This past week I had the good fortune of speaking with a few academic physicians who are very interested in incorporating Direct Primary Care experience into their residency programs. These discussions revolved around a few potential barriers that most GME programs would have in common if they were to try and initiate a true DPC residency practice under the control of the residency. Here are a few of the barriers that were identified (as well as a few others):
1. ACGME requirements for outpatient clinic visit numbers. The Family Medicine Review Committee currently mandates that all residents must conduct a minimum of 1650 face-to-face office visits in the longitudinal outpatient setting before graduation. Given that DPC practices are not volume-driven– and often obviate the need for office visits for some common complaints– it may be more challenging for residents in a longitudinal DPC practice to make the ACGME visit requirement.
2. Creation of a culture of continuity in a residency program. Residents are busy people, and rarely are they in one place for very long. Whether it’s hospital call, continuity OB deliveries, or outpatient rotations around town, residents are often hard to track down. Patients in a DPC practice often are drawn to such practices because they offer enhanced accessibility to their own doctor. How can residency practices fulfill this promise of continuity and access for DPC patients and still meet the other demands of residency training?
3. The role of longitudinal faculty physicians. The key to economic viability for most DPC practices is the maintenance of low overhead in the practice’s operation. Many of the efficiencies in DPC are achieved by shedding the overhead associated with third-party payer contracts, including Medicare and Medicaid. Residency-based DPC practices would face the challenge of negotiating the status of supervising faculty physicians within CMS and commercial insurance programs. If the faculty physician severs relationships with third-party payers, this leaves the residency program unable to submit charges for the physician’s services in other areas (inpatient service, conventional residency clinic, etc). However, if the faculty physician maintains third-party contracts, s/he must care for patients insured by those payers according to the terms of the contract. How should programs negotiate this apparent conflict when implementing a DPC practice in their residency?
4. Incongruous culture with the sponsoring institution. Let’s face it, the ethos of Direct Primary Care is not exactly what most health system CEO’s have in mind these days when they think of the direction of their institutions’ primary care practices. Many of the rampant changes in health care today are about forecasting payment structures and aligning incentives to maximize payments from third party payers, which often entails the gathering of large amount of data on the part of doctors and practices. To an ordinary primary care physician on the street, it seems as though we’re caught between two conflicting messages: the nation needs more primary care physicians to deliver on the promise of improved access and reduced costs, and at the same time the hyper-objectification of our work makes it seem harder than ever to remain a respectable board-certified physician. How likely are sponsoring health systems to support the establishment of independent Direct Primary Care practices under the auspices of a residency program in this climate?
While these challenges seem like they’d be common to most, if not all, residency programs, I’m sure there must be circumstances where some of these barriers don’t apply. In our conversations around this topic, we came up with a few responses to these challenges, which I’ll share in my next post.
In the meantime, I’d be very interested in your thoughts on challenges to implementing DPC in a residency program, as well as any solutions to meet these challenges!
academic dpc 