TL;DR: It’s important that we (that is, DPC as a movement, whatever that may be) agree on and build a solid and basic ideological foundation defining our relationship with third parties, so that as DPC grows, it doesn’t grow into the same corrupt, broken, and abusive 3rd-party cash machine that we all escaped.

With interest, I recently read Dr. Kenneth Qiu’s excellent article “DPC Generations”. Ask anybody who knows me and they’ll tell you about my affinity for analogies. Dr. Qiu’s analogy, which envisions the DPC movement as adventurous, pioneering people escaping into the wilderness and evolving from bushwackers, to pioneers, to settlers, to city builders, I thought was very good and certainly thought-provoking, and I immediately wanted to write to build on this analogy.

But before I even started, Dr. Farrago had already published Dr. Thomas White’s intriguing response “Taking Over The World? Or Just Driving Under The Influence?”

Because these three physicians are also my colleagues and friends, I’ll now go informal and use their abbreviated first names. Tom, Doug, & Kenny, I hope, will not be offended. Anyway, using “Doug” will be a fresh kindness to Dr. Farrago, who is used to being called much worse. Regularly.

I have a lot to say, so I’ll break this up into 3 separate articles. Today’s article is my take on Kenny’s analogy of the evolution of the DPC doc from bushwhacker-to-city builder. This is a fantastic analogy, and I have little to add. But I do want to say that I think this analogy still has a long way to take us as we conceptualize the future of DPC. Indeed, as we approach the end of my inaugural year as president of the DPC Alliance, the Board of Directors has begun to devote some significant meeting time to nebulous discussions about what the future holds for the movement and preparing for the Alliance’s role in it. It’s a wonderful unknown to be facing, considering the uncertainty we faced five years ago as we launched the Alliance.

I think Kenny’s analogy appeals so much to me because I am a very visual learner. I grew up on a farm and rural life is in my blood. My clinic sets on a picturesque hill 3 miles outside of a small town where one can look out an exam room window and literally see cattle grazing not 30 feet away. Although I love the rural life, years of education took me through large metro areas, and I lived for years in some sketchy low-rent urban areas where I never felt at home.

I have good friends who feel the opposite way. They might feel just as uneasy with the utter silence of winter on the Kansas prairie as I do with the constant din of the city. What I’m getting at here, is that in terms of Kenny’s analogy, surely we all can visualize an uncomfortable place where we were, juxtaposed against the comfortable place where we have happily, through adversity, come.

Here is where Kenny’s analogy scares me. Consider the nightmarish suburban set from Edward Scissorhands, or the stereotypical inner city apartment with the domestic violence neighbors, leaky roof and foul-mouthed landlord. In my mind, that’s the medical setting I escaped. It occurred to me as I read Kenny’s article,that the figurative urban place I couldn’t wait to escape, probably started as a nice small town just like the one I’ve now escaped to. The glorious small rural country safe haven that those DPC generations bushwacked, pioneered, and settled is about to be upgraded to a city, and I am scared that if we’re not careful, we could let it become the place we left.

We humans are fallen and error-prone. I’m no history professor, but I’m pretty sure we don’t learn from our mistakes. And as if humans weren’t skilled enough at making bad decisions and ruining everything good, we DPC bushwackers, pioneers, and settlers have now coalesced into groups! (Perhaps I can get Doug to violate copyright law and include the demotivational poster with the line “Never underestimate the power of stupid people in large groups” at the top of this piece.)

As we group-up and evolve into city builders, what keeps us from building it into the place we escaped? What simple foundational compass can guide us from going in circles? What ethos? What code? What charter? Sorry if this sounds negative, but I don’t feel like we have one.

I think the answer is to define our relationship with third parties. I’ll get back to that. First, here is what the answer is not.

The answer is NOT: 

“We know what bad middlemen and 3rd party payer stuff looks like, we’d never let it come to that again.” [quickly and instantly insert loud “incorrect” gameshow buzzing sound] WRONG! It’s already being done by “city builders” eager to claim that they represent independent DPC physicians. I hear abhorrent words like the oxymoron “Medicare Advantage” and nauseating phrases like “build 3rd party employer groups to pay for DPC” almost every day. Many DPC docs are quick to dismiss them as “well these aren’t THOSE kind of 3rd parties”. Let me help clear up any confusion: There are three parties. 1) The doctor 2) The patient 3) Everybody else. If money is involved and it’s touching the hands of someone other than the doctor or the patient, that’s a 3rd party. Of course not all 3rd parties are sinister. Perhaps a local church is paying for the care of a homeless person. Great. That’s love in action; works for me. Maybe an employer is just being nice and paying their employee’s DPC membership. Ok with me also, if done transparently. But even these altruistic payment arrangements are 3rd parties, and we owe it to our patients to be wary and to be careful. Many (dare I say most?) 3rd parties are wolves in sheep’s clothing–parasites fully willing to harm the doctor-patient relationship for their financial benefit, while gaslighting the doctor and the patient to believe how lucky they are to have them. 

The answer is NOT: 

“We know what they did wrong! The 3rd party FFS system wasn’t bad, it just wasn’t done correctly. DPC will do 3rd party RIGHT. (i.e. We’ll build the city, but this time we’ll make it a utopia using insurance or the government or some other corporate 3rd party.)” [loud “incorrect” game show buzzing sound, this time played 5 times at a deafening volume while I slap the speaker repeatedly in the face like in a 1950’s Warner Brothers cartoon or Three Stooges episode] WRONG! This is the very definition of insanity. This kind of thinking is right there with those who deny the cost in lives that humanity paid and continues to pay for communism: There are millions of ghosts who beg to differ with anybody who would venture to suggest that “Mao/Lenin/Stalin/etc just didn’t do it right!”

The answer is NOT: 

“My way or the highway! The way that Vance Lassey does DPC is the only way!” [Buzz!] WRONG! How about another analogy: Like a Baskin Robbins, DPC has many flavors and most of them taste delicious. We don’t all have to like all the flavors. But SURELY, we can all sit down and agree on some kind of basic rules for making ice cream, like “No fish.” Right?

Back to Kenny’s analogy: I want to add a step. Before we settlers become city builders, might I suggest we stop, slow down, open our eyes, study history, and devote significant time and effort (yes–even if it delays the building of the cities) to first becoming city planners.

Older cities that grew rapidly eventually run into huge infrastructure problems as a result of poor planning. I see no reason that won’t happen to DPC, if we let it. Unnaturally fast/forced growth of DPC invites mistakes, middlemen, and problems. Forcing the growth of DPC at an “inorganic rate” breeds overwhelming potential to accidentally build a clone of the system we risked so much to escape. Out of the frying pan, into the fire.

Let us study the history of 3rd parties in health care, and see how we got here? Maybe at one point, those 3rd parties in medicine really thought what they were doing was good/helpful, etc. If that’s true then, the effect of the law of unintended consequences was staggering. Staggering to the point that In the US, the 3rd parties became such an integral part of the system, that when you say “healthcare” most Americans think you mean “health insurance.” (Which never stops blowing my mind.)

How has our system remained this wretched hive of scum and villainy? (Thank you for describing the American healthcare system so well, Obi-Wan.) Since every system is perfectly designed to have its current result, the only common sense explanation to our tolerance of the garbage is that there are those in power who want it to remain this way. Corrupt middlemen of every imaginable administrative, corporate, and governmental variety profit greatly by the status quo. To them, 12,000% hospital markups, PBMs, sick-care over health-care, commoditization of human beings (doctors and patients), etc. are all good things. The broken system benefits them, or they wouldn’t fight so hard to maintain it.

As we move further and further from them, the more they’ll try to get in, because medical middlemen have NOTHING without doctors. Their ilk are already circling our movement like vultures.

So how do I answer the question: “How does DPC keep from repeating history?”

No. Third. Parties.

In cases where 3rd parties are felt needed, their implementations need to be radically transparent, all money changing hands being divulged to the patients potentially harmed by the relationship, and the doctor never leaves the driver’s seat.

In my next installment, I’ll look at Tom’s article.