Georgia’s conservative fans of direct primary care swoon over PHS, a 1500 member, insurance-free, hospital-based, direct primary care clinic in Altoona, Pennsylvania. PHS was the subject of not just one, but two quantitatively detailed academic journal articles addressing the efficacy of direct primary care. Since the oft-cited British Medical Journal study on the efficiency of direct primary care does not actually exist, the two articles on PHS appear to be the only academic studies addressing the question. Yet, though the author list of both articles includes the clinic’s own medical director, the data presented do not show that the direct primary care (DPC) model is superior in any way to traditional insurance-based primary care.
Astonishingly, the articles tell us that the entire physician staff of the clinic amounted to three part-timers, two of whom were uncompensated volunteers and one of whom was paid only $24,000. The total value of the donated physician services can not even be estimated, because neither article tells us how many hours or full-time equivalents the primary care physician staff worked at giving primary care. The omission is fatal to any attempt at cost-benefit analysis — and astonishing, given that direct primary care advocates usually claim that greater PCP contact is the essential source of every virtue attributed to direct primary care.
The authors do present data suggesting that primary care received in the insurance-free direct primary care clinic helped reduce the number of emergency department visits. But there was no attempt to show that the insurance-free direct primary care clinic was any better than insurance-based primary care at calling forth this somewhat obvious by-product of primary care.
The twin articles undertook only one direct comparison of the effectiveness of the clinic to that of insurance-based practices. That effort revealed that the hospital admissions rate for PHS members was about 55% of the rate for those who received primary care through nearby insurance-based practices.
The authors eagerly attribute this large difference in hospital admission rates to the superiority of the insurance-free direct primary care model on which PHS was built. But there is a better explanation.
For the years under study, about 1 in 6 adults in the US was uninsured. But only about 1 in 16 hospital admittees were uninsured patients. In other words, the uninsured typically have a hospital admission rate that is about 3/8ths that of the insured. Might that be because, relative to the insured, the uninsured have trouble paying for hospital stays?
Whatever the explanation, it turns out that 70% of the clinic’s members are uninsured, while 30% carry hospitalization insurance. Based on these proportions it can reasonably be projected that the PHS population would have had a hospitalization rate of about – you guessed it – 55% that of a fully insured population. Most likely, enrollment in the PHS clinic had no impact on the rate of hospital admissions.
Benefit? None shown. Cost? Failed even to include the cost of direct primary care physicians who delivered the direct primary care!
In sum, the only quantitatively detailed academic studies of the cost-effectiveness of direct primary care failed to show that direct primary care was in any way superior to insurance-based primary care.
DPC Referee 