Direct Primary Care: Applying Theory to Potential Changes in Delivery and Outcomes

Abstract

Direct Primary Care (DPC), where patients pay a fee to a primary care provider to obtain access to services, is a delivery model that has received notable attention and enthusiasm from some providers. Proponents of DPC believe that the model increases accessibility, reduces overhead, and ultimately improves care for patients; however, there is little evidence in the peer-reviewed literature to support these claims. The objective of this analysis was to apply Starfield's adaptation of Donabedian's Structure-Process-Outcome conceptual model to evaluate primary care to formally display the links between potential changes in clinical structure and processes from DPC adoption. Based on existing literature on the constructs in Starfield's model, expectations of DPC's impact at the patient, clinic, and system levels were defined. DPC uses changes to financing and the population eligible to trigger potential gains in continuity and accessibility to subsequently improve care processes. There is evidence to support DPC as a theoretically sound approach to improve attributes of primary care, such as first contact care and longitudinality at the clinic level for participating patients. At the health system level, DPC has low-construct validity that would suggest a positive impact on the potentially eligible population's health due to membership fees that exclude patients who are more likely to be vulnerable and complex than patients who are willing and able to stay in the practice. Descriptive and comparative research of included and excluded patients is needed to inform providers, patients, and policy makers of the DPC's ability to attain the attributes of primary care and ultimately achieve better outcomes over alternative primary care delivery and financing models.

Understanding Patient Perceptions Towards Direct Primary Care: A Focus Group Study

“…DPC also promises more flexible appointment scheduling as demonstrated by a participant who reportedly switched to DPC after experiencing difficulties with scheduling in the FFS model. These advantages can be ascribed to the smaller patient panels observed in DPC ( 20 ). Enhanced accessibility, communication, and flexibility may cultivate a stronger therapeutic and longitudinal relationship between the physician and patient.…”

The Potpourri of Family Medicine, in Sickness and in Health

“…Cole 8 considers DPC against a theoretical model of the 4 attributes of primary care, noting that DPC could have a positive impact on not only the rate of clinician burnout but also the patient-participants' health. However, DPC generally excludes patients who are more likely to be vulnerable and complex, missing one of the important aims for our country's health care system.…”

Investigating Social Determinants of Health in an Urban Direct Primary Care Clinic

“…The use of “contract practice” can be traced back to pre-Civil War U.S. medicine where patients paid fixed fees for comprehensive health services. Third-party payer systems like insurers were developed to prevent patients from using services beyond what is covered by the fixed fee [ 6 ]. Adopting a modified “contract practice” framework, DPC clinics define set primary care services for which their patients pay a monthly, quarterly, or annual flat fee (i.e.…”

“…Adopting a modified “contract practice” framework, DPC clinics define set primary care services for which their patients pay a monthly, quarterly, or annual flat fee (i.e. retainer fee) [ 6 - 7 ]. As a result, the patients bypass the traditional fee-for-service (FFS) model and restrictions placed by third party insurers [ 7 ].…”

“…With less administrative work and pressure to see a high volume of patients, physicians can revitalize a value-based care system rather than a volume-focused one. A 2005 survey of 231 DPC physicians reported that a typical DPC practice maintains a patient panel of 898 whereas the typical traditional insurance-based practice panel consists of approximately 2,303 patients [ 6 ]. These smaller panel sizes contribute several advantages including enhanced accessibility and flexibility.…”