Written by John August Blanchard, MD
It has been suggested that a clear definition of Direct Primary Care (DPC) needs to be established locally as well as industry wide. This definition needs to be detailed and clear to prevent confusion to healthcare consumers, payers, and providers alike. We understand that DPC is a health care innovation that is still evolving. We will make no attempt to predict what DPC will be in the future nor should we. This is an innovative model of primary care delivery that holds the promise of becoming the foundation of a health care system that delivers value. DPC was born from necessity, and it has evolved from the collective creativity and imaginations of early adopters in the marketplace. We do believe however, that DPC has core features that are so critical to fulfilling its promise that to eliminate any one of them would destroy the essence of the model.
DPC correctly aligns incentives for physicians to deliver the health care “Triple Aim” for populations. The model enhances the quality of health care delivery and improves the patient experience for populations while reducing cost. With incentives correctly aligned, the physician can now work directly for the most important element in the healthcare equation, the patient.
DPC is an innovative alternative payment model for primary care being embraced by patients, physicians, employer’s payers and policymakers across the United States. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider.
Empowering this relationship is the key to achieving superior health outcomes, lower costs, and an enhanced patient experience. DPC fosters this relationship by focusing on five key tenets:
- Service: The hallmark of DPC is adequate time spent between patient and physician, creating an enduring doctor-patient relationship. Supported by unfettered access to care, DPC enables unhurried interactions and frequent discussions to assess lifestyle choices and treatment decisions aimed at long term health and wellbeing. DPC practices have extended hours, ready access to urgent care, and patient panel sizes small enough to support this commitment to service.
- Patient Choice: Patients in DPC choose their own personal physician and are reactive partners in their healthcare. Empowered by accurate information at the point of care, patients are fully involved in making their own medical and financial choices. DPC patients have the right to transparent pricing, access, and availability of all services provided.
- Elimination of Fee-For-Service: DPC eliminates undesirable fee-for-service (FFS) incentives in primary care. These incentives distort healthcare decision-making by rewarding volume over value. This undermines the trust that supports the patient-provider relationship and rewards expensive and inappropriate testing, referral, and treatment. DPC replaces FFS with a simple flat monthly fee that covers comprehensive primary care services. Fees must be adequate to allow for appropriately sized patient panels to support the ability to provide the comprehensive services promised by DPC. (See exhibit A for services)
- Advocacy: DPC providers are committed advocates for patients within the healthcare system. They have time to make informed, appropriate referrals and support patient needs when they are outside of primary care. DPC providers accept the responsibility to be available to patients serving as patient guides. No matter where patients are in the system, physicians provide them with information about the quality, cost, and patient experience of care.
- Stewardship: DPC providers believe that healthcare must provide more value to the patient and the system. Healthcare can, and must, be higher-performing, more patient-responsive, less invasive, and less expensive than it is today. The ultimate goal is health and wellbeing, not simply the treatment of disease.
- Behavioral Health: DPC providers recognize that physical health cannot be achieved in the absence of behavioral and emotional health. Behavioral and emotional health services are rendered as services interwoven and in conjunction with every contact made with the patient. An emphasis on behavioral health services provides the patient with the necessary tools for the ownership of their own health and wellness.
- Technology: DPC practices utilize new technologies that empower and support population management, patient communication, predictive modeling, metric driven outcomes-oriented results, efficiency of care, and patient education.
DPC providers are committed to ensuring that American healthcare delivers on these goals. There are 6 core elements that characterize a DPC practice:
- The DPC practice charges a periodic fee for comprehensive services. (See exhibit A for services)
- The services are provided by a board-certified Family Physician or Internist or their designated and supervised member of a smart care team of allied health professionals.
- The DPC practice does not bill third party payers on a fee for service basis.
- Physicians in a DPC practice do not have a “hybrid” practice. Hybrid practices combine some patients cared for on a fee for service basis with some patients cared for in the periodic fee direct practice model.
- The DPC practice limits patient panel sizes to less than 1250 patients per physician.
- DPC practices are independent and separate entities from large multispecialty and hospital based integrated delivery systems. This separation allows the DPC practice to serve the patient and payers as a true steward of health care resources without the conflict of interest inherent in integrating primary care into larger more expensive systems of care.
Exhibit A Direct Primary Care Capabilities and Services.
A.1 Patient-Physician Engagement & Partnership
A patient-physician partnership is formed through a robust communications program which includes a signed agreement establishing the patient-physician partnership. Physicians ensure patients are aware that as a part of comprehensive management, quality care management and population management efforts, health care information is protected and shared among our care partners and business associates as necessary.
A.2 Patient Registry
An electronic registry with analytical capabilities is used to manage all patients in the practice with diabetes, persistent asthma, coronary artery disease, congestive heart failure, chronic kidney disease, obesity, pediatric ADD/ADHD or other relevant condition. The registry includes patient clinical information for a substantial majority of care received at other sites that are necessary to manage chronic care and preventive services for the population. The registry incorporates evidence-based care guidelines, and information is available to the care team at the point of care. The registry is also used to generate routine, systematic communication to patients regarding gaps in care, as well as communication to all patients in the practice regarding needed preventive services.
A.3 Performance Reporting
Performance reports that allow tracking and comparison of results at a specific point in time across the population of patients are generated for diabetes, obesity, persistent asthma, coronary artery disease, pediatric ADD/ADHD, and other chronic conditions. Performance reports are generated at the population level, care team level, and individual physician level. Data contained in performance reports is validated and reconciled to ensure accuracy. Trend reports are generated, enabling physicians to track, compare and manage performance results for their population of patients over time. Performance reports include all current patients in the practice, including well patients, and include data on preventive services. Performance reports include patient clinical information for a substantial majority of health care services received at other sites that are necessary to manage chronic care and preventive services for the population. Performance reports include information on services provided by specialists. Performance reports include care management activity.
A.4 Individual Care Management
An integrated team of multi-disciplinary providers uses a systematic approach to deliver coordinated care management services that address the patients’ full range of health care needs. A systematic approach is in place to ensure that evidence-based care guidelines are established and in use at the point of care by all team members. Patient satisfaction/office efficiency measures are systematically administered. Development and incorporation into the medical record of written action plan and goal setting is systematically offered to all patients, with substantive patient-specific and patient-friendly documentation provided to the patient. A systematic approach is in place for appointment tracking, generation of reminders, and to ensure that follow-up, for needed services, is provided for all patients. Planned visits are offered to all patients and a group visit option is available for all patients in the practice unit. Medication review and management is provided at every visit for all patients with chronic conditions. Development and incorporation into the medical record of written action plans and goal setting is systematically offered to all patients with chronic conditions or other complex health care needs. A systematic approach is in place for engaging patients in conversation about advance care planning, executing an advance care plan with each patient who wishes to do so, and including a copy of a signed advance care plan in the patient’s medical record. A systematic approach is in place for developing a survivorship plan for patients once treatment is completed, including a copy of the survivorship plan in the patient’s medical record, and ensuring that the plan is shared with the patient and the patient’s providers. A systematic approach is in place for assessing patient palliative care needs and ensuring patients receive needed palliative care services. A systematic process is in place to identify patients who would benefit from care management services based on clinical conditions and ED, inpatient, and other service use. A systematic process is in place to inform patients about availability of care management services. Inter-disciplinary team meetings are held regularly to conduct patient case reviews, with development and review of comprehensive care plans for medically complex patients.
A.5 Extended Access
Patients have 24-hour access to their physician by phone or email. The physician accesses and updates the patient’s EMR or registry info during the phone call or email. A systematic approach is in place to ensure that all patients are fully informed about after-hours care availability and location, at the DPC site as well as other after-hours care sites, including urgent care facilities, if applicable. The practice unit has telephonic or other access to interpreters for all languages common to the practice’s established patients.
A.6 Test Results Tracking & Follow-up
Each practice has test tracking process/procedure documented, which requires tracking and follow-up for all tests and test results, with identified time frames for notifying patients of results. A systematic approach and identified time frames are in place for ensuring patients receive needed tests and the practice obtains the results. A process is in place for ensuring patient contact details are kept up to date. A mechanism is in place for patients to obtain information about normal tests. A systematic approach is used to inform patients about all abnormal test results. A systematic approach is used to ensure that patients with abnormal results receive the recommended follow-up care within defined time frames. A systematic approach is used to document all test tracking steps in the patient’s medical record. All clinicians and appropriate office staff are trained to ensure adherence to the test-tracking procedure.
A.7 Preventive Services
A primary prevention program is in place that focuses on identifying and educating patients about personal health behaviors to reduce their risk of disease and injury, and a systematic approach is in place to provide preventive services. Strategies are in place to promote and conduct outreach regarding ongoing well care visits and screenings for all populations, consistent with guidelines for such age and gender-appropriate services promulgated by credible national organizations. The practice queries about a patient’s outside health encounters and has the capability to incorporate information in a patient tracking system or the medical record. The practice ensures the provision/documentation of tobacco use assessment tools and advice regarding smoking cessation. Care team members are authorized to deliver preventive services according to physician-approved protocol without and examination by a clinician. A secondary prevention program is in place to identify and treat asymptomatic persons who have already developed risk factors or preclinical disease, but in whom the disease itself has not become clinically apparent. The staff receives regular training and/or communications in health promotion and disease prevention and incorporates preventive-focused practices into ongoing administrative operations. Planned visits are offered as a means of providing preventive services in the context of structured health maintenance exams for which the practice team and patient are prepared in advance of the date of service.
A.8 Linkage to Community Services
The Direct Primary care practice conducts a comprehensive review of community resources for the geographic population at which they serve, in conjunction with the care team. It maintains a community resource database based on input from care teams that serve as a central repository of information for all practices. In conjunction with care teams, the practice has established collaborative relationships with appropriate community-based agencies and organizations. All members of the care team involved in establishing care treatment plans have received training on community resources so that they can identify and refer patients appropriately. A systematic approach is in place for education of all patients about community resources and assessing/ discussing the need for referral, and for referring patients to community resources. A systematic approach is in place for tracking referrals of high-risk patients to community resources made by the care team, making every effort to ensure that patients complete the referral activity. A systematic approach is in place for conducting follow-ups with high-risk patients regarding any indicated next steps as an outcome of their referral to a community-based program or agency.
A.9 Self-Management Support
When a patient is co-managed by a DPC physician and specialist, roles are clearly defined regarding which provider is responsible for leading self-management activities and which provider is responsible for reinforcing self-management support activities. Self-management support is a systematic approach to empowering the patient with chronic illness to understand their central role in effectively managing their illness, making informed decisions about care, and engaging in healthy behaviors. Self-management support is offered to all patients with chronic conditions. Systematic follow-up occurs for all patients with a chronic condition who are engaged in self-management support to discuss action plans and goals and provide supportive reminders. Regular patient experience/satisfaction surveys are conducted to identify areas for improvement in the self-management support efforts. Support and guidance in establishing and working toward a self-management goal is offered to every patient, including well patients. At least one member of the smart care team is formally trained through completion of a nationally or internationally accredited program in self-management support concepts and techniques, and regularly works with appropriate staff members at the practice unit to educate them so that they are able to actively use self-management support concepts and techniques.
A.10 Patient Web Portal
A patient web portal is a system that supports two-way, secure, compliant communication between the practice and the patient. Ability for patients to request appointments electronically is activated and available to all patients. Ability for patients to log and/or graph results of self-administered tests is active and available to all patients. Providers are automatically alerted by the system regarding self-reported patient data that indicates a potential health issue. Patients are also able to participate in virtual consults. Physicians use the patient portal to send automated care reminders, health education materials, links to community resources, educational websites, and self-management materials to patients electronically. Patients can create a personal health record, review test results, request prescription renewals, graph and analyze results of self-administered tests for self-management purposes, access to view registries and/or electronic medical records online that contain protected patient personal health information that has been reviewed and released securely by the physician and/or practice. Patients and staff can also schedule appointments through an interactive calendar.
A.11 Coordination of Care
For every patient with a chronic condition, a mechanism is established for being notified of each patient admit and discharge or other type of encounter. A process is in place for exchanging necessary medical records and discussing continued care arrangements with other providers, including facilities. An approach is in place to systematically track care coordination activities and to flag for immediate attention any patient issue that indicates a potentially time-sensitive health issue for all patients. A process is in place to ensure that written transition plans are developed for patients who are leaving the practice. A process is in place to coordinate care with payer case manager for patients with complex or catastrophic conditions.
A.12 Specialist Pre-Consultation & Referral Process
Documented procedures are in place to guide each phase of the specialist referral process – including desired timeframes for appointments and information exchange – for preferred or high-volume providers and other key providers. A directory is maintained listing specialists to whom patients are routinely referred. The practice has developed specialist referral materials supportive of process and individual patient needs. The practice routinely makes specialist appointments on behalf of patients. Each facet of the interaction between preferred/high volume specialists and primary care physicians is automated by using electronically based tools and processes to avoid duplication of testing and prescribing across multiple care settings. For all specialist visits deemed important to the patient’s well-being, a process is in place to determine whether or not patients completed the specialist referral in a timely manner, reasons they did not seek care if applicable, additional sub-specialist visits that occurred, specialist recommendations, and whether patients received recommended services. The practice regularly evaluates patient satisfaction with most commonly used specialists, to ensure the physicians are referring patients to specialists that meet their standards for patient-centered care. Physician-to-physician pre-consultation exchanges are used to clarify need for referral and enable primary care physician to obtain guidance from specialists and subspecialists, ensuring optimal and efficient patient care.
The DPC practice hasa robust online patient engagement and wellness management toolset that facilitates HIPPA compliant email communication, patient portal, and physician’s dashboard for the active management of patient health and wellbeing. The practice uses technology to support a patient registry for population management and communication. The practice uses technology to facilitate virtual consults with specialists to actively manage, measure, and control downstream referrals for diagnostic testing and specialty consults. The electronic medical record has integrated clinical decision and clinical practice guidelines for easy access by treating physicians. All physicians in the direct practice utilize a single EMR platform to enhance data gathering and analysis.
A.14 Patient Engagement in Self Care & Community Resources
- Assess patient/family self-management abilities
- Develop customized self-care plans for the patient/family
- Connect patient family with community resources
- Engage patients in ownership of health and wellness
- Counsel patients on healthy behaviors
- Assess and provide or arrange for mental health/substance abuse treatment
- Educate patients about how the direct medical home works
- Schedule all diagnostic tests and specialty appointments for patients
A.15 Access & Continuity of Care
- Access to a private physician for clinical advice 24/7
- Same or next day appointments always available
- Lengthy 30 to 60 minute on time appointments
- Patients have access to culturally and linguistically appropriate routine/urgent care
- Increase patient centeredness by engaging 1250 patients with a clinical “smart team” consisting of a physician, physician assistant or nurse practitioner, behavioral health specialist, and registered nurse.
- Each team member is functioning at the top of their profession Primary care physicians are trained to manage care that may have been referred in a traditional model.
- Continuity of care is maintained between one patient and one team
- Patients may select a private clinician
- The focus is on team-based care with trained staff
- Extended standard hours of operation 7am-4pm
A.16 Care Management
- Identify patients with specific conditions including healthy, chronically ill or high-risk / complex
- Comprehensive weight loss program
- Comprehensive diabetes management program
- Access to ongoing claims analysis to identify cost drivers
- Protocols to manage cost drivers
- Care management emphasizes
- Pre-visit planning
- Assessing patient progress toward treatment goals
- Addressing patient barriers to treatment goals
- The practice reconciles patient medications at visits and post-hospitalization
- Utilize low cost prescription formulary
- Use evidence based medicine protocols, clinical decision tools, and clinical practice guidelines
- Deployment of efficient and well thought out operational policy and procedures
A.17 Tracking & Coordination of Care
- Function as the steward of the health care dollar: connect patients with community resources for low cost retail lab, diagnostic testing services and specialty care
- Utilize claim data to identify when patients are “off the ranch”
- Track follows-up and coordinate tests, referrals and care at other facilities (e.g., hospitals)
- The practice manages care transitions to decrease re-hospitalizations
A.18 Measure & Manage Key HEDIS (Healthcare Effectiveness Data & Information Set) Outcomes
- Use performance and patient experience data to continuously improve value.
- Monitor utilization/overuse data
- Identify vulnerable patient populations
- Demonstrate improved performance
- Measure and manage hospitalization rates
- Measure and manage high cost diagnostic testing
A.19 Identify & Manage Patient Populations
- Disease registry
- Patient registry
- Collect demographic and clinical data for population management
- The practice identifies patients for proactive reminders
- Identify and manage patients who are “off the plan”
A.20 Behavioral Health Services
The Direct Primary Care practice incorporates behavioral and emotional health services into every contact with the patient. The smart care team utilizes a behavioral health specialist (social worker or psychologist) to educate all smart care team members in the attention to identifying at risk patients and intervening to address emotional and behavioral health needs. The practice uses a systematic approach to educating the patient regarding the importance of self-management and care as it pertains to behavioral and emotional health.