Is There Such Thing as Good Data?
It seems like half the time I write here, it’s some kind of rebuttal to a previous blog post by another DPC News contributor. I promise I’m not just a perpetual contrarian. We balance each other pretty well around here. I hope this post is just a clarification, not a contradiction.
While most of the writers here are physicians, Cristy Gupton is a benefits advisor–one of the good ones. She understands that DPC docs are deathly allergic to the word “data,” and she’s right. At least when it’s used the way insurance companies have traditionally used it. She argues for the value of data in her recent post: Did The North Carolina State Health Plan get it right? Not yet, but they still have time. She even alludes to the fact that her discussion of “data” will probably trigger most of our readers.
When DPC docs say they hate “data” with every fiber of their previously-morally-injured souls, the data they hate is the garbage-in-garbage-out medical data and “quality metrics” that EMRs inside the system collect and report to insurers. It is always a time-consuming hassle, and once doctors submit it, insurance companies manipulate the data into excuses for not paying them. This is akin to the insurance company forcing a doctor to forge a knife the company then uses to stab them in the back. Of course we hate it!
Although it’s true that “you cannot improve on that which you cannot measure,” the data-driven “quality measures” that such systems studied were perpetually inaccurate–thus a worthless waste of time. Inside the system, if a doc wanted to get paid and had patients who’s data (vital signs, A1C levels, etc.) would make them look bad, the docs or the people they worked for would simply change, massage, or delete the data. Or they’d fire non-compliant patients or not record the data likely to be bad, and like magic the “quality was great” and the money flowed. It was/is all garbage. Nobody was rewarded for anything but being unethical.
And even if it was good data, the idea that these numbers reflected a doctor’s quality level was utterly ridiculous. A doctor can give her diabetic patient Ralph all the good advice in the world, the best meds, prescribe exercise, whatever–but if Ralph just goes home, crashes on the couch and washes a box of donuts down with a 2 Liter of Pepsi, the doctor’s standard of care treatment will look pretty bad when that next A1C comes out. And then she’s penalized for his behavior, which she can’t control. That’s why we hate “data” that insurance contracts forced (to say nothing of our patient’s confidentiality).
So, when Cristy writes “When the health plan in question is structured properly, data helps everyone at the table,” People like me instinctively bristle. Our sympathetic nervous system fires up (for you non-docs, that is the “fight or flight system”. For DPC docs, however the sympathetic nervous system is called the “Fight or FIGHT System”.) The hair on our back stands on end and we are ready to defend ourselves.
But Cristy continues, referencing an excellent talk by Dr. Gross, and it quickly becomes clear she’s not talking about the kind of data that puckers our o-ring–she’s talking about the emerging data that shows the success of DPC in saving everybody involved money. This is data that insurers, employers, etc., can collect. Examples include decreases in healthcare spending for DPC patients, lower ER usage, and even decreases (if you can believe it) in insurance premiums for companies that purchase DPC for their insured employees. This is not BS quality metrics, it’s objective measurement of what DPC docs have been saying since the beginning: “we cut healthcare costs–dramatically.” (The only difference is now we see emerging objective proof, rather than people like me always just quoting the “T-bone” scene from Tommy Boy and urging my audience to “take my word for it.”)
So never fear, DPC docs–at least in this post, nobody is urging you to give anybody (insurance plan or otherwise) access to your EMR to mine data from it. Nobody is planning to make you dig your own grave. As long as this is the kind of data she and other benefits advisors are talking about, Cristy is right when she says “It’s time for a more mutually agreeable definition of “data”.
The only other thing I have to say is to repeat my oft-cited opinion of the “seat at the table analogy”. Cristy says “…the plan spends much less on many other things simply because [DPC] has the right seat at the table.” She’s right that inside the system, primary care docs don’t even have a seat at the table. They are the dogs begging at the ankles of those seated (insurance companies, PBMs, AMA, specialists, etc.), hoping for a scrap now and then.
In my view, here in DPC, the table belongs to the docs and our patients. The seats are for those we choose to invite. Invited parties must focus exclusively on our patients’ best outcomes, and the invitations are exclusive, rare, and very easily revoked.
Dr. Lassey, thank you for the acknowledgement. I do truly appreciate being heard and understood. I feel like if we sat down and engaged in a real discussion, we’d shake hands and realize that we’re both trying to solve the same problem, even if we have differing opinions on how to solve it. I want to dive a little deeper on my “seat at the table” analogy. First, it refers to a real, physical seat at a real table. In the early stages of consulting with a prospect where I’m attempting to teach them about how DPC is a game changer, there’s nothing better than having that DPC doctor right there beside me. After all, it’s the DPC perspective I’m trying to sell. So, they should be there, shoulder to shoulder with me. And moving forward after the sale is made, the DPC doctor should not be left out of the remaining planning meetings, enrollment meetings, implementation meetings, monthly performance calls, quarterly performance calls, annual renewals, etc. At least to the extent that any doctor even wants to be part of that. The point is that I welcome them to the table and desire their input at all levels. Secondly, I’m also talking about a digital seat at the table. In the plans I design as well as the highlighted FairCost Health Plan I used as an example in the article, there’s what we call the “integrated, coordinated care board”. Literally NO other health plans have this. It is proprietary technology that we knew would be needed for plans that are actively managed. On this digital communication board, all members of the health plan have a digital seat at the table and can begin care coordination in real time. Care advocacy is pushed forward in minutes (sometimes seconds) rather than days or weeks. Here’s an example — an employee (patient of the DPC doc) receives a cancer diagnosis. Dr. Gross logs onto the integrated, coordinated care board and alerts the other members of the board that we need all hands on deck to support this patient. The TPA, the nurse navigator, the PBM, the cancer management solution we vetted and chose for exactly these advanced needs, etc. are all on the board. Within minutes, the high-cost drug that was needed ($20K per month drug) was mentioned, and the wheels of care started moving. Within 3 days, the prescription assistance program for the drug was approved, and not only the patient but the health plan didn’t have to pay a dime for it. The patient was able to start their first dose that same week. Saving the employer-sponsored health plan $240K in costs for that year is no small feat. People, THIS is what I mean when I say DPC needs the right seat at the table. If the table only sat the doctor and patient at it, this result would NOT have been possible. Yes, maybe you could have advocated for your patient and stepped through the long and cumbersome process of getting your patient approved for a PAP for a $20K-per-month drug, but there’s no way you get that done in 3 days. I’m sorry, but I’m standing my ground here. It takes all of us, and in the properly designed health plans that I’m proud to work on, we value the local care team…the entire local care team. I’m smart enough to have sold the employer on the idea that the DPC doctor is the foundational role leading the local care team for a health plan that is actively managed even down to the minute. This is one example. I could tell you hundreds of stories like this. None of those stories would be possible if we didn’t work together as a team.
I’m good with this digital table, if it’s in-general, good for my patient, but it invites in opportunities for abuse and fraud. Examples:
1) The people at the table (The TPA, the nurse navigator, the PBM [gross-most should be jailed], broker, whomever) want to be paid too much to be there–that $ ultimately comes from the patient one way or another. It could be financially harmful.
2) Because they might not be needed, they’ll figure out a way to *make* themselves needed (back to the whole getting paid to be there thing.) Example: The patient might need a cheap drug that the DPC can get at their clinic for pennies, but the “table people” suddenly push for some brand-name alternative that generates income for them to “Get free/cheap”. You can see the PBM’s loving that kind of thing. (Can you tell I’m jaded by years of insurance companies and PBM’s screwing over my patients before DPC?) The “table people” begin communicating with the patient, going around the doctor selling the patient something they don’t need since they get a cut (everybody but the doctor is getting paid to be at that table, so the doctor is the only one above reproach for decisions made). Middlemen who somehow profit from the sale of an unnecessary thing will find a way to increase the demand/coverage for the thing, even if it’s not needed–this has always been the case.
I think about a patient I had years ago, who had raging metastatic liver cancer and was very terminally ill. A good insurance guy would have used his sources to help secure the patient excellent hospice services as I had recommended. Instead, his insurance guy convinced him to push for some kind of chemo, that oncology said “might work–one in 10,000 chance.” Benefits advisor or PBM or whoever it was, talked him into pushing hard for it. They got it covered. It was nearly a half million dollars. It made him sick as hell, and he soon died anyway of course. It bought him no time, only made the time he had left worse. But now somebody is paying hundreds of thousands for that useless med the middleman talked him into insisting he get, and I feel quite sure that at least one middleman got a handsome cut.
3) Often the physician with time (i.e. the DPC doc) IS all that’s needed. Perhaps what a digital table can do in one day might take the DPC doc 2-3 days. BUT…what is the difference between the cost of the DPC doc only, and all the people at your “Digital table?” They certainly don’t work for free. It might not be worth it. Maybe it is. I’m still not convinced. For the record, I’m not saying that this is exactly the situation here, but I have found it to be a perpetual truth that middlemen never grow tired of telling people why they are needed a la Tom Smykowski in Office Space: https://www.youtube.com/watch?v=m4OvQIGDg4I
Some of the DPC-included health plans I’ve seen charge the patient (via pay cuts from her employer) $90 per month. Yet my average PMPM is $52, a difference of $38. So, are the benefits of the plan like your digital table (separate from the insurance product itself, separately billed to the patient via pay cuts from the employer) worth $38/month ($456 per year?) How often is the digital table needed? Is having it worth $456 per year to every single employee? IDK if these numbers are standard, but it would certainly seem to me that a patient paying his physician directly will significantly cut the cost of her care vs. a plan from an employer. Perhaps the “extra” benefits (i.e. the digital table, TPA’s sourcing affordable cash surgeries, finding discounted name brand drugs etc) can be done for, say $5 per month from the patient via their employer, and if so, I could very much get on this bandwagon. But something tells me the administrative burden will just grow and continue to financially harm my patient and demand more paperwork, data, and so on from me, right up until our “new DPC system” is indistinguishable from the hellscape that we escaped.
One more example to compare to the “This result would not have been possible without [insert middleman/middlemen here].” narrative:
I have a patient who needed a life-saving $90,000 drug a few years ago, a drug with no generic alternative. He was crazy sick. He had insurance which resisted. I sat at my desk and made a bunch of calls. It did take a couple hours, but I had it covered and was home before dinner. Just me. No PBM, no Nurse Manager. No benefits advisor. No digital table. No additional deduction from his paycheck beyond normal DPC fee. Just his regular DPC membership which he paid me himself (i.e. no employer health plan markup). He started the treatment that very night.
Like me, most DPC docs don’t like to be told they can’t do something, or can’t do it alone. I wrote about this here on the blog nearly a year ago (https://dpcnews.com/opinion/tell-me-i-cant/).
So does a “Digital Table” and whomever sets at it make this kind of work easier? Sure. But does it make it necessary? I’m not sure. I’d love to hear more. Instead of “Tell me I can’t” (where I can prove you wrong), go for “PROVE I can’t”. Once you can prove it, you’ve got me!