Years of proctoring educational boot camps on Direct Primary Care has allowed Dr. Brian Forrest to witness firsthand how the media gets it wrong when it comes to explaining one of the only medical models that marries practice with passion. As founder and CEO of Access Healthcare Direct—a national network of direct care providers—Dr. Forrest has committed himself to making sure they start getting it right.
In 2001, Dr. Forrest opened Access Healthcare P.A., the first DPC micropractice in the country. Several years after he launched his practice, he acted as the CME director for the first Direct Primary Care National Summit in Kansas City. Since then, Dr. Forrest has served as a dedicated organizer for all things DPC. Today, he continues to mentor physicians in more than twenty states, helping them transition to direct care and hybrid health care models. Though the settings, audiences, and avenues through which Dr. Forrest has demonstrated his love for DPC have been diverse, one thing remains constant: those working under and being served by the traditional care model woefully underestimate the power of DPC—not out of disbelief, but because of rampant dissemination of misinformation.
Ten Myths About DPC Worth Busting
Direct Primary Care is just another name for concierge medicine.
Spoiler: it’s not. Dr. Forrest reports that even trusted sources like the Wall Street Journal frequently conflate concierge medicine with direct care. “They assume that concierge medicine is just a slightly more expensive version of DPC, when, in fact, legal distinctions have already been drawn between the two.” Unfortunately, the simplest, most accurate definition of DPC is the one least often used by major news outlets. Dr. Forrest explains that two specific features constitute a DPC practice: 1) the existence of a periodic fee paid by patients for primary care services; and 2) the absence of any exchange of insurance. “Some DPC practitioners will charge a nominal fee for telemedicine or an in-person visit, but that fee is typically much less than a standard insurance co-pay and must be less than the amount of the monthly fee.”
The proliferation of the DPC practice model will exacerbate the already dire physician workforce problem.
Of all the misguided criticisms thrown at the DPC model, Dr. Forrest thinks this one is perhaps the most insidious because it seems accurate. “The reason it’s not is three-fold. First, DPC has a growing following among medical students who would have otherwise gone into other specialties. Working as a primary care physician under the fee-for-service model is incredibly taxing; many students give up their interest in family medicine in favor of a specialty that offers a higher quality of life.”
The more manageable patient load made possible by the DPC model also allows older physicians to stay in the workforce longer. “I’ve had many physicians in their seventies pull me aside and thank me for educating people about this model. Most of them say they would have stopped practicing medicine ten years ago if they still had to work under the traditional model. DPC is not only bringing more doctors into primary care, but it’s keeping them in it, too.” Dr. Forrest also emphasizes that DPC patient panels are not as small as many critics suggest. “Though some practitioners only have 100 patients, the average panel size in our network is closer to 1,000. That’s a decent size. A report from the Institute of Medicine founds that an ideal patient panel is about 1,200. We’re closer to that number than those primary care physicians drowning in a load of 3,000.”
Doctors who have just finished their residency don’t succeed under the DPC model.
Though many medical residents initially express interest in the DPC model, many fear that they won’t be able to afford the start-up cost of an independent practice. Because they haven’t already developed a patient base under the traditional medical model, doctors leaving residency would have to build a patient panel from scratch—a task most people would find daunting. While Dr. Forrest recognizes the existence of these challenges, he has also seen residents overcome them. “We’ve seen multiple examples of doctors succeeding under DPC directly out of residency. All of them opened their doors before a single patient had signed up. All of them have since become incredibly successful.”
People with insurance or Medicare don’t join DPC practices.
Dr. Forrest reports that patients over sixty-five actually comprise the fastest-growing patient cohort at Access Healthcare P.A. “Hypothetically, these folks could join any other Medicare practice, but they’re finding barriers to entry.” Dr. Forrest notes three factors driving Medicare patient onboarding at DPC practices. “Many fee-for-service practices won’t accept new Medicare patients because they’re already overloaded. Those practices that will accept them typically can’t provide the kind of quality care these patients are looking for. I’ve also found that many Medicare patients have some additional privacy concerns and feel uncomfortable having their doctor transmit patient data using the EMR. Because we don’t have to send any information to insurance companies, Medicare folks are happier under DPC.”
DPC is only affordable to the wealthy.
A quick crunching of the numbers proves this myth inaccurate. Dr. Forrest finds that most DPC practices actually charge less than traditional ones for the same services. “I set-up my practice to best serve the uninsured, and, initially, they onboarded at higher rates. When we opened our doors, 60% of our patients were uninsured and 40% were insured. Now those numbers have flipped.” Dr. Forrest thinks the diverse socioeconomic locations of his patient panel suggest that the media doesn’t understand who actually benefits from alternative medical models. “We serve homeless patients, we serve low-income patients, and we serve middle-class patients. Our practice is very affordable—not for every patient, but for most patients.”
The DPC model better serves affluent communities than poorer ones.
In reality, the opposite is true. DPC practices thrive in communities of people struggling to get access to primary care—not communities of people who already have it. “Uninsured folks and folks with higher deductibles tend to gravitate towards DPC, especially in rural areas where the doctor shortage has hit hardest.” Dr. Forrest doesn’t find the same to be true of more affluent neighborhoods, especially urban ones. “It’s difficult to operate a DPC practice in areas where everyone has great insurance. Since DPC doctors don’t contract with insurance companies, our offices aren’t listed in their insurance directories. That makes it nearly impossible to gain a foothold in wealthier communities.”
DPC patients take advantage of 24-hour availability, creating an unmanageable call burden and after-hour intrusions.
Doctors considering transitioning to DPC tend to ask more established practitioners the same question: “Do your patients abuse your 24/7 availability?” The answer is always a resounding no. “When patients feel confident that they can easily schedule an appointment or get their doctor on the phone during normal business hours, they don’t typically have any reason to call late at night or to try to schedule appointments on the weekend. We’ve probably received less than six or seven after-hour calls in an entire month.” Dr. Forrest would go so far as to say that DPC patient make fewer intrusions than those receiving care under the fee-for-service model. “When you give patients everything they need in an office visit, what else do they have left to ask for?”
Patients should be encouraged to use Health Care Savings Accounts (HSAs) to pay for Direct Primary Care.
Though some suggest that HSAs are a viable way for DPC patients to pay their membership fees, the IRS has explicitly stated that it currently considers HSAs a second health plan and therefore not an acceptable means of paying for a direct care membership fee. Dr. Forrest hopes that future that the passage of a recently introduced bi-partisan bill--SB 1989--will make DPC fees HSA eligible. Until then, he recommends that doctors encourage their patients not to put themselves at risk of being charged with tax fraud.
DPC patients over-utilize care.
Even among those receiving the highest quality primary care, people don’t tend to seek out extra hours in the doctor’s office. Direct Primary Care patients are no exception. “Doctors who have spent the majority of their careers working under the traditional model typically have concerns about the lack of financial incentive for patients to stay out of the office. Because they’ve never been able to give patients sufficient time in the office, they have no conception of what a sufficient amount of time would be. I’ve found, however, that people don’t take more than they need.” Data released by larger DPC practices corroborate Dr. Forrest’s own findings. “Every network has similar numbers: at most, DPC patients come in for one more visit per year than average fee-for-service patients.”
Transitioning to DPC is easy.
Though Dr. Forrest would never discourage a primary care physician from opening a DPC practice, he does worry that some doctors underestimate the role that education and research play in succeeding under a new business model. “Some people have fallen prey to the myth that attending a conference and doing some online readings can prepare anyone to open a DPC practice. That simply isn’t the case.” Dr. Forrest has helped the American Association of Family Physicians design a number of workshops to help soon-to-be DPC doctors get started. While he emphasizes the value of these educational sessions, he still recommends that doctors seek out focused mentor training. “It takes at least eight hours to answer the first one-hundred questions that most doctors have about DPC. People's questions vary. Finding an established practitioner to provide thoughtful answers to yours makes a world of difference. Don't be afraid to ask for help."