The Direct Primary Care movement is growing rapidly, and for good reason. Here's a look at the reality of DPC for both employees and owners.
Each practice is unique
The beauty of DPC is that when owned by a physician, the clinic naturally is built around that physician's strengths and passions.
Want to focus more on urgent care, accessibility, and convenience for patients? That can be done.
Maybe you like more extended appointments, want to spend time diving deep with patients' health and preventive care. That can be done, too.
Want to offer some ancillary services? Functional health? Specialize in weight loss? Sports medicine? Whatever is in your skill set and scope of medicine, you're free to offer those - either by including that in membership, or offering different tiers of service. It's your practice, and you get to choose!
If you are an employee of a DPC practice, your mileage may vary. Some owners may want you to fit into their mold of practice, while others may want to lean on your strengths, passions, and wishes for how to care for patients. That's one thing to be aware of during the interview process - making sure you know how you'll fit into the practice and whether they are willing to use any special skills or services you may want to practice.
Direct Primary Care is free from corporate and insurance requirements
One of the biggest mindset changes that most physicians will face in a DPC setting is the lack of protocol or requirements that comes either from working in a corporate setting, from insurance, or both.
Just a couple examples:
Board certification? You don't need it. It's a voluntary process, and either hospital systems, corporations, or insurance companies are the ones either suggesting or demanding board certification. Suggestion: look up NBPAS as a board certification alternative.
Vital signs? You only need them when it's good medical care. Patient comes in for a possible broken ankle? No need to take a weight or blood pressure - right? No reason to step up onto a scale, and their blood pressure is likely high due to pain or stress anyway.
Charting? You're now charting for great patient care. That's it. No reason to insert false or half-truths to prove to an insurance company you can bill for a 99214. You'll eventually forget what that code even means!
As an employee with a DPC clinic you will need to follow their internal policies or procedures - you'll find they are mostly for efficiency, safety, and kindly working with staff.
As a DPC clinic owner you'll be able to install your own policies, procedures, or lack of such to your heart's content.
Most DPC clinics operate out of a desire to do what is best for the patient. When the patient's well-being is at the heart of the operation, business tends to do well, proper procedures and protocols are put into place, and everybody is happy.
Will DPC be a good fit for you?
Only you know what kind of medicine you want to practice and what you want your daily job to look like. I'm not here to convince you that DPC is a fit for everyone - it's not. Let's look at the good, the gray areas, and the bad of practicing Direct Primary Care:
What DPC solves: the 'good'...
Patient access is improved
The entire concept behind DPC is connecting patients directly with their provider / physician, which has led to small patient panels, and allowing for same or next-day access. This results in a healthier patient panel in general.
Fewer referrals / greater scope of medicine for the provider
If you have struggled to practice the full scope of medicine that your training has allowed - whether that's due to lack of time with patients, lack of equipment available, or policies from administration - DPC has an answer for that.
Providers are able to spend whatever time necessary to care for their patients, allowing a much broader scope of medicine to be practiced.
Focus more on whole health and preventive care
I found the average patient that saw their traditional physician once every 1-2 years typically visited our DPC clinic 4-6 times per year. It's fair to say that better access leads to more visits, leads to a healthier panel of patients.
And for those patients (and physicians) that are motivated, more time and effort can be devoted to preventive care and health maintenance.
Fewer barriers to care
Traditional insurance has barriers to seeing their physician - especially for acute needs. Copays are specifically created to limit visits to only those that are necessary, and deductibles are meant to make insurance more affordable, but become a significant barrier for many patients.
Since most DPC memberships include unlimited office visits without additional office visit charges, patients are much more likely to schedule appointments when necessary. And because telehealth is normally included as well - just a phone call or text to ask a question is extremely convenient and is an incredible peace of mind for patients.
Charting for care, not for pay
When ICD-10 was introduced, providers and medical billing techs had tens of thousands of codes to sift through in order to bill for family medicine appropriately.
With DPC, providers are able to focus on charting for great patient care without worrying about any requirements from insurance companies.
This is honestly cause for a lot of 'unlearning' from many providers, but once you step back and think through what is actually needed to chart for patient care, you are freed from a lot compared to the traditional system.
The gray: where DPC is misunderstood...
There are a few critiques of Direct Primary Care, and they're worth addressing.
"DPC is for the rich - what about the poor, or those on Medicaid?"
When you own your own business, you control the price. No, you can't work for free for everybody. But you can give people a break that need it.
A few examples of what DPC clinics have done:
- Create a sliding scale for families on Medicaid. They don't have to pay full price, but essentially what they can.
- Some people come across hard times: give them a break. Offer membership for 3 months for free while they get back on their feet, search for a new job, etc.
- Use donations from other patients or companies to help care for a specific number of patients in your area that are in need.
Lastly, I've seen families on Medicaid choose to pay membership for a DPC clinic because of the value it gives their family. And physicians should feel good for that. A family membership of $150-300 per month is just a couple cell phone bills, and it has the chance to save the lives of their entire family.
"There's a family medicine crisis, and DPC won't solve it through smaller patient panels"
DPC can't be blamed for a shortage of family physicians. Honestly, this argument is too narrow.
Physicians are likely staying in family medicine longer because through DPC they've found a great balance. At least they're caring for some patients rather than zero.
Also, DPC is one possible reason that medical students and residents might end up choosing family medicine over other specialties - because there's a way they can practice good medicine and get paid fairly.
"DPC won't work in rural towns - only in large cities"
DPC has worked in nearly every size of town and city in America.
Assurance Healthcare & Counseling Center is one example of a DPC clinic opening in a town of about 90,000 people. It grew to one of the largest clinics in the State of Washington, and is still in operation today.
If a physician is able to serve around 250-300 membership-paying patients, they can make a great living and serve those people incredibly well.
"DPC just doesn't seem secure enough"
I've personally heard this as feedback after trying to hire a physician. And I get it.
Physicians have gone through years of training (I know - my wife is one!), and they want the security of having a job after all of that commitment.
If you're starting a DPC business - then that business is only as secure as you're willing to invest in it - and most of that investment will be time rather than money.
If you're looking to work in another DPC business - there's nothing more secure than a group of people paying a consistent monthly fee for access to some of the best care they'll ever get.
Assurance Healthcare & Counseling Center opened in 2014 - the first year that the health care mandate was enforced. We grew to 300 members within the first 6 months.
Assurance was also open through COVID-19. We never had to consider any small business funding money, and actually gained members through the shutdowns. We were doing better than other clinics and hospitals because we still charged the same monthly membership even though we transitioned to 85% of our visits being telehealth visits.
Where DPC might miss: the 'bad'
Here are some of the honest trade-offs of working for or starting your own DPC clinic.
Smaller teams = less help
Since DPC volume is typically less, it often doesn't make sense to hire a nurse or medical assistant for each physician. In fact, I typically advise against the use of nurses and MAs.
Honestly, this was one of the first mistakes we made when opening up. I didn't have a medical background, and my physician co-founder insisted that he would need a nurse to help him room patients, take vitals, and do all the other extraneous stuff that doctors don't typically do.
We couldn't keep the nurse busy enough - at least not to justify paying her the salary she deserved.
So, if you're opening your own clinic, expect to start out doing a lot more on your own (prepping lacs, drawing meds for injections, turning over exam rooms, etc.).
If you're considering a job with a DPC clinic, ask about what help is available to you. Sometimes there's a shared MA, nurse, or non-medically-trained staff, and sometimes there may be none at all.
More time with patients isn't for everyone
My father-in-law heard many DPC physicians block 1 hour appointments with patients.
His immediate reaction: "I don't want to spend an hour chatting in an exam room with my mother-in-laws friends - that sounds awful!"
Luckily for him, he establishes good boundaries with patients and has the art of connecting with people quickly and making them feel heard in a smaller amount of time.
Some people might enjoy longer appointments, diving into the depths of someone's health, and simply chatting.
For others, not so much. And that's ok.
Patient panels are smaller
Most of the time a small patient panel is seen as a good thing, but sometimes physicians just feel better having a larger panel of patients and seeing more patients per day.
There's nothing wrong with that - DPC just doesn't work the same if each physician has a patient panel of 2500 patients (the national average). It works much better if that's kept between 250-1000.
You could be on your own
If you're starting your own DPC practice, you'll feel much more alone. You won't have fellow attendings to talk through cases or ask for quick assistance. You'll have to lean on your outside network of friends who are willing to do a curbside consult for you over the phone or text.
For this reason, I often recommend that newly graduated residents consider working in a normal, high-volume practice for 2-4 years before starting their own DPC practice. The more you practice, the more cases you'll see, the more confident you'll be.
If you're considering working for another DPC practice straight out of residency - there's pros and cons. Reach out to me if you have questions or join our Skool group (link at the bottom of this article).
Growth can be slower than expected
Although the term DPC is gaining traction, gaining members is still a process. If you're starting your own practice, be aware that you likely won't start your practice with 300 patients on day one unless you've done months of work ahead of time.
Why is that? Because you're not just 'selling' a great product, you're asking people to completely rethink how they purchase healthcare - and health is a huge decision for a family.
Read more about this in How Fast Can I Grow?
Insurance doesn't disappear
You don't have to bill or code for insurance. However, anytime you refer out and your members have insurance, you may have to deal with their insurance as a service to them.
As long as your patients carry insurance, you'll still have to send referrals, do pre/prior authorizations, and more. The headache doesn't completely go away, so prepare to deal with insurance when it comes to sending patients elsewhere.
Read more on dealing with insurance as a DPC physician here
Direct Primary Care is fantastic
If you've seen one DPC clinic, you've seen one DPC clinic. Very few of them operate the same way.
Yes, they'll often include the same benefits, but the real magic is the practice ends up looking and feeling like your own style and flavor of medicine.
I really hope you consider moving towards DPC if you haven't already. I'd love to help you start your own practice or join another. Let's meet sometime so I can at least cheer you on!
Still deciding if DPC fits you?
Join the Direct Care Tools community on Skool.