Person: Hi, I would like to get my car washed.

Car Wash Serviceman: Of course, may I see your insurance policy for car washing please?

Person: Ah, I must have it here somewhere… (rummages through bag). Here it is.

Car Wash Serviceman: Let me check if you have car washing coverage under your policy. (pauses) I’m sorry, it looks like you have a $100 deductible for car washing.

Person: What does that mean?

Car Wash Serviceman: That means you’ll have to pay $100 out of pocket before your insurance will cover the cost of the car wash.

Person: Can’t you just wash my car without going through insurance?

Car Wash Serviceman: I’m afraid not. All car washes must be processed through your insurance policy to ensure proper coverage and documentation.

Person: Can you give me a quote for the car wash so I know how much I’ll be paying?

Car Wash Serviceman: (mumbles something)

Person: I’m sorry what?

Car Wash Serviceman: (mumbles something)

Person: Okay, never mind how do I start the insurance claim process?

Car Wash Serviceman: Great. I’ll need you to fill out some paperwork and provide some documentation. Once we have everything we need, we’ll be able to wash your car and have your insurance cover the cost.

Person: (filles up paperwork) now what?

Car Wash Serviceman: Now I’ll file this with the insurance companies and we’ll process your claim as soon as possible, you can go home now.

Person: But, what about my car wash?

Car Wash Serviceman: I’m afraid not. All car washes must be processed through your insurance policy to ensure proper coverage and documentation, may I see your insurance policy for car washing please?

Person: I just filled it up for you

Car Wash Serviceman: Did you?

Person: I JUST HANDED YOU THE FORM

Car Wash Serviceman: Can you prove that?

Person: I SAW YOU

Car Wash Serviceman: Ok, no problem! We’ll just need you to fill out some paperwork, and provide some documentation of submitting the form. Once we have everything we need, we’ll be able to wash your car and have your insurance cover the cost.

Person: ….

Car Wash Serviceman: …

Person: …

Insurance is deeply intertwined with the delivery of healthcare and emergency services around the world. So, when lifestyle medicine (LM) started gaining traction it seemed intuitive to take an insurance-driven approach to funding these services. After all, if people adopted healthier habits, it would yield insurance companies greater profits due to lower preventable disease rates and everyone ends up happy. Sounds about right?

This could be a grave error. Insurance was designed to protect individuals against high-cost, unpredictable, and rare “black-swan” events. Car insurance does not cover car washes, nor is it used for new tires or routine replacement of brake rotors. In the same sense that car washes are preventive care for cars, lifestyle medicine is preventive care for people: it encompasses a holistic and integrative form of care which aims to improve health outcomes through behavior change.

Using that analogy, it makes sense to explore alternative financial models which can improve access and delivery of lifestyle medicine, without the bottlenecks of the insurance system. One such model will be discussed in this article - Direct Primary Care.

What is direct primary care (DPC)?

DPC is an example of a proactive investment in primary care that seeks to provide transparency and deliver essential services at a lower cost.

In DPC, a transparent contract is created between the provider and patient with a known upfront inclusive cost for a specific set of care needs. This cost typically covers all visits, in person and virtual, well and preventive care, and acute and chronic disease care

- Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine

The DPC framework means that patients have a direct agreement with their care providers and incur a predictable and recurring fee, unrelated to the utilization of care services. This is similar to Software-as-a-Service (SaaS) membership models, as in Netflix and Spotify, which most people are familiar with.

In contrast, the prevalent payment method today would be the “fee-for-service” (FFS) approach, which incurs a fixed cost for a fixed service ($30 for a consultation). Depending on the country of residence, the payer model for the service also varies: the National Health Service in the UK (single-payer), insurance and employers in the US (multi-payer).

To be more specific, the Society of Actuaries defines a DPC service as one that

1. Charges patients a recurring fee to cover almost all primary care needs
2. Does not charge patients per-visit out-of-pocket amounts beyond the monthly recurring fee
3. Does not bill any third parties on a FFS basis for services

Example of a DPC service network - TRI-DPC

Critically, the DPC approach means that physicians can directly support a patient’s personal health goals, without justifying it to a third-party insurer. Additionally, this can be done while maintaining transparent costs for any payor involved.

DPC vs Fee-for-service

In 2019, a survey by the American College of Lifestyle Medicine (LM) showed that 59% of LM practitioners were not being reimbursed for their services, and 34% needed to use multiple reimbursement methods. The fee-for-service model is prone to interference and requires value attestation from external parties, which are not necessarily compatible with a patient’s needs. Especially in the context of complex single and multi-payor attestation systems, these processes take a major toll on both care-providers and patients.

More broadly, despite the acknowledgment of primary care as essential to the Quadruple Aim, many primary care professionals (PCPs) are reporting symptoms of burnout especially in the US.

In a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers anew.

-From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The rise in burnout symptoms is commonly attributed to:

1. Large patient panels which increase physician stress and worsen patient experience;
2. Lower pay in comparison to other specialist care providers;
3. Increased administrative burden from Electronic Health Records;
4. Performance-based incomes, which shows far higher burnout rates than in salaried physicians; and
5. Long work hours.

These all culminate in a shortage of PCPs, perpetuating the cycle ad infinitum. DPC doesn’t directly address these challenges, but the idea that primary care should be excluded from insurance and unmediated by a third party appears to rectify many of them.

For health professionals

For health professionals, the ability to run a medical practice that is independent from a healthcare system has a significant impact on freedom and flexibility. With smaller patient panels (between 200-600 in comparison to FFS panels which are over 1000) and longer office visits, DPC allows physicians to focus on meaningful work and deliver in-depth and customized care. The reduction in administrative work from insurance and other non-clinical burdens also eases the time-stress on many primary care physicians.

…. only 26.4 percent of DPC clinicians reported spending greater than 10 hours per week on “non-clinical (paperwork) duties” versus 48 percent of PCPs in the FFS survey group. Nearly 46 percent of this survey’s respondents report working zero to five hours per week on these duties versus 21.3 percent of the FFS survey respondents.

- Society of Actuaries

DPC also provides financial stability, through its recurring revenue model. The stability opens the door for physicians to invest in tools enabling higher-quality care, like telemedicine and behavior change programs. This is especially relevant to lifestyle medicine, as behavior change requires a long-term relationship between patients and care-givers, which is expected to be the default in a DPC system.

For patients

Proponents of DPC claim that it boosts the care experience for patients. Chronically ill patients do show significantly lower inpatient hospital, outpatient hospital, emergency department and ambulatory care utilization rates, when enrolled with high-touch, team-based models of primary care.

These are precisely the models of care that DPC empowers, albeit not directly. One gap in the research around DPCs relates to subjective aspects of care like “provider engagement”, “patient engagement” and “quality of care”. The following word map shows the testimonials from a diverse selection of patients in the Integrated Family Care Practice, but this remains anecdotal and warrants a deeper review.

Word map of patient testimonials from the Integrated Family Care Practice

Additionally, as mentioned above, the development of long-term relationships between care-givers and patients allow for continuity of care while boosting patient adherence to health intervention. These are critical features for both preventive care and the Quadruple Aim.

It is also important to note the DPC does not function as a catch-all replacement for insurance, as it only covers predictable and regular health services. In fact, most DPC clinicians encourage their members to carry catastrophic health insurance in addition to their memberships. This means that patients need to be informed with a framework on how to optimally balance both insurance and DPC payments.

For payors

The analysis of cost in DPC practices proves more tricky. There are observed differences in demographic and health status between DPC and traditional cohorts: DPC patients generally hold a lower health risk score. However, with adjustment for differences in health status, the Society of Actuaries reports that DPC cohorts experience a statistically significant 12.64% reduction in total claim costs.

Providing access to primary care also ensures employee well-being, in the case of employer-paid DPC memberships. An increasingly millennial and Gen-Z workforce demand access to well-being services as a critical component of work compensation, especially given the rise in awareness of mental health conditions. DPC allows workplaces to support their employees in prioritizing personal well-being, while boosting productivity and employee retention.

Criticisms

Design of studies

Critics of DPC raise that any observed reductions in utilization or costs are either “aberrant, due to small sample sizes or are driven by patient selection” (where healthier patients choose DPC).

Although risk adjustment strategies have been utilized in DPC analyses to counteract patient selection, the sample sizes are insufficient for analysis of measures like inpatient admission rates. As mentioned previously, the lack of measures to quantify “quality of care” and “patient satisfaction” makes it hard to assess the impact of DPC on those aspects of care.

Variability

Additionally, there tends to be a large degree of variability in care delivery between DPC practices.

Specifically, and perhaps more than any other primary care model, we believe the effectiveness of the DPC model of care in achieving any of its practitioners’ stated goals depends heavily on the unique training, skills, experience, motivations and care that each DPC physician provides.

-Society of Actuaries

This means that outcomes are highly specific to the DPC clinics themselves, and data obtained from a single clinic is not generalizable. Because DPC clinics operate with more liberty as compared to FFS clinics (with insurance oversight), there also needs to be sufficient regulation to protect patients from any mal-intent.

Scalability

The DPC model is also criticized for being unscalable, as it reduces the number of traditional care providers who would otherwise have larger patient panels. Thus, DPC preferentially improves access for enrolled patients while reducing access for others. This runs against the primary mission for healthcare delivery, which is to expand overall access to healthcare.

However, the Quadruple Aim argues that overworking PCPs through large patient panels is not a better solution. Instead, technology and training could be developed such that DPC can be delivered with fewer physicians and a heavier reliance on a variety of healthcare professionals. In that way, physician time can be optimized in DPC settings by taking a team-based approach which does not centre the physician as the only source of medical expertise.

For health professionals, starting a DPC also requires start-up capital, and knowledge of legal and compliance issues alongside a set of entrepreneurial skills like marketing and technology use. This makes starting a DPC service risky for many providers, although the usage of DPC continues to demonstrate a strong 13% annual growth.

Direct Preventive Primary Care (DPPC)

The application of DPC is an evolving field of study on a financial model which is growing in adoption. There are many gaps in the research on its ripple effects regarding access to traditional primary care, due to a lack of data measuring confounding effects like patient selection. There is also insufficient analysis to definitively show the impact of DPC on the quality of care.

A low-risk approach to test DPC models would be to apply DPC to preventive care. DPPC gives lifestyle medicine practitioners, who have yet to receive widespread recognition from health insurers, the ability to start financially viable health services.

The previously discussed benefits of DPPC enable LM providers to operate autonomously and align incentives between patients and providers to encourage long-term relationships. These relationships are essential for health promotion and holistic behaviour change, which is the goal of LM. This shows a promising path forward to increase access to preventive care.

Testing DPC through preventive care enables data collection and analysis on its market dynamics, to evaluate its suitability for general primary care. This minimizes disruption to existing primary care networks and reduces the risk of unknown, undesirable side effects.

Together, DPC and preventive care point to a financially sustainable framework for delivering LM at scale. It might finally be time to pay for our own car washes.