A Well-Balanced Diet

Tea and toast hyponatremia is a condition of malnutrition that occurs when individuals lack nutritional variety, often resulting from  a more serious issue like dementia or frailty. No one of sound mind and body chooses to eat only toast, but underlying conditions can cause one to default to the simplest food available, or even physically prevent them from finding and preparing nutritious food on their own. Primary care physicians in the traditional system exhibit a similar problem. For many, their golden handcuffs force them to take the quickest, least nutritious income source or they don’t have the capacity to seek a healthier option. Today’s traditional primary care is hyponatremic, metaphorically speaking,  Direct primary care (DPC) brings primary care a more nutritious diet. 

To understand the potential DPC has to rebuild our primary care system requires a complete rethinking of its name and a look at how DPC has evolved through several generations. Generation 0 was the Bushwhackers. Bushwhackers knew insurance-only wasn’t the answer, so they looked for something different. They said, “what if we ate something besides bread–let’s try meat!” For the sake of the metaphor, “meat” refers to payments made directly from patients. Observing the benefits of consuming meat, Generation 1, the Pioneers, built a culture around meat eating. They followed and preached a carnivore diet, swearing off bread forever as the cause of their previous sickness. Today’s generation,Generation 2- The Settlers, learned from the horror stories told by Generation 1, and were quick to switch to a carnivore diet after only briefly experiencing hyponatremia, if at all. 

Right now, most DPC enthusiasts define DPC by its patient-only revenue source, as expressed by Dr. Shane Purcell in his recent post. However, what transitioning out of an exclusive diet of insurance did for primary care was that it opened the door to pursue other nutritional options, providing a more varied revenue diet and reversing primary care’s financial frailty. The next generation of DPC may be defined  not by what payments it won’t take, but rather by what payments it can. 

Roughly half of Americans receive health benefits from employers thanks to salary controls implemented during World War II. Another third are covered by Medicare and Medicaid. Just 7% receive health insurance through the individual marketplace. There is an expectation by some that all Americans should deeply understand the healthcare financing system and make informed decisions about the most optimized solution to suit their particular health and budget needs. Yet the reality is that for the last century, most Americans have given responsibility for their health care financing to either employers or the government. These in turn have historically trusted health insurance companies to provide “care” through insurance-based “coverage”. At the dawn of the DPC movement, physicians got fed up with insurance payments and patients got frustrated by the poor care they received by insurance-only practices. Thus began a grassroots movement of physicians and patients who sought solutions outside the traditional system and directly contracted with each other. Direct contracting with patients proved wildly successful, and the primary financiers of healthcare – employers and government – are now gaining and increasing interest in the DPC solution. 

At the 2017 DPC Summit, the talks about contracting with employers were relegated to side rooms at a “pre-conference” event, symbolically marking them as a fringe topic. Generation 1 Pioneers who preached the carnivore diet dominated the movement at the time. Working with employers was considered akin to eating potatoes–close enough to bread, and definitely not meat. By contrast, the last couple of summits showcased presentations about working with employers as a key feature of the main summit agenda. In fact, Dr. Purcell in his recent article describes “true” DPC by saying “We contracted directly with patients or their employers” and even wrote a book on contracting with employers. In fact, contracting with third parties goes back to the very beginning of the DPC movement. Dr. Garrison Bliss, largely regarded as the Godfather of DPC, founded Qliance in an effort to bring the culture and quality of care of DPC to Medicaid recipients. Unfortunately, Qliance imploded, and many point to its failure as reason not to contract with third parties. But those who choose curiosity over criticism have studied the Qliance experiment to try and find better ways to deliver care to a population for whom direct contracting is out of reach. Zest Pediatric Network, led by Dr. Drew Hertz, has begun a pilot with Medicaid in Ohio as the latest example. Those who insist DPC means only contracting directly with patients do not understand the historical reality of this young movement, nor do they see the promise of growth and sustainability through more revenue options, even as employers supercharge the DPC movement. 

A diet of tea and toast leads to malnutrition, but beware of a second threat to nutrition and health: obesity. The obesity epidemic can be traced to the proliferation of high calorie, nutrient deficient food. As more payers seek to contract with DPC practices, opponents of payments from anyone other than patients fear recreating another bloated, unhealthy system like the one they left. This concern has merit. However, diversification of revenue can cause good, healthy growth if done properly. Part two will address the current and coming opportunities for DPC practices, as well as the pitfalls to avoid so as to not create a new broken system.