TEXAS PUBLIC POLICY FOUNDATION
Addressing
the Primary
Care Crisis
by Expanding
Access to Direct
Primary Care
Abstract
Primary care providers are the vanguard
of healthcare. The decisions they make
influence patient outcomes and patient
experience as well as the cost efficiency of
the healthcare system. However, primary
care is, by many accounts, in a state of
crisis characterized by physician burnout,
outsized patient panels, increased administrative
burden, reduced time spent with
patients, low reimbursement relative to
other specialties, and a shrinking workforce
in the face of an increasing demand
for primary care services.
Direct Primary Care (DPC) is an
alternative to the traditional fee-for-service
method of financing and delivering primary
care that can address many of these
challenges. Although the DPC practice
model is still evolving and there is no single
accepted definition of what constitutes
24 DALLAS MEDICAL JOURNAL • February 2021
a DPC practice, DPC physician practices
generally include certain elements: they
contract directly with patients, charging
them a recurring—typically monthly—
subscription fee to cover most or all
primary-care-related services; they do
not charge patients per-visit, out-ofpocket
amounts greater than the monthly
equivalent of the subscription fee; and they
do not bill third parties on a fee-for-service
basis for services provided. DPC practices
have shown the potential to generate
reductions in unnecessary healthcare
utilization, including emergency department
usage and hospitalizations. Commonsense
policy approaches are needed to remove
barriers to wider adoption of DPC, including
to public programs like Medicaid.
The Essential Role of Primary Care
“Primary care” has been defined in various
ways: according to the specialty of the
provider, as a set of functions served by a
usual source of care, and as an orientation
of a health system to provide that care
(Friedberg et al., 2010). In 1996, the Institute
of Medicine (1996) defined primary
care as “the provision of integrated, accessible
healthcare services by clinicians
who are accountable for addressing a large
majority of personal healthcare needs,
developing a sustained partnership with
patients, and practicing in the context of
family and community” (p. 1)—a definition
that characterizes primary care as the logical
foundation of an effective healthcare
system and essential to achieving value in
healthcare.
Although the variability in definitions
of primary care makes data collection
challenging, there is good evidence that
having a primary care doctor can result
in better health outcomes at lower cost.
A 2019 study published in the Journal of
the American Medical Association, Internal
Medicine (Levine et al., 2019), reported
that receipt of regular primary care was associated
with significantly more high-value
care and a better healthcare experience,
while individuals without a stable source of
primary care missed substantial healthcare
benefits, including high-value cancer
screening, diagnostic and preventive testing,
diabetes care, and counseling. Acording
to a July 2020 article published in BMC
Family Practice (Hostetter et al., 2020),
one or more primary care visits per year is
associated with an increased likelihood of
By David Balat
Policy Director, Right on Healthcare
John O’Shea, MD
Senior Fellow, Right on Healthcare
(Published by the Texas Public Policy
Foundation in November 2020)
KEY POINTS
• Primary care providers are essentialto
the nation’s health. Their decisions
determine patient outcomes as
well as the efficiency of thehealthcare
system.
• Primary care is in a state of crisischaracterized
by physician burnout,
outsized patient panels, increased
administrative burden, reduced time
spent with patients, low reimbursement,
and a shrinking workforce.
• By reducing administrative burdenand
allowing primary care providers to
spend more time with patients, Direct
Primary Care (DPC) addresses many of
the challenges facing primary care.
• In spite of the potential benefits and
growing popularity of DPC and ongoing
legislative efforts, barriers to wider
adoption of the model remain.
• IRS definitions need to be updated
to permit individuals who hold health
savings accounts to access the benefits
of DPC, and policymakers should
include DPC as an option in public
programs.
R E S E A R C H
NOVEMBER 2020
LEGISLATIVE PREVIEW