I was just listening to Maryal Concepcion’s brilliant recent podcast with Clint Flanagan, MD about his journey via DPC to what is now a widely scaled DPC company that is anything but DINO.  I have known Clint since 2009 when he and I first had dinner in Denver after a day of listening to an AAFP DPC Summit, which he describes in detail during this interview.  He recalls a moment in which he asked himself “for whom was this health care system designed”?  I had the same moment of revelation sitting in my son’s hospital room at Children’s Hospital in Seattle in the early 1980s.  This question was and is highly relevant both to health policy wonks and to DPC docs.

To clarify what I am talking about, consider what would happen if you decided to build a football field and, because you made a living making swimming pools, you would invent a 100-yard-long swimming pool stadium.  You could do a lot of cool things on this playing field, but football is not one of them.

The best place to start designing playing fields is in tough questions:
Whom was our playing field designed to serve?  Why is the service so bad?  Why is the price so high?  Why is access nearly impossible for the poor and even inadequate for the fully insured?  As DPC docs, we already have a lot of answers to these questions, because we are actively engaged with the solution.  

Some of my answers to the above questions were:
The playing field was most obviously designed to make money for private bankers while taking a wild shot at a big problem in American healthcare delivery.  We call these companies insurers or payors, but they are really bankers since they pay for virtually everything in health care and get to keep 15% for their trouble.  They take little or no risk, by law. Federal programs like Medicare and Medicaid were designed to use taxpayer money to solve huge problems in the US for populations that could not afford existing care, particularly hospital, ER and specialty care.  It was hoped that the model would be so successful that it would someday morph into a national healthcare system.  At the time, both insurers and the AMA were opposed to a national healthcare system, so the idea was and still is dead in the water as far as I know.  Since all other industrial countries have national healthcare systems. and all are cheaper and provide better healthcare outcomes (like maternal and fetal mortality, accessibility, and most recently life expectancy), it still is bizarre that our politics prevent even discussion of the option in public.  The decision to permanently prioritize specialty care, invasive care, end of life ICU care, etc., over primary care, hearing and vision care, mental health care – that decision was made early in the Medicare world and was happily adopted in the private insurance world, which is why PCPs now call themselves DPC rebels rather than just doctors.  The other beneficiaries of the current playing field are attorneys, computer companies that design the FFS billing and payment systems, the AMA which makes enormous money overseeing the ridiculously detailed and pointless coding system, etc, etc.  Why is service not a priority?   Because there is no code and patients have no say.  Why is the price so high?  Because the bankers like that.  They get the 15% of a bigger number every year.  Who else likes that?  How about Pharma, Oncologists, Surgeons, Hospitals, Medical equipment and suppliers, etc.  Why is access impossible for the poor?  Because in America, we think that being poor is what generates the rare rags-to-riches success stories that we love to hear.  After all, patients need some skin in the game to control their apparent hunger for too much medical care if it’s cheap.  At this point, both the poor and the middle class can’t afford care, because they are shoveling so much money into their insurance and their copays and deductibles continue to rise.

How do you fix this mess?  How do you alter this skewed and bizarre playing field.  First you have to vacate the old field.  It sucks.  It may be a nice swimming pool but you aren’t a swimmer.  You are a Primary Care Doctor.

The basic elements I wanted to see in 1997 were – Create a playing field built by doctors and patients to optimize the care and service.  Make that care sustainable by limiting the panel sizes and providing a steady flow of income that would make great care possible.  No need to produce millionaires or billionaires – just healthier and happier people.  Make a version of Primary Care that will endure and flourish.  Create a kind of care that works for the wealthy and the poor and everyone in between.  Set an example for the rest of healthcare about how to get this done.

Rules of my DPC playing field:

1. The care is financed with a recurring fee (usually monthly) paid directly to the doctor or DPC clinic.  This should cover all work provided over that period.  The fee must be high enough to allow the care provider to pay for all business costs and expected profits.
2. If it doesn’t work for patients (service, price, access. Long term doctor-patient relationship), it doesn’t work.  Patients control the flow of money and can leave any time they wish, without penalty.  Please notice that I don’t say anything about patients having to pay the monthly fee themselves.  Third-party payer deals must be carefully designed so that the patient remains our sole concern.  This is tricky, but not impossible.  If you plan to do third-party deals, I strongly recommend that you chat with Clint Flanagan or someone who has experience with these deals before you jump in.
3. If it doesn’t work for Primary Care Docs (Long-term doctor-patient relationship, adequate salary, lots of time with patients, panel sizes that allow the right amount of time with patients, enough free time so that you can have an honest profession AND a life), it doesn’t work.  Make sure that you don’t take on too many patients to do the work you are promising.  Make sure that your price per patient is enough to satisfy your needs so that you can focus on the care, not on survival.
4. A contract with transparent pricing and guaranteed services.  Make bold promises and put them in writing.  Tell your staff that they are welcome to notify you if you are failing to deliver on the promises.  Let your patients know that you require that they inform you if your clinic is not delivering.  It is hard for doctors to face such complaints, but it is crucial to this movement that we keep our heads above the sand and deal with our mistakes quickly and openly.
5. Incentives must be designed intentionally to avoid rewards for too much or too little care.  No kickbacks, no side hustles and no gatekeeping.  We know that DPC done right provides dramatic savings without compromising care.  Don’t redesign your care to please employers.  They will get happier employees, lower overall cost and great care.  You should focus only on the question of what is the best care I can offer to this patient.  If you want to sell stuff to your patients, sell it at cost or with minimal profit.
6. Understand that you aren’t just offering your own services.  You are also offering to help your patients interface with the rest of the healthcare system, with a PCP at their side who can help find them the best specialist, the best services and the most reasonable pricing possible.  If you don’t know how to do this, talk with DPC docs (and their staffs) who do and start building your own list of best referrals and best deals.  Ask your patients to let you know if your referral hit the target or not.  Alter your list appropriately.
7. A rewarding life for doctor and patient.  This is a direct consequence of mastering the steps above.
8. If we prove that this approach to care checks all of the above boxes, then we will be able to attract lots of medical students and residents to this specialty area over the coming years.  The reputation of DPC, built on thousands of doctors and millions of patients will provide long-term stability to this movement.
9. A balanced American healthcare system – by which I mean roughly 50% Primary and 50% Specialty Care.  As Barbara Starfield MD showed many years ago In her research, this is the balance point at which costs are lowest and patient morbidity/mortality is also lowest.  DPC is the only road I can see to that goal.
10. It is my hope that by saving Primary Care, we will help realign the American healthcare system and eventually bring about a unified, high quality, high functioning healthcare system with common goals and a playing field that we all wish to play on.  No mud wrestling or swimming allowed.

How could this go wrong?  That is the question I am considering at the moment.  Perhaps I will have something to say at a later date.