February 2021 • DALLAS MEDICAL JOURNAL 25
specific evidence-based preventative care
interventions, such as vaccination (127%
increase), colonoscopy (122% increase),
and mammography (75% increase), that
improve longitudinal health outcomes and
decrease future healthcare costs.
Current Primary Care Crisis
In spite of its essential function, primary
care is often described as being in a
state of crisis, characterized by physician
burnout, large patient panels, increased
administrative burden, reduced time spent
with patients, low reimbursement relative
to other specialties, and a shrinking
workforce.
Burnout
Given their central role in the healthcare
system, it is particularly concerning
that primary care providers (PCPs) report
some level of burnout at a higher rate than
providers in many other specialties. The
most commonly cited factors that lead to
burnout among PCPs include increased
administrative burden from charting, paperwork,
and electronic health records (EHRs);
too many hours at work; lack of autonomy;
government regulations; and an emphasis
on profits over patients (Kane, 2019). In
a 2019 survey of U.S.-based physicians
(InCrowd, 2019), 79% of PCPs reported
experiencing burnout at some level.
Too Many Patients
Primary care panel sizes are a critical
component of primary care practices. A
panel size that is too large (or too small)
has implications for patient access,
physician workload, clinician/patient
satisfaction, care comprehensiveness, and
overall quality of care. Although 2,500 is
often used as the “standard” primary care
panel size, it has been estimated that a
PCP would need to work 21.7 hours per
day to adequately deliver recommended
health services to a panel of 2,500
patients (Yarnall et al., 2009). According to
the American Academy of Family Practice
(AAFP) Practice Profile (White & Twiddy,
2017), in 2015, the average panel size
among family physicians was 2,194.
There is evidence in the literature
suggesting a correlation between panel
size and some measures of the quality of
care. For example, larger panel sizes have
been associated with poor diabetes control
(Angstman et al., 2016) and decreased
rates of preventive services, including
cancer screenings, as well as increased
rates of admissions for ambulatory-caresensitive
conditions (Dahrouge et al.,
2016). Across primary care specialties,
physicians report that pressure to provide
greater quantities of services effectively
limits the time and attention they can
spend with patients, detracting from the
quality of care provided (Friedberg et
al., 2013). PCPs with larger panel sizes
are also less likely to discuss health
promotion activities, such as smoking
cessation, healthy eating, or increased
physical activity, with their patients (Hogg
et al., 2009).
On the other hand, in a traditional
primary care model, where reimbursement
is tied to the number of services provided,
a panel size that is too small can result
in financial instability for the practice and
reduce the likelihood that the practice
could weather a financial downturn. During
the COVID-19 pandemic, primary care visits
dropped precipitously, and it has been
estimated that, nationally, the primary care
system could face aggregate losses of as
much as $15 billion (Basu et al., 2020).
However, DPC practices that had a steady
source of revenue from recurring payments
were better positioned to weather
the storm, and many have reported that
their finances were relatively unchanged by
the decline in patient visits caused by the
pandemic (Pifer, 2020).
Administrative Burden
All physicians, and PCPs in particular,
spend an increasing amount of time and
effort performing nonclinical administrative
and regulatory tasks. A time and motion
study of ambulatory care published in
the Annals of Internal Medicine in 2016
(Sinsky et al., 2016) found that physicians
spent 27.0% of their total time in the office
on direct clinical face time with patients
and 49.2% of their time on EHRs and desk
work. Even when in the examination room
with patients, physicians spent only 52.9%
of the time on direct clinical face time and
37.0% on EHR and desk work. Physicians
also reported one to two hours of afterhours
work each night, devoted mostly to
EHR tasks. A 2016 Health Affairs study
(Casalino et al., 2016) estimated that
an average-size medical practice spends
785.2 hours ($40,069 per physician, or
$15.4 billion per year in the aggregate)
reporting on quality measures that do
little to help improve care or assist
patients with treatment decisions. It has
been estimated that PCPs spend 9.9%
more time on nonclinical paperwork than
providers in other specialties (Physicians
Foundation, 2018).
Workforce Issues
An analysis of projected supply and
demand by the Association of American
Medical Colleges (AAMC) predicts a
shortage by 2033 of between 21,400
and 55,200 primary care physicians.
Based on an analysis of American Medical
Association Physician Masterfile data,
the 2020 AAMC estimates include a
slightly lower number of physicians trained
in primary care who subspecialized or
became hospitalists. However, this is
offset by an increase in the number of
physicians planning to retire earlier than
previously modeled, according to analyses
based on AAMC 2019 National Sample
Survey of Physicians data (Association
of American Medical Colleges, 2020, p.
5). This increase in the rate of retirement
is consistent with reports of the effects
of high levels of burnout on workforce
turnover in primary care (Willard-Grace et
al., 2019). There is also concern that the
number of medical graduates entering the
primary care workforce will not adequately
offset the increasing number of retirees.
Although a record number of primary care
positions were offered in the 2019 National
Resident Matching Program (“the Match”),
the percentage of primary care positions
filled by fourth-year U.S. medical students
was the lowest on record (Knight, 2019).
The Match figures for 2020 show that, of
the 34,266 first-year positions offered in
the Match, 17,135 were in the primary
care specialties of family medicine, internal
medicine, internal medicine - pediatrics,
internal medicine - primary, pediatrics, and
pediatrics - primary, a 7.4% increase over
the number offered in 2019. Of those,
16,343 (95.4%) were filled, and 7,369
(45.1%) were filled by U.S. MD seniors.
(National Resident Matching Program,
2020, “Primary Care Specialties” section).
Overview of DPC
DPC is a practice and payment model
where patients contract with their physician
or physician practice directly in the
form of periodic payments for a defined
set of primary care services. The DPC
practice model is still evolving, and much
like primary care in general, there is no
consensus on what constitutes a DPC
practice. However, the most commonly
used definitions generally include the following
elements (Busch et al., 2020, p. 5):
1. The practice charges patients a recurring—
typically monthly—subscription fee
to cover most or all primary care-related
services.1
2. The practice does not charge patients
per-visit, out-ofpocket amounts greater
than the monthly equivalent of the subscription
fee.2
3. The practice does not bill third parties
on a fee-for-service (FFS) basis for services
provided.
One way to broadly categorize the various