Direct Primary Care: Consistent Care in an Inconsistent World

"And the first one now

Will later be last

For the times they are a-changin'’

-Bob Dylan, The Times They Are A-Changin', 1964

The 1960s were well before my time, but Dylan’s lyrics from that turbulent decade still resonate today. In the US, we’ve weathered yet another historic election, marked by a deepening political divide and a heightened sense of urgency that seems to intensify with each cycle. This feeling of significance, much like Dylan’s words, will likely endure. The political tug-of-war continues to throw curveballs our way, with volatility as the only constant. The economic landscape offers no safe harbor from these shifts as the economy peaks and drops like the line on an EKG. No matter how you feel or vote, everyone will eventually need healthcare—and the economic outlook and policy decisions made in Washington will inevitably influence the quality and accessibility of that care.

For many patients and doctors, Direct Primary Care offers a shelter from this storm and some much welcomed stability and predictability in a world in constant flux. In 2020, the Covid pandemic presented a global challenge to every major health system, but in the United States as the primary care industry buckled, with nearly 16,000 practices closing under the strain, the Direct Primary Care model proved extremely resilient and the number of patients served increased. Elation Health, a health record system used by many Direct Primary Care doctors, reported a 38% increase in new Direct Primary Care practices in 2020, and this was no anomaly. 

The primary care field was not in good shape heading into the pandemic. Eroded by reducing payments to doctors in light of rising business costs, ongoing physician shortages, and a growing population that needed care, the sector barely scraped by. The number of visits to primary care was reduced by about 60% in the early pandemic months. For doctors that are paid per visit this financial hit was often fatal, with the average practice losing about $68,000 per physician in 2020. Patients suffered too, while the number of visits went down, the need for those visits was at an all-time high. New forms of media clouded the airwaves with contradictory reporting and advice, and the value of having a trustworthy and accessible doctor in your life who could help you make sense of it all was on full display. Telemedicine was thrust into the spotlight, but it wasn’t yet ready for prime time, as an overburdened and underfunded healthcare system had no assurance how, when, and sometimes even if they would be paid for these visits. 

Despite the uncertainty around payment, no primary care doctor I know hesitated to adapt when their patients needed them most. I taught a senior colleague who only ever saw patients in the office and still kept paper notes to connect to a patient on Zoom, and the question of how to bill and code never occurred to either of us, though perhaps it should have. The bills eventually did come due, and for many of those nearly 16,000 practices, the lost revenue from the abrupt transition to telemedicine proved insurmountable. In contrast, many of the DPC doctors had already been including video consults as part of their services. The few that did not were quick to add them to existing communication channels that included email, text, phone calls and now videochat. The DPC doctors met their patients where they were and demonstrated remarkable flexibility and adaptability. The predictable monthly membership payment direct from their patients afforded doctors financial security to not only weather the storm but to harness the winds to grow and serve more patients. The flexibility and adaptability that allowed DPC to navigate and grow through the pandemic crisis may prove just as useful for dealing with a volatile political landscape. 

Governmental policies directly impact how healthcare is delivered, and also funded. The administrations that shape these policies can shift in a single election in ways we sometimes don’t see coming. As John Maxwell put it, “Change is inevitable. Growth is optional.” The DPC model eliminates much of the influence that a political shift can have on the continuity and quality of your care. Patients enrolled with a DPC practice have a much greater extent of autonomy over their healthcare choices, and removing insurers and Medicare/Medicaid from the equation gives those agencies less leverage over your decisions. Although the only two people physically present in the exam room are doctor and patient, the influence of the insurers and government bureaucrats in the traditional model is ever present. It can feel as if that party of two has become a committee. When you enroll with a DPC practice you have chosen to kick them out. The influence is never fully gone, but mandates and regulations are restored to the category of guidelines and recommendations. Power shifts back to shared decision making between doctor and patient, directly. 

By reducing the likelihood of policy and market disruptions, DPC patients can more reliably control their costs, choose their doctor, and shape the nature of their care. The transparent and predictable fee structure eliminates most surprise health expenses, allowing patients to better budget. The greatest benefit of DPC membership remains the consistent quality and personalized nature of care patients can expect. However, the flexibility that propelled the burgeoning practice through the pandemic provides a certain economic and political insulation that should not be overlooked. A DPC membership offers you not just a great healthcare model, but is a strategic choice for long-term quality care that is less vulnerable to external forces. 

“And you better start swimmin'

Or you'll sink like a stone

For the times they are a-changin'”

References

Basu, Sanjay, and Benjamin P. Linas. "Health Care Spending and Utilization After High-Deductible Plan Enrollment." Health Affairs, vol. 39, no. 8, 2020, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00794.

Dylan, Bob. The Times They Are A-Changin’. Columbia Records, 1964.

El-Kareh, Robert. "Direct Primary Care: A Growing Payment Model Fit for a Pandemic and Beyond." Ohio Academy of Family Physicians, 2023, https://www.ohioafp.org/wfmu-article/direct-primary-care-a-growing-payment-model-fit-for-a-pandemic-and-beyond/.

Levey, Noam. "The Pandemic Is Forcing Physician Practices to Switch Business Models." Healthcare Brew, 11 May 2023, https://www.healthcare-brew.com/stories/2023/05/11/the-pandemic-is-forcing-physician-practices-to-switch-business-models.

Medley, Christopher. "It’s Been a Good Year for Direct Primary Care." Atlas.md Blog, 2022, https://blog.atlas.md/2022/02/its-been-a-good-year-for-direct-primary-care/.

Tran, Nancy. "The Rise of Direct Primary Care in America." KevinMD.com, 2024, https://kevinmd.com/2024/01/the-rise-of-direct-primary-care-in-america.html.