Leverage in the Free Market Belongs to the Consumer (or: The Bobs Enter the Debate)

I read Dr. Qiu’s recent piece on DPC leverage with genuine appreciation. He gets a very important thing exactly right: physicians built DPC from the ground up, clinic by clinic, without VC backing or institutional cover. That is real. And because of it, “authentic” physician-owned DPC clinics absolutely should not be intimidated by “aggregators” when negotiating terms. If a contract is bad, walk away. That leverage exists. Full agreement.

(Brief aside: in the referenced article, “aggregators” appears to be the newest term for a DPC Management organization, PCMO, DINO, etc., and refers to companies that connect employers/employer groups to DPC practices.)

Yes- DPC doctors have leverage in spades. But there is a deeper question that never gets asked in his article. And I think that before we discuss how to wield leverage, we need to ask whether we need to wield it at all — and more fundamentally, who the leverage actually belongs to.

After finishing this article and taking a moment to review it, I noticed something striking: at no point in the discussion of leverage is the patient mentioned. Not once. For a DPC-centric (i.e. free-market) article about DPC leverage in healthcare, that is a conspicuous absence. And it turns out to be more than an oversight. It is the highly visible and unstable crack in the foundation the entire argument is built on.

The patient is conspicuously absent
Let’s be clear about what leverage actually is in a free market. It is not the negotiating position of one business relative to another. It is the power of the consumer — the billions of individual decisions made by consumers every single day about where to spend their money.

DPC did not succeed because physicians negotiated clever contracts or found better aggregators. It succeeded because a growing number of patients decided, on their own, that they would rather pay their physician directly than route dollars through a broken insurance system. Every subscription paid, every cash transaction at the front desk, was a vote. That is the free-market-powered leverage that built DPC, and that remains the force that pulls the lever today. Not aggregator deals. Not employer contracts. Patients.

When we begin talking about physician leverage over middlemen without ever mentioning the patient’s leverage, we have already gone wrong. And worse — we start treating the patient as a passenger in a negotiation they should be driving.

The foundation: “Because that’s just the way it is.”
I won’t camp here long because I’ve tackled this argument in DPCNews more than once.  Dr. Qiu’s entire argument rests on a premise that sounds reasonable until it’s tested: large employers and governments require standardized contracts, predictable performance, and a single point of contact. They “cannot easily strike one-off arrangements with one clinic on one block.”

But “cannot easily” is not the same as “cannot.” Today’s analogy for this is lawn care. A national company with offices in fifty cities does not hire a national lawn-care conglomerate to mow every patch of grass. Each regional office makes an arrangement with a local provider. Sometimes it’s a kid with a mower, sometimes it’s a local landscaping company. The national employer doesn’t have a single contract with an expensive middleman — it has fifty direct ones. The grass gets cut either way.

I see no reason DPC can’t work exactly the same way. Every regional office, school district, county employer, and community health department is capable of making a direct arrangement with local DPC clinics. No national aggregator required. No middleman needed. The work is harder, yes. But harder is not the same as impossible — and convenience has never been a valid reason to surrender autonomy.

I’ll hold up just short of calling the aggregators “parasites” but I will say that they are not a bridge the system needs. They are a bridge they chose to build because it serves their business model, rarely the physician’s interests and virtually never the patient’s.

When thinking about this idea of using the aggregators to connect employers with DPC’s, I simply cannot help but clearly see and hear the scene in the timeless genius that is the film Office Space, where “The Bobs” (corporate consultants charged with helping a company decide which employees are expendable) meet with Tom Smykowski. Dear reader, I was about to describe Tom’s defense of his (obviously superfluous job) for you, but you know what?  This is already going to be a long post, let’s just take a break and enjoy Mike Judge’s brilliant script writing for a second, copied here from IMDB:

• Bob Slydell: What you do at Initech is you take the specifications from the customer and bring them down to the software engineers?
• Tom Smykowski: Yes, yes that’s right.
• Bob Porter: Well then I just have to ask why can’t the customers take them directly to the software people?
• Tom Smykowski: Well, I’ll tell you why, because, engineers are not good at dealing with customers.
• Bob Slydell: So you physically take the specs from the customer?
• Tom Smykowski: Well… No. My secretary does that, or they’re faxed.
• Bob Porter: So then you must physically bring them to the software people?
• Tom Smykowski: Well. No. Ah sometimes.
• Bob Slydell: What would you say…you do here?

The scene gets funnier from there.  Go watch it. I laugh so hard every time. Easily in my top 5 films of all time.  

False leverage is the fastest way to lose leverage
Believing you have negotiating power when you don’t is the quickest way to sign a deal you will regret. The leverage that Dr. Qiu describes — the ability to walk away from a bad contract — exists clearly before the DPC doctor enters the relationship. The moment her payroll, loans, growth projections, or her panel size depend on that aggregator, the walk-away option moves from easy to at best painful, and at worst, theoretical.

You can always decline a deal on paper. You cannot always walk away in practice when that deal now represents the majority of your revenue.

This is why the very fact that physicians can walk away is the strongest argument against getting into these relationships in the first place. If you don’t need them, why invite them in? And let’s be honest about the motivation: much of the push toward aggregators is not strategic — it’s laziness.  Because building direct employer relationships one at a time is hard work. Avoiding that work isn’t smart business. It’s convenience in a suit.

The only leverage that persists is that which cannot be taken away by a contract renegotiation: the patient who pays you directly and decides every month whether to keep paying.

The frog and the scorpion
In the comments to Dr. Qiu’s article, Dr. Purcell, America’s DPC-Employer-Relationship guru, uses this excellent analogy.  The idea here is that it does not matter how well-meaning the aggregator’s initial terms are. The business model controls the behavior, not the good intentions. Control data, promised savings, and aggregate lives are not neutral goals — they naturally drift toward “utilization management” and ever-harder forms of prior authorization over time.
That is not malice. It’s just structure. You cannot train a scorpion out of stinging. You can only choose not to pick it up.

The longer the dollars flow through the middleman instead of from patient to physician, the more the scorpion behaves like a scorpion. That is simply the nature of the structure.

Optional in theory, coercive in practice
For established DPC practices with full panels (with or without directly-contracted employer relationships) and strong cash flow, avoiding aggregators is genuinely optional. For new DPC docs with loans and thin margins, the pressure is very real — especially as the cultural narrative increasingly normalizes aggregator deals as the “grown-up” way to scale a practice, and condescends and gaslights the rest of us as “mom and pop” outfits. As bad deals become the norm, the pressure on the next wave of physicians intensifies. Individual choice gets harder when the entire ecosystem assumes you need a middleman to survive. What starts as optional becomes quietly and culturally coercive.

Mission drift is inevitable when the patient isn’t paying you
When your revenue comes from a middleman, your accountability shifts. The incentives move in ways that are easy to miss in the short term but hard to reverse later: panels swelled, slower access for legacy patients who built your practice, and metrics defined by suit-wearers who have never seen a patient. The clinic slowly starts optimizing for the payer and not the person.

DPC’s entire purpose was to make the patient the boss. Employer-aggregator arrangements make the middleman the boss. 

The real path forward: rebuild on the patient
I share Dr. Qiu’s goal. DPC physicians, via physician-owned private clinics, should shape the broader system. Building that bridge does not require inviting foxes into the henhouse and hoping they have changed.

The path forward is straightforward but difficult: return to first principles. Patients directly fund their primary care. Physicians respond to patients. If employers want to participate — and many should — they do it through models that preserve that direct financial relationship, with patients in the driver’s seat. Direct reimbursement structures. Cost-sharing frameworks where the patient’s dollar still drives the decision, even when an employer is contributing.

Physicians write the standard contracts. No utilization management, no data resale, no retroactive clawbacks, transparent payment terms. Shared model agreements so new docs know what healthy looks like before they are desperate enough to sign something bad.

All of this is good work; productive discussion/debate. But none of it matters if the patient’s dollar no longer drives the decision. Because the lever that is the patient’s autonomy and what happens with their own money is the one lever that actually matters, it follows that its leverage was never ours to negotiate.

Dr. Qiu and I agree on the destination: DPC should shape the system, not the other way around. We just disagree on where the leverage actually lies. I believe it belongs to the patient. The more DPC keeps that leverage exactly where it is — in the free market, in the hands of the person walking into the exam room — the person actually able to objectively and subjectively discern the quality of the care provided, and who can vote with their wallet   —  the less any middleman, well-meaning or otherwise, will ever need to exist.

If we can endeavor to preserve patients’ control of financial leverage, we can avoid distracting debates about foxes and henhouses, instead devoting ourselves to the perpetual pursuit of excellence in the practice of medicine, and serving our patients above all.