The JABFM puts out a study on Direct Primary Care and it is one big turd while also being a lie of omission

This is going to be long. Very long. The reason? This study was just published in the Journal of the American Board of Family Medicine and you can read the whole thing here. First my bias. The JABFM is from the American Board of Family Medicine which is one big Ponze scheme of an organization. I was bummed that they even published anything about Direct Primary Care. Alas, they did and so I need to discuss it. Right off the bat, there is one good thing that came from the study:

Nevertheless, this finding counters the perception that DPC clinics primarily draw from affluent neighborhoods.

All of us in DPC know this fact but I guess it is a positive for the world to read. I am sure that will repeated over and over.

Now for the problems. These researchers did NOT do their homework so their conclusions are 99% bullsh%t.

Here are their conclusions:

An academic institution launched a DPC clinic to address the needs of low-income, uninsured individuals. Patients used the clinic frequently and sought care for chronic, and not just acute, conditions. The clinic ultimately closed because of external factors like inflation, COVID-19, and a failure to secure synergistic partnerships, like employer-based contracts. Nevertheless, we found that patients from vulnerable neighborhoods wanted to receive services from this model. If arranged differently, we hypothesize that other DPC clinics could successfully serve low-income populations. Specifically, these DPC clinics should monitor the amount and structure of the monthly fee, minimize staffing, and identify aligned partners that can provide a source of referrals or offer affordable services. To advance our knowledge in this field, DPC clinics that have already overcome these barriers should partner with researchers to measure the extent to which their practices are reaching low-income populations.

This is where I need to refresh you with the REAL story.

For those who don’t know, I had first written about the University of Houston Medical School opening a DPC clinic twice in 2021. Here are my articles:

The University of Houston College of Medicine is Actually Opening a DPC Clinic. Is It A DINO?

I Have Communicated With the University Of Houston College of Medicine About Their DPC Clinic and They Do NOT Want It To Be a DINO!

After that last article above in DPC News I decided to reach out to the school to see if I could help. I offered to consult for FREE. Yes, you read that right. FREE! I did, however, want my expenses paid if I flew down to Houston. That’s all. I had a meeting via ZOOM with the dean and the medical director of the medical school. It went well and it seemed like their hearts were in the right place. Here is my follow-up email from that call:

Steve and Omar,

I truly enjoyed our discussion this morning. I want to formalize a consultant agreement to move forward.  Being retired from clinical medicine has allowed me to do this kind of stuff but it is bigger than that.  What you are doing is a big swing that can’t miss.  Other than my massive network of connections,  I bring a lot to this table and I think I can help with:

1. Recruiting – I will push hard on DPC News and elsewhere to find someone
2. Retention – the key here is building in the right perks BEFORE you start and continuing them so the doc stays!
3. Purity – you do not want to be DINO
4. Marketing – I know this very well and need to work intimately with your marketing team
5. Leanness – you want this to last and build that network.  I know what isn’t needed and what is. 
6. Reputation – See DINO thoughts. This should be the model to other schools to do this and the country (including DPC docs) should be proud of it.
7. Other:  EMR advice, workflow, subscription management, doctor agency, etc. 

Your timeline is fast approaching.  We (I) have to get moving.  I am fully aware how I would start that clinic as I have done that before.  Yours is different, however.  I need to learn how to work with you so that I don’t step on your toes while also feel that I am being heard.  You have shown you do the latter already. 

With your permission, I will get a VERY simple consultant template and boiler agreement sent to you.  Before I do that, I want you to think about this some more and let me hear some of what you would expect of me in this consulting role. That way we are on the same page.  My asks are simple: all expenses paid (I don’t foresee 5-star hotels and first-class tickets).  I am not looking to gouge anyone.  I would also like an official role and announcement so that I can use that on my resume in the event other schools come asking.

You are on the precipice of something great here. It really could change the system.  We don’t often get opportunities to put a dent in the universe.  This is one of them.

I was excited for them to try this and really wanted to help them. Then I heard back from the dean who stated they could not let me consult for free due to legal reasons but would have to pay me at a rate of $200/hr. Umm….okay, twist my arm. Now the catch. All I had to do was work with their lawyer on the contract. Uh. Oh. Cue the screeching car sound.

The lawyer, unfortunately, was an ass and sent a massive contract. It became a mess because she wouldn’t even respond to my questions and I had to email the dean back to try and square things:

Steve, I need your help in facilitating this.  You have to love bureaucracy and lawyers.  

As I told you, I have no problem doing this consultation gratis.  As it turns out, the contract seems to be doing that. I am attaching the contracts sent to me.  Here are the problems I am having:

1. The contract has a total cap of $4K.  That’s 20 hours of work.  As I said, I can do this gratis because I will be doing more than 20 hours of work.  That would be eaten up just by coming down there. 

2. They do not put coverage for expenses.  That’s a problem. 

3. They want to OWN all work I do.  Well, I have written 3 books on DPC and much that I will be recommending is from my work.  I have an issue with their claim of ownership. 

4. They want me to purchase insurance and I am not going to do this. 

5. They are not allowing me to publicize, in any way, that I am working with your medical school which is what I would like to do to show the work we are doing. 

So, my question to you is where do we go from here?  I want to start helping ASAP.   The people that send me emails (Paule, Liz, and one other) never email me back with my questions.  I can send those 5 rebuttals above but it will take forever, if they respond at all. 

Any thoughts?

Do you want to know how they responded? They ghosted me. All of them, even the dean. WTF? 

I tried a few more times to contact them but nothing. I had to give up. Remember, no good deed goes unpunished. And I kept this whole experience to myself because I still wanted them to succeed. 

A few months later I heard they found a great doctor to start at their clinic. She was a local doc and bilingual. Awesome. But then, out of the blue, I got emails from this physician. Interestingly, she didn’t even know that I had been trying to work with the school. This doctor found me on Facebook due to DPC News and she was having trouble at the clinic with such things as: 

• I had asked if appointments were going to be extended/longer. I was told yes. But I am now seeing patients every 20 minutes and running behind an hour. I have brought this up and they use the excuse of the waiting list that started in Nov 2021. They launched the clinic then with big publicity, but no doctor to staff it, thus I came into a problem. Their solution lets hire more MAs and call you at 745 am for a huddle. I have 3 exam rooms and for multiple reasons, there is no good flow, one of them being they have not translated documents to multiple languages, not even Spanish.
• I had tried to make sure this was a DPC model: extended visits, low patient panel (I have heard from 700-800 but nobody gives me an exact number), price transparency, voice and leadership guiding the clinic, be able to make the schedule, taking time to build the panel (currently they want 500 by summer) and low overhead…but I feel like this is a fee-for-service model with the operation team making all decisions, not listening to the doc and working in assembly line medicine. 
• The dean says that the other DPC clinics in the area are not doing it right, because DPC was developed by Dr. Garrison Bliss to serve poor people w/o insurance. And they spoke with Erica Bliss on how to provide care to the poor…this came as a surprise to me…I have yet to find this anywhere.
• I was told we could not do some of the things of private practice, but it was not clear that what they meant was operational team making all decisions, leading this like a FQHC/fee for service model and billing a monthly membership and therefore calling it a DPC.
• Am I missing something here? I feel like I missed something, said yes and all is blowing up…I am also concerned that they are calling this DPC and with all the publicity they will ruin the model.

This was bad. I reassured her as best as I could and told her to voice her concerns and work through this because I was staying out of it. And she did try but to no avail. She left a few months later. 

I tried to follow what was going on at the clinic online as best I could and it seemed they never found another doctor after she left. They just used the medical school faculty, including the dean (who actually is a co-author in this study), to see patients. Was it even a DPC clinic? Who knows.

And they closed in 13 months. 13 months!

Now let’s go back to the study in the JABFM. Here is what they said:

Lessons Learned

Unfortunately, in November of 2022, the DPC clinic closed after memberships fell, suffering the same fate as Qliance which closed in 2017.³⁰ While the clinic attracted the target population, the model, as implemented, was not sustainable for several reasons. First, while the clinic attracted low-income individuals, it did not enroll enough to break even. There were contextual factors that affected the clinic’s financial status, including historic inflation, COVID-19, and the loss of the anchoring physician. Inflation, in particular, increased the cost of all goods and services, leaving patients with less money for health care. Anecdotally, our staff reported that nearly one-third of those cancelling memberships were unable to consistently afford the fees. While the clinic was unable to sign up enough patients, the break-even point, approximately 800 active memberships, was also influenced by the staffing model. To ensure the clinic had adequate staff, it hired 3 clinic staff, which is higher than the average (1 staff) for DPC clinics.⁸

Second, the amount and structure of the membership fee played a role in the clinic’s sustainability. While the amount ($60) is consistent with other DPC clinics (where fees range from $65 to $85 for adults), it may have been too high for low-income individuals.⁸ A lower monthly fee may have attracted more patients but would also have increased the panel size needed to break even. Because of the target population, the clinic was intentional about how the monthly fee was paid. For example, while patients agreed to pay the monthly fee for 12 months and had to provide a 30-day notice for termination, they could end the contract without penalty, and there was neither a waiting period to resume the subscription nor a re-enrollment fee. Internal records demonstrate that 17% canceled their subscriptions. By comparison, 74% of DPC practices report that less than 10% terminate their membership after a year.⁸ Those who lacked credit cards paid in cash, making it difficult to receive payments during the intervening months. Due to University policies regarding banking and security, the patient-facing functionality of the membership management platform could not be used; therefore, patients could not enroll in the program, make appointments, pay bills, or set up recurring payments online. The end result was that some patients paid only when they needed care. In contrast, DPC clinics rely on payments that are automatically received regardless of utilization.

Finally, effective partnerships are crucial and elusive. For example, employers can provide referrals and income. One study found that two-thirds of DPC practices have employer-based contracts.⁸Despite considerable effort, the clinic was unable to secure these arrangements. Partners can also provide discounted services typically covered by insurance, including specialty care, labs, imaging, and prescription medications. The literature indicates that the cost of these services, in addition to the amount of the periodic fee, have a strong effect on the utilization, both appropriate and inappropriate.^31,32 While the clinic acquired these partnerships, they were not implemented as envisioned, in part, because the partners were unable to adapt their work flows to the needs of uninsured patients. Taken together, all these factors contributed to the level of patient churn that made the clinic unsustainable.

All the above are generic excuses. Remember, I spent the last year studying why some DPC practices close and did the keynote at the DPC Summit this year. Let’s look at what the authors wrote for the reasons the U of H Medical School DPC clinic closed. Inflation? Bullsh$t. COVID? Maybe. Lowering the price probably would NOT have worked as it was so low already. Getting employers to send their employees would have been great but a hail mary and that was not their mission. The poorer people were their target audience. And last but not least they mention the loss of an anchoring physician! YES!!!!! Look at the doctor’s email to me above and see why they went out of business. The key from this study should have focused on how to make a DPC model work with an employed physician. You need to retain the physician because patients stay due to the relationship with the doctor (I even wrote a book on this). The real lessons learned were:

1. The staff were not properly trained in the DPC model and were treating it like a FFS one. They were cramming visits in 20-minute slots. They probably had NO idea how to sell the model on the phone either.
2. The staff had no allegiance to the anchoring doctor but instead listened to the administrators.
3. Listening to the anchoring doctor is critical and making sure they have some type of ownership is extremely important.
4. Retain the doctor and respect the doctor-patient relationship!

Lastly, here is something the authors conveniently didn’t mention. They had a $1 million grant to make this work!! ONE MILLION DOLLARS! I could have opened 50 clinics with a 90% success rate and would have 45 still in business to this day. These people who tried this were idiots and couldn’t let their egos get out of the way to listen to others. Could my consulting have helped them? I have no idea as I wasn’t given a chance. Now I am glad that they ghosted me like a petty little teenager. 

You may be asking how many members this DPC clinic had in those 13 months. Here you go:

Total Memberships through June 2022: By the end of June 2022, the total number of active memberships was 183 while the total canceled memberships were 123. The peak number of active memberships was 200 in April of 2022 (Table 5).

My thoughts: 183 is not that bad for a one-person start-up with $20K in a rented office. For U of H with a million dollars to market this thing, that is horrible. And 123 leaving is atrocious. If only there was a book on slowing the churn that they could have read.

Overall, it is sad that they couldn’t pull this off. If you look at the seven points of concern I initially gave them you would see how relevant they were.  I was spot on.

This massive failure by the University of Houston Medical School also begs the question of whether academia (like corporations) can do DPC right. 

Answer: probably not, especially when bureaucracy gets in the way. 

Here is my last question to the authors. Where’s the rest of the $1 million? Why didn’t you look into that?