I read Dr. Bliss’ great article with enthusiasm and I am happy to see his thoughts becoming part of this blog.  Dr. GARRISON BLISS ARTICLE

I’m glad this discussion is happening. I have a few points and counterpoints to offer:1)  I don’t know that I can follow where this last sentence wants to go: “This may also be the year that the federal government removes some of our shackles…” My issue here is that the government has no shackle keys. When they receive the shackles from the shackle company, they trash the keys, they’ve never had a use for them. Bureaucracies can only grow, and inviting the government into any DPC conversation always feels to me like inviting the fox into the hen house. The government has proven over and over that they can’t properly, efficiently, or affordably administrate healthcare. Look at the abysmal service in our local Indian Health Service clinics, and at the VA where patients die on waiting lists. Nobody who’s being honest can objectively demonstrate highest quality, efficiency, or affordability (including to the taxpayer) in any governmental healthcare entity at any level (arguably outside of active military healthcare). These facts lead me to continue to seek direct, pure routes around any entity (government, insurer, employer group, etc) who would get in our way of serving our patients and make their care more expensive in the process. (Visually demonstrated in the animated GIF above.)

2) I agree with Dr. Bliss that DPC isn’t likely the only way to improve healthcare and save patients money.  And if corporate entities like One Medical or others figure out something that brings affordable high-quality care to patients, then I’m all for it. I am skeptical they could do it as well, as affordably, or as efficiently as independent DPC, because DPC doesn’t have to pay skyscrapers or corporate campuses full of people. Garrison said Tom Lee “never called his company DPC” and if that’s true–great, it shouldn’t be called something it isn’t. Proper nomenclature notwithstanding, I’d still prefer to see DPC save patients more money than a corporate entity probably ever could, but if it’s better than the status quo, I’d say let it happen if at least it’s a step in the right direction.

3) Lastly, I’d like to say something about the use of “jet fuel”.  I like Dr. Bliss’ analogy of  DPC entities using insurance money as jet fuel.  As readers of this blog know, I have a simple mind and I appreciate analogies, so let’s play with this one: In this analogy, healthcare is being compared with methods of transportation. We are looking to find a better, more efficient way to get people from point A to point B (point B being a better quality of life, in theory). This analogy assumes the way we are doing that is by reinventing the car, making it a jet or rocket.  DPC docs use Buckminster Fuller’s quote all the time: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”  We aren’t trying to re-invent the car in DPC. We are working on teleportation. I am of the opinion that One Medical and others can have all the jet fuel they want to produce their jets. We’ll keep perfecting our teleportation technology. Like many innovations, it’s inefficient at first, you can only move 1 person at a time per device – but with the energy and efficiency savings you are ultimately able to move more people farther and faster with 1 teleportation device than you are 1 jet or rocket. And you don’t need jet fuel.  As more and more teleportation devices are built, and people realize how safe, efficient, and effective it is, it quickly becomes mainstream while the others are sitting around with a bunch of unused jets.

For historical perspective…the Wright Brothers’ flyer had no wheels. When their prototypes failed…I doubt they ran out and put wheels on it because wheels work so well on cars. Because they knew they weren’t improving cars, they were inventing airplanes. (As Oren Harari famously said: “The electric light did not come from the continuous improvement of candles.”) Jet fuel or not–the middleman problems that accompany insurance money, I believe, would bog us down, like adding wheels on the first airplane. 

I think this is that frequently-alluded-to implication that “DPC needs to grow faster”.  (And the jet fuel assertion is that insurance money will help facilitate that.) But nobody has said why DPC should grow faster, only that it should.  I’m a born Gen X skeptic and I ask “Why?” to everything, and I refuse to accept the answer “because it’s always been done that way.” Indeed, that might be the single-worst reason to do anything. Insurance/government payers have not been shown to do what we endeavor to do: lower healthcare costs or improve quality (indeed the opposite). So “the way it’s always been done” (the jet fuel of insurance money) would seem like the wrong fuel for our movement.  I’m not saying it’s wrong.  I’m saying it seems wrong to go to the thing that has a proven track record of failure–but what do I know? That’s why I love having this conversation.

DPC is growing fast- I showed data at my recent talk in San Diego that 64% of DPC practices opened in the last 5 years with an exponential growth curve. Even so, to me, the goal of DPC isn’t rapid growth, it is taking care of patients and eliminating financial harm. With insurance money comes an army of middlemen who demand ever-increasing paydays. That money comes from patients, and that harms them.

I guess if we’re talking speed analogies, we should discuss the “Tortoise and the Hare.” In that fable, (and the fantastic Bugs Bunny versions of it), the tortoise always wins. Sign me up for continued ORGANIC growth of DPC, whatever that looks like and however slow (or fast!) it naturally grows.  One primary care physician at a time, desiring to get back to the roots of the calling- docs who just want to develop mutually advantageous and trusting relationships where they can take care of people. These docs can exchange money for goods and services and affordably make themselves available to everybody of all socioeconomic statuses (as many of us prove day in and day out), not just rich patients, insured patients, or patients whose employer made a deal with some broker who in-turn made some shady backroom insurance deal, etc.  And without the government mandating or screwing it up.  As more docs learn about what we do, our acceleration should continue, and do so safely, sustainably, and without complicated middlemen taking money from our patients.