Warily, ACP Eyes New Primary Care Model

Physicians who practice in concierge and direct primary care models have been put on notice by the American College of Physicians, which warns against creating barriers to care, particularly for low-income and minority patients. DPC physicians say the ACP has it all wrong.

New care models, such as direct primary care (DPC) emphasize that the doctor-patient relationship can be a lifeline to physicians who are burned out, stressed out, and thinking about getting out. But the American College of Physicians isn't sold on the idea.

The ACP's medical practice and quality committee released nine recommendations in the Annals of Internal Medicine for "direct patient contracting practices," an ACP term that lumps DPC, cash-pay, and concierge practices together. Though the recommendations neither endorse nor reject those models, some DPC physicians are upset the models are grouped together in the first place.

"The ACP draft inaccurately lumped concierge/boutique, cash-only and DPC as one entity, and questioned the ethics of such physicians, which we do not agree with," says Omar Durani, MD, a DPC physician. Durani and his partner Howsen Kwan, MD, are about to open their first DPC practice in Dallas next month.

Normally, I don't split hairs over semantics, but in this case, Durani and Kwan have a point. DPC and concierge models are very different. DPC is an offshoot of the well-established concierge practice model. Both types of practices charge patients a fee in exchange for longer appointment times and 24/7 access. Concierge and DPC physicians also have smaller patient panels.

But that is where the similarities end.

Concierge practices are expensive. Their annual fees can run in the thousands of dollars and their patients typically carry traditional health insurance policies. DPC practices charge a monthly fee that can range from $10 to $99 per month and their patients are usually insured by a major medical policy only.

Both models and cash-only practices have a place in patient care because patients are using them. This key variable is often overlooked, and in many ways the DPC model is growing in popularity because it is meeting patients' needs.

The Ethical Case
An overarching theme of the ACP's recommendations concerns the ethics of seeing fewer patients because of the burden it places on other physicians. The ACP is also calling on physicians in these models to see more Medicaid patients and to be advocates for removing barriers to patient care.

Kwan says he and Durani, who met during residency at Parkland Hospital, Dallas County's public hospital, chose a DPC model because of its flexibility to see many types of patients. "We trained at a county hospital and we were still being told, 'You can't order that [test] because it costs too much,' " Kwan says. "This is a way for us to take back control."

Durani adds that the DPC is a place where the uninsured fit because the prices are affordable ($49 per month, then adjusted for age). "I got to really see what some people have to go through to get medical care," Durani says. "Our goal is to make this a win-win for everyone."

For those who eye DPC models skeptically because the practice model treats fewer patients, consider the patient who is in a traditional practice and gets six to seven minutes with the physician because the physician has to churn through visits just to break even .

"Forcing physicians to see more patients because insurance reimbursements are going down is wrong," Doug Nunamaker, MD, co-founder of Wichita, KS-based, insurance-free AtlasMD, told me.

Now, to be clear, there are other forces that contribute to that model and no physician I talk to is happy about it. But Nunamaker and AtlasMD co-founder Josh Umbehr, also say the DPC practice model is set up to see low-income patients.

"If we take our oath seriously, 'Do No Harm,' that has to mean 'Do No Financial Harm,'" Nunamaker says. He and Umbehr say they've helped patients reduce their financial burden by keeping them out of emergency rooms and managing their medication costs and overall care better.

Qliance Medical Group, in Seattle, is one of the oldest DPC practices that does see Medicaid patients. The six-location practice began in 2007 and grew from seeing individuals only to now providing care to Washington's health insurance exchange members, employers and the state's Medicaid population.

That doesn't answer the ACP's concern, though, which is rightly included because health disparities are a huge problem. But there are some strong indicators that the DPC model of care is more than just a new trend.

Quality Questioned
There is uncertainty about the quality of care in DPC practices. But, frankly, there are big questions about patient quality at every kind of practice. Standardizing processes to improve care goes beyond screening rates and numbers, says Durani.

"These quality requirements are randomized decisions," he says. "Just because my A1C panel is dropping, does that mean my patients are better? Does that show the patients are being taken care of?"

These aren't questions only DPC physicians are asking. There are strong arguments for the quality standards being pushed down to physicians; however, Durani recognizes these quality indicators have a place. He says he and Kwan are planning on tracking patients' chronic disease improvement in a certified EHR.

QLiance has stronger data on the quality of care DPC patients receive. In its own study, patients who were in QLiance's DPC practice had fewer visits to the ED, specialists, and radiologists. Erika Bliss, MD, FAAFP, CEO and cofounder of QLiance told me that patient satisfaction rates were also higher.

The ACP is right to eye closely these new models of care that are outside the traditional sphere of practice. But it should also recognize the stark differences among these models of care because patients use them differently. DPC practices are a first wave of care model innovation from primary care physicians who are frustrated but aren't leaving.

"The beauty of the DPC model is that there is no cookie cutter blueprint," says Durani. "It is a fluid model based on the patient population and it is up to the doctor and patients on what constitutes a successful practice. We are here to help the insured, uninsured [and] underinsured discover better health and rethink primary care."