DPC Education: Admittedly, it may just be the most formidable obstacle DPC doctors have yet faced.’

The most visible example of such a challenge comes in the form of a bill introduced in the U.S. Senate (S. 1989, also known as the Primary Care Enhancement Act). This Bill, which ostensibly works to assert the validity of direct primary care as a payment model that is not classified as insurance, also moves to establish a definition of “qualified direct primary care medical home practice” for the purpose of enrollment of practices in a Medicare primary care demonstration project. In order to qualify for this pilot project, qualified DPC practices must comply with a prescriptive set of operational requirements regarding manner and scope of practice (including such requirements as “availability of ongoing care appointments seven days a week”). The Bill also outlines a series of performance benchmarks — the same quality measures used to measure accountable care organizations in the Medicare Shared Saving Program — which “qualified DPC medical home practices” are required to report if they are to maintain their inclusion in the demonstration project.

The promulgation of this pilot project among direct primary care practices places DPC on the same trajectory as many of the social movements that have gone before. While the inclusion of DPC among the practice types of CMS’ pilot project may seem like a flattering gesture to some at the top of the DPC pyramid, it nonetheless represents the first large-scale move to accommodate to the societal norm of third-party payment for primary care services. The illusory belief that this accommodation is necessary in order to make DPC ‘scalable’ and more widely available undermines the defining characteristic of the movement — the direct financial relationship between doctor and patient.The topic of DPC’s flirtation with the Medicare pilot project evokes visceral reactions from many in the DPC community. From what I can gather, supporters of S.1989 view it as an exercise in pragmatism that is necessary in order for DPC to grow and move to the next level. Opponents by and large feel betrayed by the acquiescence of the movement to the regulations and requirements of Medicare in return for a larger slice of primary care market share. The discussion about how to negotiate with third-party payers sounds a lot like Yogi Berra’s “déjà vu all over again.”