Blog | Wednesday, October 5, 2016

Direct primary care--understand the appeal before you criticize

ACP has an excellent position paper on direct primary care, Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians

Martin Donohoe, MD, in a letter criticizing the paper Academic Medicine and Concierge Practice makes what I consider the tired, holier than thou, ethical argument that such practices are in fact not ethical. He writes, “For such institutions to teach students to treat all patients equally, combat inequalities in health care access and outcomes, and practice evidence-based medicine while at the same time supporting clinics that do the antithesis is troubling. At the least, trainees should not be allowed to work in such clinics.”

Bob Doherty, writing for ACP, offered a very thoughtful rebuttal, Academic Medicine and Concierge Practice. His discussion is very worthwhile. It reads, “I believe that it is important that, as we research and consider the policy and ethical implications of DPCPs, we also consider the external factors that are driving many physicians toward them—including excessive paperwork associated with insurance interactions, electronic health records that are designed to meet the needs of payers and regulators and not the clinical needs of physicians and their patients, and productivity-based payments that penalize physicians for spending more time with their patients. I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spending time with patients. Many say that they charge low monthly fees so that they can be accessible to moderate- and low-income patients at less out-of-pocket cost to patients than many high-deductible insurance plans offer. I caution against painting with too broad a stroke in assessing the motivations of physicians in practices that charge retainer fees or limit the numbers of patients they see and about the effect that such features have on poorer patients. Rather, we need more unbiased research and evidence—while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is nondiscriminatory based on a patient's income, gender and gender identity, sexual orientation, race, or ethnicity, regardless of the type of practice—concierge or not.”

As I have often written and espoused, physicians often adopt direct primary care (whether the retainer model or cash only practices) because the insurance system (private and CMS) has failed them. They are often the burned out dedicated internists and family physicians who want to connect with patients rather than paperwork (hence the ACP “Patients before Paperwork” movement). Knowing the reasons behind viral movements can help identify causes and understanding. Self-righteous criticism without such understanding bothers me (obviously). As Covey said, seek first to understand then to be understood.

Full disclosure, my colleague Dr. Tom Huddle and I wrote this paper 5 years ago, Retainer Medicine: An Ethically Legitimate Form of Practice That Can Improve Primary Care.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.