Challenges and Opportunities in DPC

This is the transcript of my talk at Hint summit last week titled DPC goes mainstream: Challenges and opportunities. It’s meant to stimulate discussion and I encourage comments and feedback on the ideas throughout this talk.

What has wheels and gets you from one place to another? Who first thought of a car? Who thought of a bike? Who thought of planes? Each of these is a correct answer and our answer to this question shows how we hold general concepts of ideas and objects in our head. Ambiguity causes us to default to our individual biases. We also use this trait to clarify new concepts. For example, most DPC docs have at some point compared our practice to a Netflix subscription to help prospective patients understand membership based care. In our local communities we can shape the understanding of DPC through networking and marketing. As DPC enters the healthcare mainstream, we have less control and as a relatively new concept people will apply their own biases to it. Heading into primetime comes with scrutiny and comparison to what exists. People will raise questions like what abouts- poor, elders. Conflating concierge and DPC will undermine all the efforts DPC practices have done around helping the underserved. We must define who we are so we can properly answer these questions and allow others to understand our role and potential. We will also be challenged to take on larger scale issues like the worsening PCP shortage. Will our model continue to be one of small panel sizes with one to one visits or will we innovate, leveraging tech and other professions to deliver more care to more people? Finally, going mainstream means more eyes on us and more opinions about us. Do we stay in a corner and celebrate ourselves in isolation or do we actively engage the interested and counter the critics?

As we approach this new phase, we need to focus on three key areas: Definition, Progression, and Collaboration. DPC- pretty easy to remember. The middle word was originally innovation, but it wasn’t as good of an acronym.

Definition

How we define DPC has major implications. When Dr. Garrison Bliss first created the DPC model, the Washington State Insurance Commissioner wanted to regulate it as insurance This push for regulation was a key reason for naming the practice model. Just like most of you thought of “car” when I said “wheels which transport you”, the insurance commissioner saw monthly fee for health services and reflexed to categorizing this new model as health insurance. We still see this train of thought today with the IRS defining DPC memberships as health plans despite pretty much every state having legislation saying it’s not. Defining our model also affects how patients view us. How many people here think concierge medicine and direct primary care are interchangeable terms? Some practices lean into the concierge moniker because more people recognize the term concierge and associate it with high touch care. Others have called DPC concierge for the masses. I’ve chosen to die on the hill that concierge and DPC are wholly separate because most people hear concierge and expect expensive, exclusive care whereas I want them to understand DPC as fundamentally accessible for everyone. Recently, the model has gotten grouped under the umbrella of value based care models, which are basically different flavors of capitation. But DPC is different from all the other VBC models. DPC is also different from concierge care, otherwise it wouldn’t need a separate name. And of course, we all know DPC is not health insurance. I actually spent over three hours with a former federal regulator arguing about this issue at a conference. I finally gained some ground using the Netflix analogy and having him agree that Netflix does not in fact bear risk for entertainment services. 

We need to define DPC better for ourselves and everyone else who will become acquainted with the model. Let’s start with the word Direct which is what makes direct primary care different from the other types of primary care. There are purists who believe the true definition of direct means payment only from patients and no one else. In other words, primary care with no third party payer.  But over the last several years, employers have played a big and growing role in the growth of DPC. Employers paying for DPC membership technically makes them a third party payer. On a smaller scale, a non-patient family member paying for another’s membership could count as a third party as well. What truly defines direct is the separation of primary care from insurance. Primary care services as part of insurance is the result of 100 years of historical momentum. When modern health insurance started in the US, we had just discovered penicillin and we were still 30 years away from knowing high blood pressure and cholesterol were bad for us. Growth of DPC is a natural separation of non-insurable services from the wrong financing model. So direct = no insurance. 

Stepping outside of insurance, we find ourselves with a host of other healthcare services, namely direct to consumer companies. We have vanity companies helping with hair loss, erectile, dysfunction, and weight loss, tech pods to gather vitals, cash pay virtual urgent care, and many more. This brings us to the second part of DPC, primary care. I’ve heard if you put 10 economists in a room, you’ll get 11 opinions. As I’ve talked with people across the healthcare landscape- clinicians, tech, policy, finance- everyone has their own definition of primary care. Rather than sticking to a strict definition, I prefer a framework to define primary care. My favorite is the 4 C’s of primary care authored by Dr. Barbara Starfield: point of first contact, continuity, comprehensive care, and coordination. Satisfying every C in one setting is crucial to real primary care, which is what we claim to provide in direct primary care. 

Putting the two parts together, we have direct, meaning insurance-free, and primary care, meaning a service which satisfies the 4C’s. Direct Primary Care is a healthcare service that is not funded by insurance payments which acts as the point of first contact and offers comprehensive, continuous care with care coordination. This isn’t meant to be the definitive legal definition, but rather a working definition for categorization. So the next time someone calls something a DINO or DPC in name only, check it against this definition and when someone mistakenly calls something obviously not DPC, like One certain Medical company that was recently acquired, use this definition to explain why it’s not. While this definition helps delineate what is and isn’t DPC, it also allows for variation within DPC. Think of insurance as planes, which are impractical for driving from home to the grocery store, even though that’s what we do in the traditional system. DPC is like cars, which are more practical and economical for everyday use. Within the category of cars exist everything from the smart car to the F-150 and lamborghinis to camrys. Similarly, there exists different types of DPC. The DPC movement has largely been led by family medicine physicians but we’re now seeing growth in the other specialties as well. Our pediatrician colleagues have greatly increased in number as pediatrics faces its own crisis of low insurance reimbursement and high administrative burden. Specialists in emergency medicine, internal medicine, OBGYN, and psychiatry have also functioned as primary care and many have joined the ranks of the DPC community. Variations can also include which clinicians deliver care, virtual only, mostly employer vs mostly individual, price points of $30 a month up to over $500 a month. I’ve seen people label others as DINO simply because they disagreed with the price point or the style of practice. But variety is necessary; doing things differently is the definition of innovation, which leads to progress. 

Progression

I was in residency when the Butterfly handheld ultrasound came out. Someone in the DPC community talked it up and in no time just about every DPC practice had one. Compare that to my hospital system. After I got mine and hyped up several faculty to get their own, the hospital formed a committee to study them. They debated how to get reimbursement, and then, after much deliberation, decided to ban them from use. More recently, someone in the community talked up an AI scribe company and shortly after just about everyone was using it. Both the DPC model itself and the grassroots nature of the movement allows for rapid innovation and adoption of new tech and processes. However, in many ways DPCs today act more like planes without wings rather than a distinct category of car. Let’s explore areas where DPC can fundamentally change primary care. 

Quality Metrics: A two word phrase that may as well be a four letter word to most doctors, especially in DPC circles. Most of the mom and pop DPC practices have an anaphylactic response to metrics and refuse to participate in any attempts at proving quality. Those who work with employers have been forced to measure something in order to maintain their contracts. Often they use archaic metrics like A1c and blood pressure or seemingly logical but ultimately useless measures like engagement. We are lucky to have Dr. Rebecca Etz at the Larry Green Center who spearheaded the person centered primary care measure as an example of redefining quality metrics. This survey addresses all the C’s of primary care and just about everyone in primary care can agree these measures are meaningful, important, and deliverable. We can’t keep promoting how great DPC is without proof. Too many people think proof means old metrics dictated by insurance and government.  Well guess what? They don’t pay you and can’t tell you what to do anymore. Think about what matters most to you and measure that. Is it your response time? Track that. Is it your scope of care? Label times where a patient would’ve been referred or gone to the ER. Those working with employers have an extra role to educate them on what actually matters and show how good care aligns with their business goals. DPC gives us the ability to redefine what really matters in primary care and subsequently the responsibility to measure and report these meaningful metrics to prove our impact on the healthcare landscape. 

Med Ed: Every several months someone will bring up the idea of a DPC residency, but I have yet to hear any details besides “residents should have earlier experience in DPC”. Medical students and residents should absolutely experience DPC as early as possible, and we’re working on that at the DPC Alliance through our  Resident and Medical Students or RaMS committee. Students need to know about the future of primary care, which is direct primary care, so we can reverse the continuing decline in primary care interest. But establishing a DPC residency is the wrong answer. During medical school, the primary function of the student is to learn as much textbook medicine as possible both in the classroom and on the wards. In residency, the primary function is to take the textbook knowledge and apply it to the real world with a supervision safety net. There is value in volume at this stage in training. Plus learning the traditional model helps better explain why DPC exists. The current DPC model with fewer patients and longer visits is absolutely the wrong answer. Instead, let’s look to fellowships. For those unfamiliar, fellowship is the stage of training after residency where doctors can specialize further, like an internal medicine doctor becoming a cardiologist or  pulmonologist. Today, the most popular fellowships for family medicine graduates include sleep medicine, sports, medicine, and emergency medicine. What?! Family doctors are training for primary care and then leaving it for something else??? Fellowships should double down on a specific skill or knowledge base within a specialty. We can lead the way in making new family medicine fellowships which actually reflect our function in primary care. DPC practices excel in care navigation and price transparency. We generally learn this individually on the job after opening our DPC practices, but we could formalize training in these skills at the fellowship level. A fellowship in care navigation could include learning how to develop systems to find the best specialists, understanding how to establish lines of communication with local hospital systems, and developing an understanding of resources available for uninsured patients. A price transparency fellowship can teach how to shop between hospital systems, the difference between outpatient centers and hospitals, and what rights patients have to cash prices. I bet there are practicing DPC docs right now who wish they could have gone through these programs. The traditional system will never develop these programs because they are more concerned with RVUs. This explains why family docs are specializing in sports and sleep rather than focusing on primary care. DPC physicians involved in medical education are key to evolving how we train future primary care physicians to maximize their effectiveness. 

Clinical practice: Scope of practice, in other words who can do what, is one of the most controversial and contentious topics in medicine. Nurse practitioners and physician assistants have played crucial roles in medicine for decades. In certain specialties, they have very defined roles. For example, during bypass surgery, while the surgeon works on the heart in the chest, the PA harvests the bypass vessel from a vein in the leg. Primary care has been trickier. PCPs tend to hande everything from urgent care to chronic care and the common cold to complex multi organ disease. This issue is worsened by a payment system defined by non-discriminating E/M codes which incentivize shorter visits and generating more referrals. This is why in many FFS practices, nurse practitioners and doctors work in parallel with little difference between the type of patients they see. NPs and PAs have been called physician extenders, but in the traditional system, the only thing they extend are the clinics profits. Many DPC practices today follow a similar playbook. The physician has their own panel and the NP or PA has their own separate panel. Part of the reason for this is most mid-career physicians are used to doing things a certain way, everything for everyone. They would rather supervise someone else doing the same than share a panel. I believe, in primary care today, 60-80% of care delivered by doctors can be delivered the same or better by other professionals. We are divided by a conflation of skills arising from the immovability of habits and tradition. What’s lacking in this conversation is true team-based care. Imagine a clinic where physicians see undifferentiated and complex patients while nurse practitioners maintain patients with stable chronic conditions, all within the same panel. Patients move between them as their needs change, with a constant, open line of communication between the entire care team.  The DPC model makes this possible. Whoever figures out how to do this well can increase their clinic panel size without compromising care quality or patient experience. Another under-appreciated and underutilized profession in healthcare are our pharmacists. These folks go through four years of school and earn a doctorate in understanding deeply the meds we prescribe. We trust them in the hospital to catch our mistakes and consult them to ask about drug interactions. Why aren’t they more involved in bedside care for our polypharmacy patients? These aren’t just ideas I came up with last week. People are already doing it. Vertically integrated systems like Kaiser use clinical pharmacists and Oak Street, a medicare advantage company, even has its own nurse practitioner fellowship to better teach team based care. DPC practices have the freedom to advance how medical care is delivered and who delivers it. With innovative financing, there needs to be more innovative care delivery. 

Tech

Every area I just discussed- quality metrics, education, clinical practice- can all innovate faster with the right tech. But here’s the catch: tech doesn’t innovate by itself; it only accelerates what’s already happening. Just look at the hot AI tools right now- AI for speeding up prior auths, recognizing CPT codes in notes, and ambient scribing. As the DPC community innovates, tech will naturally partner to supercharge these changes. The key to tech innovation in DPC is a clear understanding of the model’s unique needs. 

Collaboration

A rock only becomes a foundation when you build something on it. DPC is reshaping healthcare by making primary care the foundation, not health insurance. But if we don’t collaborate and create our shining city on a hill, we’ll just remain scattered rocks in the desert.

Tech: In the early days of DPC, most clinics used gym membership software for its monthly billing capabilities. A young tech entrepreneur attended some of the first DPC summits and was drawn to the mission and spirit of DPC. After getting to know the community, he built a platform specific for DPCs, rapidly replacing the old gym software. That young entrepreneur was no other than Zak Holdsworth. Hint has contributed to and grown alongside the DPC movement. The success of the original product and newer products like All in One and Hint Connect is a result of Zak’s close relationship with the DPC community and continued support through various channels, including this Summit. I’ve met plenty of people who want to build for DPC, but have no idea how we work or what we’re about. There are some who scrape email lists of DPC practices and cold email everyone. Which is actually very effective. That is effective in getting blacklisted by all the DPC practices. On the flip side, DPC clinicians need to engage more with the health tech world. There are places where health tech congregates: online communities like the health tech nerds and out of pocket, as well conferences like HLTH and Vive. People in those circles talk about DPC and are often wrong about what we are and what our tech needs are. By engaging with them, clinicians can introduce them to our model while also  expanding their own understanding of what’s possible with tech. 

Finance: Time to turn up the heat again. If there’s a boogey man in DPC, actually all of medicine right now, it’s the money people, that is, private equity and venture capital. You can understand why a community that values long-term relationships with local communities would naturally distrust people whose vocabulary frequently includes the words “exits” and “scaling”. Most in the DPC community believe DPC will always be a grassroots movement, driven by individual docs opening local clinics, with no need for outside money. Some, however, want DPC to grow rapidly and eclipse all the traditional models of primary care, in which case PE or VC rocket fuel may help. Just like quality metrics, capital isn’t inherently good nor evil. With the right partners, we can determine how it’s used properly. Perhaps I am young and naive, but I am open to the possibility that with the right conversations, we can figure out how to utilize capital to effectively grow the DPC movement without compromising its core values,and I am watching recent developments with interest. 

Policy- While dressing up and reading prepared one pagers at legislators has its value, I often feel like a door to door salesman doing it and prefer to get to know legislators and regulators personally. We certainly have our share of DPC specific issues like having to opt out of Medicare and the HSA designation, but we can contribute to solve issues at all levels of government that benefit our model and our patients. For example, price transparency is a big part of the DPC model. In Texas, HB 2002 allows patients to apply cash pay pricing to their deductible if it’s cheaper than the average in network price. So, if you find a $90 xray at an independent imaging center, and the in-network rate is $150, the patient can apply the $90 cash rate to their deductible. That bill was introduced by those who also support DPC, and a new initiative aims to apply DPC memberships toward insurance deductibles as well. In Maine, DPC doctors got a bill passed so they can make referrals for their patients with HMOs as if they were in-network. Engaging with the legislative process not only helps solve problems facing our practices and patients but also opens the door to other efforts where we can contribute to fixing our broader healthcare system.

One of the best parts of the Hint Summit is getting to see people from all the different silos come together in the interest of growing the DPC movement. I’d like to demonstrate that right now. I’m going to call out different groups of people and if that group describes you, stand up. If you’re already standing, raise your hand. Let’s start with clinicians, where are my clinicians at? DPC is the foundation of a new healthcare system and these individuals are the foundation of DPC. Where are my health tech people? How we talk to patients, how we measure quality, how we innovate relies on the widgets made by these individuals. Money people, I know you’re out there- PE, VC, and anyone with an MBA or MHA. Ok everyone grab your rotten tomatoes and go. Just kidding. Capital can supercharge our influence in the healthcare landscape. Let’s try to find how we can supercharge the right things. Any policy people in the crowd? These individuals can help define what reality looks like as DPC goes mainstream.

I challenge each of you to better define who we are, improve how we deliver care within the model, and collaborate with as many people as possible. Together, we can make direct primary care become simply primary care which will serve as the foundation for a truly functioning healthcare system.