Normalization of deviance is a concept first used to describe the NASA Challenger disaster. It refers to an insidious phenomenon whereby “people within an institution become so insensitive to deviant practice that it no longer feels wrong.”1 Looking back over the past several decades, we observe normalization of deviance within our U.S. healthcare system: serious problems that have slowly become ingrained into the culture. Examples include five-minute appointments, difficulty accessing one’s physician, lack of price transparency, complexity of coding and other documentation,2 and loss of physician autonomy and work-life balance.3 It is no coincidence that 2019 marks the first year in history that employed physicians outnumber independent physicians.4
But this is a story of hope. As insurance companies and health systems have increased in power, complexity and unaffordability over the past several decades, a grassroots movement, known as direct primary care (DPC), has quietly emerged. Around the country and here in the Pittsburgh area, both primary care physicians and specialists are embracing direct care. Based on DPC Frontier data,5 there are now approximately 1,100 known DPC practices across the United States, more than a 10-fold increase over 10 years.
DPC is an alternative payment model whereby patients contract directly with physicians to receive medical services. Because this model removes third-party payors and healthcare administrators from the doctor-patient relationship, common sense and affordability are restored. DPC practices typically operate via subscription model with a national median monthly fee of $70 per patient and panel size of about 600 patients per full-time physician. The pillars of a DPC arrangement include adequate time, ease of access, price transparency, affordability and trust. In this model, documentation serves a purpose of facilitating ongoing patient care rather than creating a barrier between physician and patient, and patient satisfaction is determined by retention rate rather than surveys.
From the patient’s perspective, the value proposition in choosing a direct care practice is as follows:
Consumers expect to know the cost of goods and services before completing a purchase in every industry except healthcare. In contrast, the direct care system offers patients full price transparency. Whether the direct contract is subscription-based or fee-for-service, the patient is aware of every cost before the service is rendered.
Affordable diagnostic testing
Costs of most outpatient diagnostic tests are negotiated between the direct care physician and the lab or imaging center in advance. For example, a lab panel including a CMP, lipids and HbA1c costs about $25, which is less than most insured patients would pay.
Affordable generic medications
Articles in medical and lay literature describe patients forced to forego medications due to cost. Generic drug costs are inflated due to numerous markups along the supply chain. Most direct care practices include an office dispensary. Generic medications are ordered from the wholesale supplier and dispensed directly to the patient at cost. DPC patients have been known to save hundreds of dollars every month on prescriptions.
Increased access to physician
Between short appointment times, centralized call hubs and layers of staff required to maintain physician offices, it has become increasingly frustrating for patients to contact their doctors. As a result, “Googling” symptoms has become the norm. In contrast, most DPC practices allow patients to contact the physician directly via office visit, E-visit, phone call, email or text messaging.
From the physician’s perspective, the benefits of a DPC arrangement include the following:
DPC physicians tend to have a higher level of career satisfaction6 than their counterparts in the traditional healthcare system.7
It has been said that lack of autonomy has been one of the largest contributors to the epidemic of physician burnout.8 Direct care practices restore autonomy; a DPC physician makes decisions about everything from scheduling to staffing, and even the artwork on the office walls.
Because scheduling is controlled by physicians and documentation is no longer onerous, work time is more easily set apart from family and leisure time.
When lecturing on the topic of direct primary care, I invariably receive two questions that I’d like to address here:
“Since DPC doctors limit panel size, won’t this create even more of a primary care shortage?” Indeed, the United States faces a shortage of primary care physicians that is worsening every year. In fact, the number of medical school graduates choosing primary care fields has been steadily declining since 2011.9 When we look at the reasons for physicians choosing fields other than primary care, we can see that many of these problems do not exist in the DPC model. It is my belief that the growth of the DPC model will result in a reversal of the primary care shortage.
“Doesn’t the DPC model encourage ‘cherry-picking’ of healthy, wealthy patients?” Typical DPC patients include the uninsured or underinsured; those with complex medical problems who feel “lost” in the system; and low-income persons who often have not sought healthcare in decades due to fear of cost.
As one of my direct care colleagues frequently remarks, “DPC is a Ferrari everyone can afford.”
Price MR & Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. Journal of Patient Safety. 2018; 14: 1-2.
Sinsky CA, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Annals of Internal Medicine. 2016; 165(11): 753-760.
Arndt, BG, et al. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations. Annals of Family Medicine. 2017; 15(5): 419-426.
DPC Frontier. DPC Mapper. https://mapper.dpcfrontier.com.
Corba KL & Watson M. Direct Primary Care May Be the Link to the “Fourth Aim” of Healthcare. Medical Economics. 2018; 95(11).
The Physicians Foundation. 2018 Survey of America’s Physicians. https://physiciansfoundation.org/research-insights/the-physicians-foundation-2018-physician-survey/
Ariely, D. Disturbing Trends in Physician Burnout and Satisfaction with Work-Life Balance. Mayo Clinic Proceedings. 2015; 90(12): 1593-1596.
Knight, Victoria. America to face a shortage of primary care physicians within a decade or so. The Washington Post. July 15, 2019.