Direct primary care for the poor

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A third-year family medicine resident inquires about the direct primary care model (DPC) and caring for the poor.

Hello Dr. Accad,

I’m a 3rd year Family Medicine resident, 2 months short of graduation.
This summer, I’ll be starting my first job as a primary care physician at an FQHC [Federally Qualified Healthcare Center].

I’ve read a fair amount about the Direct Primary Care model and really believe that if it gains momentum, it can be an important means for improved quality of care, improved physician job satisfaction, and significant cost savings. I’ve thought a great deal about pursuing a future in DPC.

Nevertheless, I have also made a personal commitment to serve the poor in my community in some meaningful way. In all the reading I’ve done, I haven’t encountered any DPC physicians discussing ways to specifically target the poor and still run a sustainable business.
This DPC model seems great from the perspective of doctors, the population, the economy, and patients, but as far as I can tell, those without access to a stable source of income are only dealt with on a charity basis.

So, for the time being, I’ll be working at an FQHC, which is the best (only?) model that our current system offers to serve the poor in primary care.

Have you encountered any DPC models that have successfully achieved this goal? Or what has been your experience in treating those without means?

In my opinion and experience, caring for the poor within the confines of a regular practice is hindered primarily by regulatory and medico-legal conditions, rather than by doctors being unwilling to serve poor patients.

I know of one noteworthy effort: the St Luke Family Practice in Modesto, CA.  This direct care practice was started by Dr. Robert Forester, a family physician who intended from the get-go to set up the clinic to serve the poor in a systematic fashion.

The clinic is organized as a not-for-profit entity.  Benefactors make a yearly donation which gives them access to concierge-type primary care services.  They can write off whatever is unused from that donation as a tax-deduction.  The funds raised from the benefactors (and from additional grants) pay for the clinic expenses and for the salaries of the two docs and staff who provide free healthcare to the poor, typically migrant workers in California’s central valley.

This is a remarkable operation, and Dr. Forester is a true visionary.  I had the chance to meet him a few years ago and I invited him to speak at a conference to describe his model.  The journey to overcome the regulatory barriers to set-up this unusual clinic was extremely long (years) and arduous.  In caring for the poor, the government does tolerate competition very well…

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4 thoughts on “Direct primary care for the poor

  1. After checking out the St. Luke’s link, a question occurred to me: are they the primary care doctor for the poor patients or do they provide a walk-in type clinic for them?

    • I believe they do provide continuity of care for management of conditions like diabetes, etc., if that’s what you are asking, although the actual operation of that part of the clinic is likely different from the “concierge” part.

  2. Also, do you know of any DPC models that allow for in-patient and outpatient care? Basically where you can admit your patients that see you in
    the DPC clinic?

    • Not that I know of. Hospitals have become very inhospitable for primary care physicians…That said, if you needed more info, you should follow some of the DPC online publications, such as the Direct Primary Care Journal, as they may have additional info.