We don’t really know, according to an ACP policy paper, written by me on behalf of our Medical Practice and Quality Committee and Board of Regents published in the Annals earlier this week. What we do know that the numbers of such practices are relatively low but there is growing interest in them, and judging from a live twitter session I just concluded, considerable passion from those who have embraced direct primary care.
Why did ACP decide to take on this issue? A few years ago, the ACP Board of Governors adopted a resolution from our Florida chapter asking us to look into developing policy on concierge practices. This resulted in a general statement of College policy encouraging physician choice of practice arrangements that best meet their patients’ needs in an ethical and accessible way. As time went on, though, it became apparent to us that a more detailed policy analysis and recommendations were needed, for several reasons.
It is now evident that increasing numbers of internists and other physicians are considering becoming part of a concierge, direct primary care, or some other practice arrangement that includes one or more of the following elements: (1) downsizing of patient panels (2) charging a retainer or concierge fee and/or (3) not participating in patients’ insurance. (Collectively, we define such practices in the new paper as direct patient contracting practices, or DPCPs.) The Affordable Care Act allows the insurance exchanges to offer direct primary care with a wrap-around high-deductible insurance policy. We also have had ACP members ask us whether the College has any policy or guidance on concierge or direct primary care practices. The growth of such practices can have a significant impact on quality, access and cost of care, as well as patient and physician satisfaction, yet little has been published in the available research literature on their impact.
For these reasons, our Medical Practice and Quality Committee accordingly decided that the College could make a positive contribution by doing an evidence-based analysis of the reasons why a growing number of physicians are interested in such models, what we know and don’t know about their impact on quality and access, what issues require further study, and ethical considerations that apply to physicians regardless of their practice mode. The members of our Medical Practice and Quality Committee who developed this paper included an internist in a direct primary care practice as well internists in more traditional independent practices. The Committee was unanimous in supporting the paper and its recommendations.
If you have not done so already, I encourage you to read the entire paper included as an appendix to the summary version published in the Annals of Internal Medicine. I think you will find that the paper is a balanced, objective, and evidence-based analysis of the implications of DPCPs as we intended. Several highlights:
• The paper clearly recognizes why many physicians are moving to DPCPs because of their frustrations with paperwork and insurance interactions, EHRs, and not being able to spend enough time with patients, and other external constraints on their ability to provide their patient with the best possible care. We call on policymakers to address such frustrations.
• We call on physicians in all types of practice to strive to provide care to all types of patients, including the poor and those on Medicaid, reflecting guidance from our Center on Ethics and Professionalism, Committee on Ethics and Professionalism, and ACP’s Ethics Manual on the obligation of all physicians to provide non-discriminatory care, regardless of their practice arrangement.
• We observe that there are examples in the literature of DPCPs that have structured their practices to ensure access to low-income patients, including Medicaid enrollees. Yet we also observe that there are concerns in the literature, supported by studies in our review of the evidence and input from our Committee on Ethics and Professionalism, which suggest that some practices that charge retainer fees and/or do not accept insurance could potentially create barriers to poorer patients who cannot afford to pay a retainer fee or pay out-of-pocket at the time the service is rendered.
• We address concerns about the potential for patient abandonment associated with downsizing of patient panels, which can create legal and ethical issues that physicians should be aware of.
• We provide practical suggestions for physicians who are in, or considering, a DPCP, to consider taking on their own to mitigate any adverse impact on poorer patients, such as waiving or lowering retainer fees, waiving requirements that payments be made at the time of service, and helping patients file claims.
• We call on all practice arrangements to be transparent with patients.
• We call for continued consideration of Patient-Centered Medical Homes
• We call for more research on the impact of DPCPs.
The paper neither endorses nor opposes direct primary care, concierge practices, or other DPCPs; rather, it just tries to provide a balanced assessment of their potential advantages and disadvantages and issues that merit further consideration by physicians, policymakers and researchers. Without more research, it would be premature for ACP to take a position on encouraging or discouraging them.
In summary, ACP affirmed our support for physician and patient choice of practices that are ethical and accessible and that best meet the needs of patients in a non-discriminatory way, whether in a more traditional independent practice, a large group practice, an academic practice, or a concierge practice, direct primary care, or other DPCP. And we call for more research on the impact of DPCPs on quality, cost and access to care.
Today’s question: What do you think of concierge and direct primary care practices, and ACP’s recommendations?