PrimaryCare24 Event Recap and Direct Primary Care’s Next Frontier

This past week, Elation was proud to participate at Primary Care for America’s third annual event, eponymously named PrimaryCare24.

Just over two years ago, a small but mighty coalition was formed under the leadership of the American Academy of Family Physicians, with 13 primary care-focused organizations intent on a singular goal: Primary Care for America. Elation was thrilled to be invited to be one of those 13 founding members, and the only technology company in the coalition. Including organizations like the American College of Physicians, the American Academy of Pediatrics, the National Association of Community Health Centers and others, Primary Care for America has worked to raise awareness about the value of primary care, promote payment reform in healthcare, accelerate innovation to support primary care success, and advocate for solutions to the primary care workforce crisis.

This year, I joined esteemed colleagues to moderate a panel titled, “Direct Primary Care Enters its Second Decade,” a discussion about how the DPC model has evolved, is scaling to reach more consumers, how employers are getting involved, and how the model is changing what patients expect from their primary care experience. Panelists included Dr. Jeff Davenport, owner of One Focus Medical and President of the DPC Alliance; Dr. Jonathan Bushman, CEO/Owner of Reliant Health DPC; Dr. Mark Tomasulo, Founder of PeakMed and now Head of DPC Strategy and Innovation at OneMedical; and Michelle Neblett, Director of Health Care Policy at Boeing.

This may seem like an unlikely group to talk about DPC, but they each had a unique and valuable perspective to contribute, which elevated the conversation beyond the sum of its parts.

Here is more about their unique place in the ecosystem, and some of the most compelling POVs we heard during the conference: 

• As a jumbo-sized employer with 147,000 employees across the nation, Boeing has been piloting and studying the direct primary care contracting method for many years, and is convinced of its value to patients and Boeing. As a result, they are aggressively building their benefit plans around DPC, and are exploring ways to offer DPC to every employee in every state. Ms. Neblett was clear, however, that their biggest barrier to scaling their DPC offering is the tax code. This is because Boeing, like most employers who sponsor health benefits, offers high deductible plans paired with a health savings account (HSA). These plans matter because the tax code dictates how employees can spend their HSA funds, since the contributions to these plans are pre-tax. Unfortunately, although an employee can use their HSA funds to pay for sunscreen, braces, and even mileage to and from doctor appointments, they are prohibited from using HSA funds to pay for primary care in a membership model. There is pending legislation sitting in Congress today which would correct this, thereby making DPC affordable for 70 million Americans, but the bill has not yet been brought to the floor for a vote, to the frustration of Boeing, many other employers, and every DPC in the nation. Boeing has thrown its full weight behind lobbying for this bill, as has the DPC Coalition, and the AAFP. (You can read more about this legislation and other relevant policy for primary care in our blog post here). 
• As a panelist, Dr. Tomasulo brings deep experience to the DPC conversation based on his own background. Dr. Tomasulo founded PeakMed DPC in Colorado in 2014 and grew it—to his amazement—into one of the largest independent DPC practices in the country. In 2022, he sold PeakMed to OneMedical, the primary care giant known for contracting with employers and offering a tech-forward patient experience with same day/next day access in exchange for a small membership fee plus billing insurance for any billable services. In 2021, OneMedical purchased Iora Health, the company best known for value-based care for seniors. With the acquisition of PeakMed and Iora, OneMedical now has 3 business lines: the concierge model (membership plus insurance billing), the Iora model (Medicare Advantage), and the PeakMed DPC model (membership only). Today, Dr. Tomasulo leads their DPC business line, and his most striking message during the panel was that we typically think of primary care payment models in extremes, with fee-for-service on one end and direct primary care on the opposite end. The common thinking has been that in order to abolish the one extreme of FFS (which, primary physicians and others all agree is bad), the only way is to adopt the other extreme (DPC). Dr. Tomasulo argues that in order to get more of the industry to move away from the FFS extreme, we have to pull them “to the middle”; speak to them in the language that they know; and then teach them a new one—helping them break the old paradigm. He sees this as OneMedical’s role, offering a gateway out of FFS and into a better payment and delivery model. There’s a plot twist though: OneMedical has recently been acquired by Amazon. Time will tell how a Goliath-sized digital platform impacts not only the business model and the scalability of the direct care model, but also the integrity of its care delivery.
• Dr. Jeff Davenport is the owner of One Focus Medical DPC in Edmond, Oklahoma and the current president of the DPC Alliance. He is a steadfast and unapologetic advocate for what Dr. Tomasulo has defined as the DPC “extreme”. He is fiercely protective of a model which has rescued many primary care physicians from the trauma of working in an insurance-based system, which robbed them of their autonomy and put them in the position of having to choose between the business or their patients. His skepticism about moving to “the middle” is shared by many, and an important message to keep us focused on our True North: we work for patients and no one else. His mantra is a quote from Oren Harari,”Edison’s electric light did not come from the continuous improvement of the candle.” His goal is to “break” the entire legacy system and rebuild something entirely novel in its place.
• Dr. Jonathan Bushman wears three hats. He is a DPC owner in Enid, Oklahoma, a rural town of about 50,000, where he has lived his whole life, and where his now-retired childhood physician is today his patient. Dr Bushman has multiple employer contracts and has leveraged local employers to rapidly scale his practice, proving that the DPC model can thrive even in rural America. He also runs a medical support operation, which provides enablement for three affiliate DPC practices, with plans to continue growing. Finally, he has become a clinical benefits advisor through Health Rosetta, helping employer benefit leaders understand the value proposition of direct primary care and work with their brokers to build their benefits offerings around DPC.

This panel (and the entire conference) highlighted the fact that there are many problems to solve in healthcare today, and the landscape is evolving rapidly. The DPC model is growing by 31% annually, and direct contracting for primary care is impacting 35 million Americans. In 2022, employers footed the bill for $2T of the $4.5T in U.S. national healthcare expenditures and they have been watching these costs escalate year over year. Direct contracting is the only thing that has ever helped them make a meaningful dent in this, and increasingly employers are taking note. In addition, DPC is making necessary,  life-changing care affordable for many who have no insurance coverage at all. There even is currently proposed legislation which would make DPC available to Medicaid recipients. It will be crucial moving forward that we pay close attention to what’s working better than what we’ve tried before—the things that eliminate the misaligned incentives and support the kind of relationship-based primary care that strong evidence supports as key to better health outcomes at lower total cost. We must adopt those models that move us in that direction, whether away from the FFS extreme and closer to the middle, or all the way to the other DPC extreme. 

I’m grateful for another PrimaryCare 24, which gives us the opportunity to learn and discuss so many relevant topics that advance our work. Its impact speaks to the powerful value of holding this event, which was live-streamed for free to all who registered and available to watch back for all who are interested (Day One; Day Two). I left the event with an even stronger sense of urgency for the work we are doing to advance the primary care agenda, and also with newfound co-conspirators and plans to make still more change happen.