In rural areas, decreased primary care panel size is a problem, not a solution.

Montana’s last governor twice vetoed DPC legislation. He was not wrong.

Over the last month or so, DPC advocates from think-tanks of the right have trotted out the proposition that direct primary care could be “the key to addressing disparities in health care access in underserved areas of Montana facing severe shortages of primary care”. They are very excited that eight DPC clinics have “opened” in Montana in just a few years. Yet, when the very same advocates testified before the Montana legislation, they brought along some real MT DPC docs whose own testimony made it clear that what really happened is that eight existing clinics or practitioners in Montana decided to switch to subscription model care.

And, no doubt, each such D-PCP significantly reduced the size of their patient panel. Typical DPC clinicians brag about reducing patient panel sizes to one-third the size of those in traditional practices. Indeed, some members of the same pack of DPC advocates in the same hearing stressed the glories of tripled visit times.

But reducing patient panels sizes by two-thirds obviously aggravates the problem of primary care physicians shortages.

The most common response of the DPC community has been that DPC lowers burnout, lengthening primary care careers, presumably mitigating that aggravation – to some unknown degree and at some unknown point in the future.

I did some math.

Each PCP who chooses DPC and reduces patient panel sizes by two-thirds would need to triple the length of his remaining career to cover the gap he created by going DPC. And it would take decades to do so.

Assume an average career length of 20 years for a burning out PCP, with retirement at the age of 50. Let’s suppose that DPC makes PCP life so sweet that he works until he is 80 years old.

By the end of those 30 additional years, the equivalent of one-quarter of the patients he left behind by going DPC will still be left in the cold Montana snow.

To fully close the gap his switch to DPC created, he would have to work until he was a 90 year old PCP. The good news is that he would be very experienced; the bad news is that some 90 year-olds might struggle with “24/7 direct cellphone access to your direct primary care physician”.

To supplement the patent insufficiency of this bleak scenario, DPC advocates further argue that DPC will lead to increases in the percentage of young professionals choosing primary care practice instead of specialties. One of the think-tank “experts” from the Montana expedition has said that “we know” this to be the case, but provided no evidence other than the naked claim “we know”. Is this knowledge, or just speculation? Feel free to put a link to any significant evidence in the comments section below.

Even if there was hard evidence that DPC had shifted or might shift career choices toward primary care, it would still be wise to “be careful what you wish for”. Physician shortages in rural areas are not limited to primary care. To the contrary, there is ample evidence, such as this study from a Montana neighbor state, that rural communities face shortages of specialists that are even more consequential than the shortages of PCPs.

If a potentially gifted surgeon is willing to return to her roots in Whitefish, why turn her into a PCP?

Montana officials, beware.

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