joined a DPC practice because they wanted to spend more time with their patients, get to know them and their families and “…get back to practicing medicine…” instead of “…generating revenue…”  On the subject of liking it, they all replied that that didn’t like the fact they no longer had a scribe (someone who sits in the room and takes notes for them) and they work longer hours (for less pay) but they know their patients and they feel they are making a difference in individual lives now.  Their outlook on the future of DPC was positive.  They all responded with some version of, “Yeah, I think this will be a thing that continues to grow because it’s what patients want.”

The Young Guns started in DPC and studied medicine with the intent of being a General Practitioner (GP).  They only want to help people and money is not their primary motivator.  This is, as I’ve come to learn over the past several years, a common motivator among our millennial population.  As for liking it, I think, partly because it’s all they’ve known, they both loved the model.  Helping people is their primary goal and all they could talk about was their friends that were “…coming up behind them…” and how they are bullish on the future of DPC.

So, based on this completely unscientific survey, I think we would benefit from an actual study that focused on the trends within the upcoming generation of physicians.  One perhaps that is not sponsored by an association who has a financial incentive to drive enrollment but rather an independent researcher.  I don’t know if there is or will be a shortage nationally.  All I know is that I belong to a DPC called One Medical and they have no shortage of physicians and I can get a same-day appointment with my doctor.

Let’s get back to the relationship between DPC and FFS practices.  I was surprised that 1 in 4 respondents was unfamiliar with the DPC model.  Numerous DPC businesses have been funded in the past five years, and are thriving across the country so how could this be?

Fee-For-Service is strong in this one…but the force is fading

While there are many DPC providers, there are far more traditional Fee-For-Service (FFS) providers.  According to the AMA’s Physician Practice Benchmark Survey the number of FFS practitioners is declining.  In 2012, 89.4% participated in FFS payments.  That number declined to 85.9% in 2014 and down again to 83.6% in 2016.

There is clearly a correlation between the decline in FFS and the rise of DPC, the shift is not likely caused solely by the rise of DPC.  Payment “reform” has been a hot topic with the resurgence of bundled-payments and other changes to the healthcare payments industry.

As I look down at my word-count for this post, I’m already 300 words past where most people will stop reading so I’ll wrap up now.  Here’s what I think:

  1. Does DPC solve for high FFS panels?  Maybe, but I don’t think that’s what DPC is intended to solve for.
  2. Is there (or will there be) a physician shortage?  Maybe, but I don’t think we have the right independent research to know for sure.

As always, I welcome your thoughts and comments, positive or negative.