Document Type


Publication Date



Maine Medical Center, Medical Education, Maine Medical Center Research Institute, Family Medicine

MeSH Headings

Qualitative Research, Imagination, Schools, Primary Health Care


Background: Direct Primary Care (DPC), where patients pay a monthly fee for access to a primary care physician, has seen steady growth in recent years. In 2015 there were approximately 10 DPC practices in northern New England; today there are over 30 practices. The growth of DPC has been attributed to problems with the conventional fee-for-service system—wherein high overhead and excessive insurance paperwork leads to shortened appointment times and increased patient volumes to generate profit. DPC proponents believe that bypassing insurance can result in more time with patients and better doctor-patient relationships, thereby achieving the IHI’s “Triple Aim” of improved health outcomes and patient satisfaction while lowering cost. Few studies have examined DPC in this region of the country. Existing research focuses on large DPC practices, but the majority of DPC practices in northern New England have only 1-2 providers. Variability among practices makes a quantitative assessment of DPC difficult. Our study aims to characterize the experiences of providers adopting the DPC model, including reasons for pursuing DPC, barriers and challenges encountered during transition, and reflections on how promises of DPC compare to experience.

Methods: We conducted semi-structured interviews, led by a single, trained qualitative researcher, with 14 DPC providers in Northern New England. Interviews were recorded and then professionally transcribed. Transcripts were coded using Dedoose software by two investigators using the constant comparative method and analyzed to identify relevant themes.

Results: Participants reported adopting the DPC model in response to problems they perceived in conventional medicine—demands on time, degraded relationships with patients, and burn-out. We identified several challenges of transitioning to DPC, including a need for supplemental funds during transition, learning to run a business, and recruiting a patient panel. Under a DPC model, participants reported having greater flexibility, more time with patients, better relationships and greater satisfaction. Ongoing challenges included balancing panel size against solvency, so that increased time and deeper relationships with patients are not compromised. Participants claimed that DPC is able to serve the needs of a variety of patients, though specific gaps in care were identified. DPC providers can give more attention and continuity of care to complicated patients, though they noted that too many such patients would overwhelm their practices. While they were able to serve patients without traditional insurance, such as small business owners, contractors and even those living “paycheck to paycheck”, patients on the lowest economic tier, such as those on Medicaid, were underrepresented or absent from panels. Finally, participants anticipated future challenges from the consolidation of healthcare and the possibility of Medicare-for-All.

Conclusion: Based on reported experiences of current practitioners, the DPC model offers a solution to many of the problems providers face in fee-for-service models. Providers who transitioned were overwhelmingly satisfied with their choice. However, the model remains prohibitive for some providers and patient populations.


2020 Costas T. Lambrew Research Retreat