In 2020, the world was challenged by a daunting viral stress that unveiled the strengths and weaknesses of every health care system. Since a pandemic is an unpredictable, medically intensive stress on our country, this was an extraordinary opportunity for health care, public health, and political systems to show their preparedness, flexibility and creativity. In the US, little of this went well, due primarily to failures of governance, but also to longstanding flaws of our insurance-based fee-for-service health care business model. The federal government response from the executive branch was that it was a “hoax”, followed by varying shades of denial, claims of unproven “miracle cures” and then a last political stand on a quicksand theory that all we needed to do was to allow everyone but the old people to become infected and the problem would be over. Thus, in the US we lost our early opportunity to fully suppress the virus and later to protect susceptible populations: elderly, poor, chronically ill and minority populations. Businesses that could not operate without direct client engagement were put on ice. The chores of managing the epidemic were delegated to each individual state and the Federal government contribution to management was severely curtailed or counterproductive aside from Army Corps of Engineers assistance in the hardest hit cities to avoid overwhelming the ICU capacity. PPE shortages were never solved fully because of the lack of a strategy to do so and an avalanche of ICU level care that resulted from the initial failure to head off the pandemic. Every State had a different approach. Every political entity (city, county, and state) was locked into a financial race to obtain PPE, ventilators, nursing capacity, critical care supplies, etc. Toilet paper disappeared from our grocery shelves and PPE vanished from medical supply companies. If we had PPE, it was because we found our own or we worked in an ICU.
Primary care was also massively stressed. PCPs in small groups, large hospitals and multispecialty clinics found themselves between rocks and hard places. Much of the patient phone traffic, emails and texts came to us. Almost all the money went to hospitals and ICUs. There were many fewer office visits and most “routine” medicine was halted to protect patients and care providers from the ravages of Covid. For most PCPs, this meant a marked reduction in cash flow simultaneous with a very significant rise in phone, email, and text traffic (assuming that our patients could figure out how to reach us) – none of which provided much income. Primary care, which previously survived primarily by seeing north of 20 patients a day or from subsidies from hospitals and specialty clinics, found itself once again on the bottom of the financial priorities list.
My office was an exception to the experience of the PCP world in the US because I am a Direct Primary Care (DPC) doctor. I hear you saying: How were my patients and I protected from Covid? For those of you who do not know about DPC, it is a simple yet disruptive approach to primary care that involves trading in your dependency on fee-for-service income for a simple contract with your patients to provide consistent access to you and the services you provide based upon a monthly or annual fee paired with a contract stating the services you will provide for that money. Here are the basic rules of DPC:
- The PCP and the patient sign a contract clarifying the periodic fee and the services provided. This fee can be paid by the patient, the patient’s family, or employer. The PCP promises not to bill the patient or their insurance company on a FFS basis.
- Those services provide at a minimum: direct access to primary care services by telephone, email and text. Because DPC providers have much smaller patient panels than FFS providers, office visits are considerably longer and can address multiple medical problems in one sitting. Other services offered by some DPC providers include: Periodic newsletters, house calls, advice on ways to obtain better and less expensive medications and outside medical services, discounted or free generic meds (no markup, to avoid incenting the provider to make medications a profit center), free osteopathic treatment service if the provider has this training, free splinting, casting and minor in-office surgical procedures (such as draining skin abscesses, joint injections, skin biopsies).
- Same or next day service for urgent medical issues (and the patient has a vote on what is urgent).
- PCP agrees to help the patient navigate the rest of the health care system. This means that DPC docs generally can refer to the best and most appropriately priced specialists rather than the ones housed in their hospital or clinic since they are no longer indebted to those institutions for financial survival. It is also understood that the PCP will not accept kickbacks or subsidies for referrals.
- Patients can at any time cancel their contract and receive a full refund of any prepaid fees not yet earned by the PCP. This means that in DPC, we work for our patients and they decide if the service is worth the price. This forces DPC docs to offer pricing that is truly affordable to patients. It also means that DPC docs must keep up with improved services being developed by competing DPC docs.
Those of us trained in primary care know that we can provide roughly 80-90% of the services our patients require in their lifetimes. When spread over a normal population of patients, this works out to an average of 1-3 office visits per year per patient and some periodic preventive discussions or visits. It also means calls on nights and weekends to help our patients know when and how to use the rest of the health care system effectively and efficiently. In short, DPC doctors work for their patients exclusively and fee-for-service insurance-based doctors work for the insurer AND their patient (but the money comes from the insurer, which means that they set the rules). The power of primary care is our long relationships with patients and the trust and knowledge that these relationships generate. With DPC, this relationship is not ended when patients change insurance or employment. Thus in 2020 that our relationship, both medically and financially, was uninterrupted when Covid hit. Patients did not fire their PCP during a pandemic. In my office, we moved from a mostly office-based care system to a pandemic redesign in a matter of days. Most DPC patients already had our office and cell phone numbers, email addresses and permission to text us. Since I already was sending periodic email blasts to my patients, it was no problem to keep them informed about the practical aspects of avoiding infection and what to do if they developed respiratory symptoms. My income did not change except for discounts to patients who found themselves in financial distress. I helped debunk the claims of miracle cures and “hoaxes”. I encouraged my patients who were employers to retool so that their employees could work from home. My staff and I spent our days primarily on the phone and developed simple protocols to screen our patients calling with concerns or symptoms. Since there was no effective treatment for Covid at that time, we treated URIs at home via daily phone contact until they were out of the woods. We sent patients to the ER ONLY if they appeared to be on the threshold of admission. Since Covid was spreading at the same time as influenza, I treated patients with fever and cough (but no respiratory distress or symptoms to suggest bacterial pneumonia) with Tamiflu. With rare exceptions, all of this could be done without bringing patients to my office or to any ER.
My panel of roughly 400 patients, most over age 65, completed the year without a single hospital admission and only a handful of ER visits. My practice had no financial stress and I lost only a handful of patients due to financial stress (because we provided discounted or free care if patients were willing to accept our charity). Nobody died. I was able to scrounge masks (both surgical and N95 from China) and makeshift gowns (disposable raincoats from Amazon). As soon as testing became available, we did drive-by nasal swabs from our sidewalk to avoid unnecessary ER visits and testing delays for our patients and their families.
In September 2020, I retired from medicine at age 70 as I had planned years prior. I brought on a superb Family Medicine physician and merged my practice with another DPC group in Seattle so that my patients could have a seamless transition to a younger more energetic and remarkably empathetic physician picked by me and interviewed by a panel of my patients before I hired her.
While US medicine was struggling through Covid and trying to survive financially in a FFS environment that made this nearly impossible to do without burnout, DPC was alive and well. In April 2021, Rebecca Etz PhD, a cultural anthropologist, and Co-Director of the Larry Green Center for the Advancement of Primary Health Care who has been doing remarkable research on the experience of both PCPs and patients during the pandemic, sent me questionnaire data showing the contrast between DPC and FFS primary care in her national sample of 657 Primary Care Physicians. In the December time frame when Covid was going through an enormous spike, 15.1% of the PCPs in the national survey reported that the pandemic would cause the closure of their practice without federal or state assistance and only 44.2% reported that closure was not an issue, whereas DPC PCPs reported no indication of impending closure and 85% of them reported that closure was never an issue. On a detailed question regarding stressors, DPC providers consistently reported less stress on all items.
DPC doctors are not better trained, more mentally stable, or more motivated to care for patients in times of crisis than FFS DPCs. They simply are functioning in an ecosystem with far less unnecessary complexity and far more autonomy, patient focus and financial stability than PCPs tied to FFS care and insurance related documentation, incentives, and constraints. Working exclusively for patients is demanding, but these are the demands that doctors signed up for and expected when they applied to medical school. Having dual masters and inadequate financial support drives harried inefficient care, suppresses innovation, and generates burnout and despair. The Pandemic has exacerbated a process that has been worsening for decades. DPC, which is a value-based model of health care, appears to greatly enhance the stability and wellbeing of both patients and PCPs who care for them. It is time for this to become an accepted and encouraged version of Primary Care in the US. Adequately funded primary care without FFS incentives should become the dominant form of primary care in the US and could form a foundation for a more humane, less expensive, highly effective, and patient-centric care system nationally.
Dr. Bliss is widely credited with being the first in the country to adopt the DPC model. He was the founder of Qliance, the first large scale DPC practice in the country. Dr. Bliss graduated Harvard College with a Bachelor of Arts in Biology in 1972, University of Utah Doctor of Medicine 1977; Internship: University of Washington Internal Medicine 1977-1978 Residency: University of Washington Internal Medicine 1978-1980.