What is Direct Primary Care (DPC)?

Direct Primary Care (DPC), primarily developed in the United States, is a healthcare model where patients pay a monthly subscription fee directly to their general practitioner or practice. In exchange for this flat fee, patients typically benefit from:

• Unlimited or very frequent consultations, often longer in duration.
• Easy access to the doctor (phone, email, SMS, telehealth).
• Shorter waiting times.
• Basic services included (certain examinations, rapid tests, vaccinations).
• No insurance reimbursement (Medicare, Medicaid, or private insurance), which reduces administrative bureaucracy for the physician.

The goal is to give doctors more time for their patients, strengthen the doctor-patient relationship, and focus on prevention and personalized follow-up.

Challenges of Implementing DPC in France

The French healthcare system is very different from that of the United States. It relies on a universal health insurance system, with significant reimbursement for care by the Sécurité Sociale (national health insurance) and complementary health insurance providers.

• Principle of Universal Access and Equality: DPC, with its subscription model, could be perceived as a two-tiered system, creating one type of medicine for those who can afford a subscription in addition to their social contributions, and another for everyone else. This would go against the principle of equal access to care, which is a cornerstone of the French system.
• Sécurité Sociale Reimbursement: In France, patients are accustomed to being reimbursed for a large portion of their consultations. A DPC model where there are no claim forms to send or reimbursement from Health Insurance would be a major disruption and difficult for patients to accept. Private doctors are « conventionnés » (contracted) with Health Insurance, meaning they accept the agreed-upon fees and their patients benefit from reimbursement. A DPC doctor would have to « deconventionner » (uncontract) or find a complex hybrid framework.
• Fee Regulation: General practitioner consultation fees in France are set by agreement. The DPC model allows doctors to freely set their subscription fees. This would raise questions of regulation and transparency.
• « Mutuelles » and Complementary Health Insurance: Mutuelles supplement Health Insurance reimbursement. How would they integrate into a DPC model without fee-for-service billing?
• Medical Deserts: DPC could worsen the situation in « medical deserts » (areas with a shortage of doctors) if doctors prefer to set up practices in affluent areas where they can attract patients willing to pay the subscription.

Factors That Could Favor a DPC Approach in France (or Inspired Models)

Despite these challenges, some aspects of DPC address current concerns in general medicine in France, which could lead to adaptations or hybrid models:

• Medical Time and Quality of Relationship: Many general practitioners in France complain about the lack of time per consultation and administrative overload. The idea of spending more time with patients and reducing paperwork is very attractive.
• Prevention and Chronic Disease Management: The DPC model, with easier access and more personalized follow-up, is ideal for prevention and managing chronic diseases, areas where the French system seeks to improve.
• Alternative Remuneration Models: France is already exploring alternative remuneration models to pure fee-for-service payment.
  • « Forfaits Structures » (Structural Packages): Multi-professional Health Centers (MSPs) and Health Centers receive packages for care coordination and management of certain pathologies.
  • « Rémunération sur Objectifs de Santé Publique » (ROSP – Public Health Objectives Remuneration): General practitioners are remunerated for achieving public health objectives (screening, vaccination, chronic disease follow-up).
  • Article 51: Experiments are being conducted under Article 51 of the Social Security Financing Law, allowing derogation from usual funding rules to test new care models.
• Telemedicine and Digital Access: The COVID-19 crisis accelerated the adoption of teleconsultation. Services offered by DPC (easy communication with the doctor via message, teleconsultation) are increasingly expected by patients.
• Private Initiatives/New Generation Centers: Some initiatives in France are not DPC in the strict sense because they remain contracted with Health Insurance. However, they incorporate elements of the DPC experience: a broader range of services (annual check-ups, multidisciplinary team), easier access via applications, and an emphasis on personalized follow-up. They do not require a subscription in addition to classic fees but offer « free program enrollment. »

Scenarios for the Medium Term

• Hybrid and Contracted Models: The most likely scenario is the emergence of practices or health centers that integrate « premium » services (easier access, longer consultations, proactive follow-up) while remaining contracted with Health Insurance. These services could be financed by packages paid by Health Insurance for coordination or care of specific populations, or by « mutuelles » offering complementary services.
• Development of MSP/CPTS-type Structures: The strengthening of Territorial Professional Health Communities (CPTS) and Multi-professional Health Centers (MSPs) already allows for pooling resources, improving care coordination, and offering easier patient access, drawing inspiration from the benefits of DPC without adopting its funding model.
• « Out-of-System » Care Niches: Non-contracted practices could emerge, but they would remain very marginal because reimbursement by Health Insurance is a decisive factor for the majority of French patients.

Conclusion

In conclusion, a « pure » American-style DPC is unlikely in the medium term in France due to the foundations of our healthcare system. However, pressure on general medicine, the desire for better quality of care, and evolving patient expectations could encourage the development of contracted models that integrate certain DPC characteristics, notably improved access, longer consultations, and personalized follow-up, funded by packages or remuneration based on quality and public health objectives, rather than a direct patient subscription.