Is Direct Primary Care a Game Changer?

Direct primary care: Family physician perceptions of a growing model

INTRODUCTION

Direct Primary Care (DPC) is a relatively new primary care practice model in which patients receive unlimited access to a defined set of primary care services in exchange for a monthly practice-specific membership fee. DPC is a bottom-up physician-driven approach in contrast to typical top-down insurer-centric healthcare delivery reform efforts. The degree to which physicians are aware of this practice model and whether they believe it addresses two key challenges facing primary care, access and administrative burden, are unclear.

METHODS

An online survey was distributed in July 2017 to 672 members of a research marketing sample of the American Academy of Family Physicians (n=225; response rate 33%). Based on AAFP definitions, the survey consisted of both open- and close-ended questions that gauged family physicians' awareness of DPC, as well as their perceptions about the model.

RESULTS

Most respondents (85%) had heard of DPC and 8% practised in a DPC model at the time of the survey. In general, respondents reported that DPC can offer positive outcomes through lower administrative burden for physicians, improved doctor-patient relationships, and better access. Respondents also suggested DPC may result in improved patient health outcomes and lower overall healthcare spending. Respondents' concerns included inappropriateness of the model for vulnerable populations and physician shortages. Survey responses differed depending on whether the respondent practised in a DPC model. DPC physicians had a more favorable view of the model and were focused on benefits to patients rather than benefits to physicians.

CONCLUSIONS

Any changes to practice models will require a better understanding of clear definitions of practice models. Further education is required about the specific benefits to vulnerable patients and practice standards. As the perceptions of DPC vary by practice experience, DPC physicians appear to be strong potential advocates of the model.

Toward a National Conversation on Health: Disruptive Intervention and the Transformation from Health Care to Health

Over a century ago, Abraham Flexner's landmark report on medical education resulted in the most extensive reforms of medical training in history. They led to major advances in the diagnosis and treatment of disease and the relief of suffering. His prediction that "the physician's function is fast becoming social and preventive, rather than individual and curative," however, was never realized.Instead, with the rise of biomedical science, the scientific method and the American Medical Association, the health care system became increasingly distanced from a holistic approach to life that recognizes the critical role social determinants play in people's health. These developments created the beginning of the regulatory controls that have come to define and shape American health care - and our unhealthy obsession with illness, disease and curative medicine that has resulted in a system that has little to do with health.To realize Flexner's prediction, and to transform health care into a holistic system whose primary goals are focused on health outcomes, six disruptive interventions are proposed. First, health needs to be placed in the context of community. Second, the model of primary care needs to be revised. Third, big data need to be harnessed to provide personalized, consumable, and actionable health knowledge. Fourth, there needs to greater patient engagement, but with fewer face-to-face encounters.Fifth, we need revitalized, collaborative medical training for physicians. And finally, true transformation will require market-driven, not regulatory-constrained, innovation. The evolution from health care to health demands consumer-driven choices that only a deregulated, free market can provide.

How can we change medical students' perceptions of a career in family medicine? Marketing or substance?

Family Medicine (FM) is the care of unselected patients with undifferentiated problems in the settings where people need care in our communities. It is intellectually challenging, providing breadth and depth unparalleled in other areas of medical practice. In one survey only 19% of Israeli students reported being interested in FM. Students interested in FM had greater interest in bedside and direct long-term patient care. Students not planning FM residency training had preconceived notions that the discipline had lower academic opportunities and prestige. What can be done to increase student interest in careers in FM?

This commentary includes perspectives of family practice leaders from several countries:

The problem isn’t the students it is the scope of practice and expectations both of which can and should change if FM in Israel wants to stay viable. The scope of FM should be broadened to include more procedures and new technologies. This may also increase the earning potential of Family Practitioners (FPs). Payment policy and credentialing barriers should be change to expand scope of practice and allow FPs to practice at the full extent of their training.

FM should offer clear professional horizon with potential for many sub-specialties and areas of focus. The Israeli HMOs, the Ministry of Health and the Israeli Association of FM should invest heavily in building academic departments of FM and promoting research. This will enhance the image of FM in the eyes of the students, the profession and the public.

The clinical work environment should be improved by reducing bureaucratic assignments, such as issuing certifications, dealing with quality measurements and renewing chronic prescriptions. Much of this work can be done by nurse practitioners (NPs) working as part of an FP-led team. These NPs can also take care of patients with limited complaints to make the work of the FP more challenging and attractive.

Training must include opportunities to develop longitudinal relationships with patients and families across problems and over time. It is these relationships that add value to the process of care, improve patient outcomes and provide meaning to sustain clinical careers that meet the needs of patients and communities.