Direct primary care practices (DPCs) – health care providers that charge patients a regular membership fee, instead of billing private insurance, the government or another third party, to cover most or all medical care – are steadily becoming more common. In fact, 9% of respondents to a 2023 American Academy of Family Physicians survey reported operating a direct primary care practice, up from only 2% the year prior. An additional 2% in 2023 said they were transitioning to the direct model.
The growth of this model raises questions about the state of health care access in the United States. With physician shortages creating health care “deserts,” could direct primary care help fill the gap? Or could it exacerbate primary care physician shortages, particularly in rural areas where they tend to be most severe? Could it expand access or will it simply fuel existing inequities for low-income patients?
The findings of a Dornsife School of Public Health study published this week in Annals of Family Medicine tackle these key questions and provide some reason for optimism. The Drexel News Blog asked lead author Neal D. Goldstein, PhD, an associate research professor in the Dornsife School of Public Health, about this health care model, which patients are typically served by it, according to the study; and what its growth might suggest for the future of health care.
What made you look at the direct primary care model, and not the similar model of concierge practices, which also charge patients a fee, but may also accept third-party insurance, (among a couple other differences)?
Concierge practices tend to have higher fees than direct primary care practices, while also typically catering to a more affluent patient base, often with traditional insurance. DPC is more likely to serve a broader range of patients and be accessible to those without health insurance. That said, it would be useful for future studies to look at the income levels of DPC patients versus those not in a DPC practice and see how income may influence care access.
You looked at 2023 data on areas of health professional shortages – mapped according to severity by the Health Resources and Services Administration (HRSA) – to find which areas of the country are served by direct primary care practices. What did you find?
Compared to traditional primary care practices whose doctors that accept third-party insurance, we found that DPC clinicians were less likely to practice in the highest priority areas – the worst health care deserts – but that DPCs were more likely to practice in rural areas.
Nearly half, 44%, of direct primary care physicians practiced in a “health professional shortage area” as designated by HRSA. But we also found that only 14% of DPC doctors are practicing in the areas with the most significant health care shortage. Clinicians under the more common fee-for-service insurance model are slightly better represented with 20% of them practicing in geographic areas of greatest need, but there still is a need to increase primary care access in general.
You took it a step further, to see how the map of DPCs differs from that of primary care physicians in rural, partially rural and non-rural areas. What did you find out?
DPCs seem to fill the biggest care gaps in rural and partially-rural areas; it’s where 47% of DPC practices are located. That is a bit more encouraging than the 38% of primary care practices in the fee-for-service insurance model based in rural and partially areas.
What’s the main takeaway?
DPC practices, on average, are less likely than primary care practices to exist in health care deserts, but our data shows that’s not the full picture. It’s important to acknowledge that a DPC practice opening doesn’t necessarily guarantee that they will treat all the patients in the surrounding area that need care.
Cost, distance and ability to travel to the practice, availability of appointments and many other factors may still keep patients from getting care. Plus, DPCs can draw patients who are already receiving care from existing primary care practices.
The picture isn’t all sunshine and rainbows. We don’t yet know whether an expansion of DPC practices will help or hurt groups of people who’ve historically lacked access to care, but their success in rural areas suggests that people are getting much-needed care through this model in areas with few, or no, other options.
What else is important for readers to understand about the findings of this study?
It’s important to delineate availability versus accessibility of care. In this work, we focused only on availability; but there is so much more to accessing care than simply how close the nearest provider is. Wait times, hours of operation, comfort with staff, commuting time, and so forth all factor into this. Telemedicine can help fill these gaps.
For example, DPCs may not require close proximity for office appointments, as they are not billing by traditional in-person visits, which may in turn expand the reach of primary care doctors to patients who otherwise would have some of these barriers to access. This is certainly an area which warrants further research and we will be looking into this in the near future.
Reporters interested in speaking with Goldstein should contact Greg Richter, assistant director of News & Media Relations, at gdr33@drexel.edu or 215.895.2614.
