Fork in the DPC Road

More than twenty years ago, we proclaimed our “Declaration of Independence” for Direct Primary Care, rebuffing the long-held power of the government and insurance-based system over physicians. Dr. Garrison Bliss wrote about this in the DPC News, stating that DPC is “not a business model but a culture,” or, as I like to say, a mindset. This culture of autonomy, purpose, and passion for providing transparent patient-centered care was the proverbial “life, liberty, and pursuit of happiness” of our DPC independence. 

Now, twenty years later, I asked hundreds of DPC physicians what principles and values created the foundation of DPC. What principles did they use to begin their own DPC? In a sense, what was their “why”? As you can imagine, I got a bevy of answers, many of them similar: do-no-harm, respect, loving, dignity, accessibility, transparency, individuality, relationship, independence, patient-centered, and hope. These are all summed up by autonomy, purpose, and passion.   Autonomy for physicians (and patients, too) to do what is best and right for each patient. The purpose to provide high access, transparent pricing, and build long-term relationships. The passion for hope, respect, and dignity. That is our foundation in direct primary care, our “why.” 

How did we achieve that “why”? Simple. We cut out the “middlemen”. We dumped all the insurance and government contracts that separated us from our patients and created “direct” payments. We contracted directly with patients or their employers without the interference of any third parties to hamper care or increase fees. What a genius idea! Routine primary care does not require insurance but can be done with one low monthly fee. DPC in its “pure” form took flight. 

As DPC has grown slowly but steadily over the last two decades, others on the outside began to take notice: benefits advisors, business owners, CEOs, and third-party organizations. As larger employers began to tap into DPC and its benefits, the financial potential connected to DPC started to increase, leading to new organizations that sought to connect employers with DPC clinics across the country, i.e., the good old-fashioned “network.” I call these Patient Care Management Organizations (PCMOs) thanks to Dr. Ryan Neuhofel, MD, who coined the term. These PCMOs create networks and systems to link DPCs and employers for a fee, of course.  There are many of them out there now, and they seek to contract with every DPC physician possible in hopes of creating a massive network yielding monthly fees in their pockets. Is it any wonder many of these organizations have been funded and backed by big-money venture capital? And why would venture capitalists take those bets on DPC? One need only look at the contracts these companies ask physicians to sign to gain access to their employer “network.” They are unfavorable to physicians and read more like the insurance contracts we all canceled to pursue DPC. Have you seen a physician’s insurance contract with one of the big insurance plans? Horrible. Unfortunately, I frequently see questions and discussions on social media pages about these third-party PCMO contracts. Many new DPC docs are confused by them and yet seem eager to sign right up. (Maybe one reason system-based physicians are oblivious to these PCMO contracts is that they have never seen an insurance contract that physicians must sign to accept insurance payments.) So, why would a DPC physician sign a PCMO contract that reeks like an insurance-based contract? What values and principles are they willing to give up when signing these agreements with a new third-party group like a PCMO? Reread those questions and let them sink in deep. 

So, DPC physicians stand at a massive fork in the road to our future. Down one road lies these new contracts, PCMOs, and relinquishing some of your principles in the name of “scaling” and money. The “purity” of DPC, its culture, and its mindset will have to change to travel this road. This year, I heard a prominent DPC leader speaking to a massive audience say, “I was pure DPC,” but not now. This same person in another forum said we must move away from “pure” DPC back towards the middle and give ground if we want to work with large employers. These comments were made while speaking alongside some of the giants of the DPC movement. So, you can see why I fear this path will lead to a watered-down illusion of the original dream of DPC. Ten years from now, if we go down this path, will direct primary care still mean the same thing? Will physicians be in charge at the end of that road? Will patients have any say on this path?  I don’t believe so. 

The other path of “pure” DPC will continue to be led by physicians, with patients as the focus and our principles as the foundation. DPC physicians can work with benefits advisors and employers if we desire to create our unique systems to connect without increasing costs or paying third parties. We don’t have to “give ground” or go back on our foundational principles to work with employers or grow DPC. “Direct” in direct primary care has to mean something. Don’t fall back into the trap of third-party networks and contracts. Don’t go back on your principles. Unfortunately, over time, I fear this “pure” DPC path will be the one less traveled. 

 Two roads diverged in a wood, and I—

                                          I took the one less traveled by,

                                         And that has made all the difference.

                                                                                    Robert Frost