The direct care subscription delivery model is rapidly growing. Hint Health, a national leader in the direct care space, identified an increase of patients receiving direct primary care by 241% and an increase of direct primary care clinicians by 159% over the past 4 years.
Direct care (DC) reestablishes the primary relationship between doctors and patients without the involvement of insurance. Care is provided via a subscription model paid directly to the doctors, lowering overhead, reducing patient volume, and significantly improving patient access. By restoring physician autonomy, doctors focus on patients rather than excessive bureaucratic insurance rules. DC practices have existed for over a decade with estimates of over 1,800 current practices.
The DC model has repeatedly demonstrated success for adults. A Society of Actuaries study published in 2020 found that DC enrolled patients had a statistically significant reduction in utilization of overall healthcare services (-12.6%) and emergency department services (-40.5%). Furthermore, they found that DC achieved better health, better quality, lower cost, and happier doctors.
Multiple adult-focused direct primary care networks currently exist. Amazon is purchasing a subscription-style network, One Medical, in a $3.9 billion deal. There is speculation that CVS will acquire one of these networks in 2022. But what about the kids?
We have previously outlined how current pediatric systems are failing our children. Direct pediatric care (DPC) is a possible solution to this national systemic failure. Approximately 22% of the total U.S. population are children, offering an opportunity to cultivate a direct pediatric care network. However, it must be substantially different than that for adult-focused networks. The following outlines why.
Children Are Not Just Little Adults
The physical, mental, social, and developmental aspects of children set them apart from adults. The office environment must be child-friendly to ensure a trusting, warm, and non-threatening experience. Furthermore, children’s physiology, bones, mental capacity, and thought processes all change dramatically throughout childhood. Children learn differently. The impact of environmental influences (pollution, electronics, social media, bullying, etc.) on current and future health changes over time. Social support structures and the related support services needs are different. Applying the principles of adult primary care to children and their families is simply a failure to appreciate the many and unique needs of children — which is why pediatrics evolved as its own specialty over a century ago.
What Happens in Childhood Does Not Stay in Childhood
Countless studies have demonstrated the long-term impact of early social-emotional development on adult health. Safe, stable, and nurturing early childhood relationships are key to a person’s adult health trajectory. The current pediatric delivery framework does not allow the time, nor the meaningful doctor-patient relationships, necessary to impact long-term health. DPC does afford these opportunities. Care provided now matters forever.
Children Require Family-Centered Care
A child’s health needs cannot be addressed without considering the needs of the entire family and social structure of the home. Sibling, parental, and often grandparental conditions must be appreciated and addressed to optimize a child’s health. Childcare, school vacations, sibling rivalry, household discipline and play rules, mealtime, and so much more must be accounted for. This family or household approach takes time and skills not supported in a traditional care delivery model.
The Lower Cost of Pediatric Care Necessitates a Unique Approach
The lower total cost of care for children compared to adults means that any real dollar financial savings from a direct care model will be smaller. This necessitates a lower overhead structure than that for an adult model. This can be done, but not without effort and implementation of best practice technology, leveraged vendor contracts, and unique patient access and operational workflows.
Economies of Scale and Shared Network Resources Matter
Provider networks have been shown to have many advantages. They provide camaraderie for fellow physicians and professional learning and support environments. Networks provide pricing leverage for technology and vendor contracts. They support the sharing of lessons learned and best practices. In fact, the 2022 Hint Health survey demonstrated that DC network practices grew at almost twice the rate as independent practices.
Networks can also help decrease the barriers to DPC entry for pediatricians. Doctors want to doctor; many do not want to run their own businesses, and receive little to no business training in medical school or residency. The barriers to starting a practice from nothing are high. However, a network could provide a turnkey solution and financial assistance to doctors, thereby eliminating the barriers to DPC entry.
Alleviate the Moral Injury
Some call it physician burn-out. Others call it moral injury. Doctors know how to help patients; however, they do not have the time, resources, or energy to do so in a traditional practice model. The DPC model puts the doctor back in charge, thereby offering the potential to decrease rising rates of moral injury among pediatricians and increase satisfaction and longevity.
Pediatric Care Needs to Become More Innovative, Nimble, and Collaborative
Children interact with many community sectors unique to them, from schools and community behavioral health services to childcare, camps, sports teams, and community child-focused service organizations. Developing relationships in these areas is paramount to full advocacy for pediatric patients. Adult-focused networks have their own unique relationships to foster and may not necessarily have the same child-friendly resources available. Collaborating across community sectors requires a practice to be innovative and nimble. It requires rapid adaptation and adjustment to modern technologies and opportunities without bureaucratic hurdles or competition with financial or workforce resources of adult medicine.
DPC Could Decrease Child Health Inequities
Concerns exist that DC models may increase health disparities. However, if broadly adopted and made accessible, they are more likely to decrease disparities. As previously outlined, DC models improve patient access and doctor-patient trust — two driving factors in health equity. If employers adopt DPC subscription as a benefit, their employee’s children would benefit, regardless of socioeconomic status. Additionally, if the subscription payment model were adopted by Medicaid managed care plans, physicians would be enabled to move towards a value-based rather than volume-based care model. The neediest of children would receive DPC model benefits.
A Needed Change
Children are not OK. Pediatricians are not OK and unable to provide needed care. Children are our future. We must pilot innovative care delivery models that may address the woes of the current system.
Considering the reasons above, it becomes clear why we need a direct pediatric care physician network.
Andrew Hertz, MD, has been a general pediatrician for 30 years. He has overseen a network of over a hundred pediatric providers, and is now a pediatric healthcare consultant. Keili Mistovich, MD, MPH, is the co-founder of a pediatric direct primary care practice in Beachwood, Ohio, and has been a practicing pediatrician for 7 years.