Thoughts about the present and future of DPC

From About Garrison Bliss, MD:

In recent weeks, as I prepared for yet another trip to DC, for the DPCC Fly-in as well as giving a talk at RosettaFest,  I went through the process of rethinking the question of what DPC is and why it works so well in so many places without any constraints on medical decision making or process.  Here are some thoughts that I have been pondering and that I invite you to consider:

DPC is not a business model:  Defining DPC as primary care paid for by the month is like defining an automobile as a horse and buggy without the horse.  Both are true, but neither divulges the mechanism or the promise of the thing itself.  In the case of DPC, it also fails to explain why monthly fee primary care is different from capitation.  To think about DPC and present it effectively to others, I suggest that we will be more successful and accurate if we regard DPC as a culture, and more clearly, an intentional culture with rules, automatic reinforcement of those rules, and accountability for failure to follow those rules.  If you want to think of comparable cultures we see every day, think about Free Market Theory and Science itself as intentional cultures that have produced remarkable benefits while being self-modifying, innovative and flexible.

Specifically, DPC culture begins with a commitment that we work exclusively for our patients and that all other influences are ignored or avoided.  When this was first conceived, the ONLY business model that was simple, practical, profitable and stable was to have our patients pay us for that care with modest periodic payments that they could afford, and for us to promise them the services we would offer in writing.  No existing payors wanted anything to do with us, so we were forced to do the one thing that has brought us as far as we have now gone, a simple market solution.  

When I was designing DPC, I purposely built guardrails into it so as to prevent our natural human tendencies from undermining the purpose of the culture: better health and well-being for our patients:  

1)  Patient oversight: To make this service for patients, we allow them to decide whether or not we are doing good work and permit them to fire us at any moment if we are not serving them well.  Subsequently, we have demonstrated that self-insured employer contracting, if done right, can achieve the same goal if employees can fire us and redirect their care to another DPC doc at will.
2) Excess capacity: We build in excess capacity by installing open spots each day to allow same and next-day service
3) Panel size:  To adjust panel size for maximal patient access and enough time to optimize both outcomes and relationship.
3) Patient Contracting: Have a formal written contract disclosing a full list of services and a transparent annual cost that could not be altered if they became ill or needy, thus incentivizing doctors to get them well, and not to milk their illnesses for profit.
4)  Avoidance of greed:  This is a tough one, in part because in the US we value wealth, no matter how it is achieved, as desirable.  The term “at all costs” is a mantra for many, particularly large corporate entities with boardroom decisions designed solely to maximize profit margins rather than increasing value or quality.  In healthcare, the damage caused by greed is obvious and immense.  The description of DPC I presented at HealthFest included:  “make a living, not a killing”.  In our line of work, when we “make a killing”, the net result may in fact be a killing.  When the price of care is too high, people can’t afford or won’t engage with the care, and will get none of the benefits we can offer.   When parts of our healthcare system that do NOT have our culture “make a killing”, they add trillions of dollars of cost annually that impairs the ability of individuals and businesses, and even the US government, to afford the care while doing anything else.   It can easily be argued that our failure to manage medical costs has undermined the American dream itself.  In many otherwise successful businesses, all increases in profits are simply nullified or overwhelmed by medical inflation.  This endangers the financial wellbeing as well as the medical health of our citizens.
5) Avoidance of fee-for-service payment:  The current “reimbursement system” is a serious and deadly disease of healthcare.  It rewards expensive, complex, potentially toxic behaviors and eviscerates primary care.  Every policy person in the country understands this problem, but we are the first to actually walk away from it.

Dave Chase was the first non-physician in America to write enthusiastically about DPC in places like Forbes Magazine.  His visionary company Health Rosetta has been identifying and supporting cultures elsewhere in our medical system that are adopting approaches very similar to ours.  These Include:
1) PBMs that have transparent and modest markups which can drive down everyone’s cost of medications dramatically and crush existing PBMs in the process.
2) Medical Centers of Excellence, like the now famous Surgical Center of Oklahoma, with transparent “all in” pricing for their surgeries and post-surgical infection near zero.  Their presence in the medical marketplace forces their competitors to lower their prices and increase their quality in order to survive.  There are now curators of these services who allow DPC docs, and others, to send their patients to specialist whose cultures are compatible with ours. 
3) Medical analytics experts who are exposing the previously well hidden and illegal markups in the health insurance world that have been kept out of sight until now
4) Medical insurance brokers who have sworn to act for the benefit of employees and employers only, refusing kickbacks from anyone to whom they refer.   Self-insured employers now luxuriate in benefits packages that lower their costs by 20-50%, eliminate copays/deductibles and universally include DPC as the foundation on which all of the other services can be supported and managed. 
5) Medical Malpractice Insurers that are gearing up to significantly reduce the premiums for DPC enterprises, based upon data suggesting that DPC doctors are rarely if ever sued.  This compares with regular Primary Care that is affiliated with hospitals and large clinics, in which the malpractice at the top of their food chain invites law suites involving everyone in the chain who has seen the patient.  Roughly 17% of the victims of these increasingly large payout suites are Primary Care doctors.  Since DPC is almost entirely independent, we do not have that problem.
6) Etc., etc.…..

Outside of Health Rosetta, DPC has attracted a wide array of vendors who are drawn to serving our culture and advancing the growth of DPC both throughout the US and now spreading to healthcare in other countries.  These include EMR makers and billing systems, but also include services that match us up with employers or individuals seeking our services.  This arena is enlarging rapidly, in part because of DPC Conferences, Health Rosetta and companies like Hint Health which have created active pipelines of patients for DPC to care for, at pricing acceptable to us and in quantities that we can manage and care for effectively.  According to Dave Chase, fully 50% of all DPC patients today have come from employers, and these pipelines are growing geometrically.  This lowers the risk of starting a DPC practice and should finally allow medical residents to go directly out of training into a DPC with little risk and considerable support.