Doug et al,

I agree that it would be a good idea not to beat this or any other dead horse.  However, if you think that One Medical is a dead horse or that Tom Lee, the founder of One Medical, was anything but a genius and a visionary, I beg to differ.  I met Tom in August 2005 at a Roundtable discussion in Cambridge, Mass.  The discussion was put together by another visionary Rushika Fernandopulle, who would later go on to design a revolutionary approach to the care of Boeing employees, then another even more unlikely approach to caring for the poorest and sickest inner city patients in Camden, NJ – later memorialized in a brilliant article by Atul Gwande in the New Yorker:

https://camdenhealth.org/wp-content/uploads/2011/03/Gawande-Camden-Annals_17.pdf

Rushika then went on to create IORA Health which demonstrated that DPC concepts could be applied successfully to the care of Medicare Advantage patients without being crushed by the insurer (Humana in his case).  Rushika also incorporated the use of trained health coaches as well as daily team meetings to identify the patients most in need of care and support and rigorous follow-up of patients to improve their health and wellbeing.

It was quite a meeting in 2005 since we were all bleeding edge innovators and none of our futures contained a drop of certainty.  Tom Lee had not yet started One Medical and I had not started Qliance, but I was getting up the gumption to take the jump off that cliff.  Tom was the only one with a feather in his cap since he had cofounded the Epocrates App and served as the Medical Director for Epocrates while still a student.  By 2010, 40% of American Physicians were using his software (including me).  Unlike me, Tom had a Stanford MBA as well as an MD.  He too wanted to try a monthly fee affordable practice, but unlike me, he was willing to also take insurance money.  He also developed the first software I know of that allowed patients to schedule their own appointments.  

History interlude:

Concierge medicine in the form of MDVIP was attacked soon after it started by politically savvy individuals in Florida where MDVIP was just taking off.  They were unhappy that Medicare doctors had the temerity to charge them a monthly fee in addition to fee-for-service charges for the health care itself. This moved to the federal level when Representative Henry Waxman, chair of multiple committees in the House of Representatives began criticizing the “double dipping”.  His efforts were quietly blocked by a letter from Tommy Thompson (Secretary of Health and Human Services in the Bush administration) in a short letter declaring that Medicare doctors had some discretion and that they did not have to accept all patients on Medicare.  He also said that Medicare doctors had to follow all Medicare rules, but that there was no rule against a monthly fee for “non-covered services” (see image).

Because Tommy Thompson supported concierge practices and rebuffed Henry Waxman, concierge practices have never had to undergo the kind of state-by-state passage of laws that DPC has had to pursue.  Tom Lee just used an altered concierge concept to institute a low annual fee concierge practice (under $200/year) and used insurance money to fill out his cash flow.  This made his model less “pure” from a DPC perspective, but it sure as hell made it easier for him to get money for growth and to avoid legal and government challenges.  When confronted at a conference about his lack of purity, he called insurance money “jet fuel”.  He also never called his company DPC, so calling him a DINO is not appropriate since he never claimed to be DPC.  Unfortunately, Tommy Thompson’s position also led to the exclusion of DPC from Medicare and Medicaid because their rules require that we take their money.

As far as the stupidity of the deal, paying $3.9 billion for One Medical, which occurred after One Medical had already bought IORA for $1.4 billion – I suggest that had nothing to do with stupidity.  So why did Amazon buy One Medical?  I cannot tell you with any certainty since I wasn’t there, but Jeff Bezos was one of the early investors in Qliance and a very good friend of our first investor Nick Hanauer, who was the first non-family investor in Amazon when it first began.  The two things you cannot assume with Jeff Bezos are that he is stupid or that he didn’t know what he was buying.  Because of rapid growth and “rocket fuel”, Amazon bought 220 medical offices in 27 markets, and 836,000 members.  Even though their clinics were less pure than DPC, they had enormous numbers of primary care physicians working in a much nicer environment than most of those outside of DPC.  MDVIP now has over 1000 primary physicians and 325,000 patients and they have their own data about happy patients and remarkable reductions in the cost of medical care.

DPC is NOT the only model in health care that can take care of patients well.  DPC has a much smaller footprint in terms of Primary Care physicians and patients, but we have a brighter future. We have built a model that grows slowly because we seek a service that is not dependent on rocket fuel,  that works for all socioeconomic groups, and is even affordable to the poor with modest outside support.  We should be VERY proud of our accomplishments.  This movement has survived DESPITE potshots from the established and often corrupted care systems.  I suggest that we appreciate what others have done to incrementally improve patient care and access.  I also suggest that we look for ways to make use of their experiences to look for ways to accelerate our growth without falling into the potholes.  The beauty of DPC is that it was built to function, not just for the wealthy, but for everyone in this country.  I hope to be alive when the vast majority of Primary Care is in the hands of DPC docs.  There is still much to do,  This may also be the year that the federal government removes some of our shackles, and I hope to tell you that story soon.