As I am wont to do, I have been making lots of analogies, following the wonderful articles published in DPC News in the last few weeks by Dr.s Qiu and White. In today’s 3rd and final installment, while the analogies are running amok, let me propose a new one. When I conceptualize the future of DPC in conversations with leading DPC docs, we have vastly different visions, and this is a good thing. We need to be planning this city; we can’t just throw it up real fast and hope it all works. One of my favorite patients, a retired Marine Corps Officer, often says “Hope is not a plan.” I love that quote. So let’s plan.

So many people I talk to often say something like “If we can’t forcibly scale up DPC, it will never get big enough to be anything but a niche market”. The implication, here, is always that we need to work with middlemen to force large-scale growth. Whether that means working with Medicare, Medicare Advantage, or massive employer groups, in all scenarios, with the stroke of a pen, there are millions of dollars ready to be grabbed to funnel taxpayers or employers into DPC clinics. (And you can bet the middlemen will want to grab every penny.) I’ve heard doctors and DPC-adjacent middlemen say that there’s no other way to grow DPC. Wrong. DPC has been growing from day 1, sans middlemen. The obvious fallacy/assumption here is that there’s some hurry to see DPC become the chief payment system in primary care. Why the hurry? Let’s plan the city, and build it as it grows organically! It doesn’t need to become some massive Primary Care Costco like the one where Frito got his law degree in Idiocracy.

With a new analogy, I can respectfully demonstrate my disagreement, thanks to my wife’s beautiful hair. Thanks to her hair, I realized that we are not the only large-scale industry built on personal relationships, that can exist as an accumulation of small businesses.

Of course, I’m referring to your local Beauty Shop. Most folks I know have a salon or barber shop that they visit regularly. Around here, the ladies frequently refer to their “beauty operator”, and men their “barber”. I don’t know of any salon/barber shop around here that has more than 3 chairs and full-time cosmetologists. Small businesses, every single one of them. And just in my town, those small businesses fix the hair of thousands of people. Sure, there are probably salons/barber shops here and there that are larger, or to some degree franchised. But there is no Costco for hair. No corporate behemoth exists that comes close to dominating the cumulative small business empire of the cosmetology industry. 

Could the salon industry be forced to scale? Ask my wife. Her stylist is Mikayla, and just like our patients’ relationships with their DPC doc, her relationship goes way beyond fixing hair. At least in Holton Kansas, her beauty operator is so much more than the lady who does her hair. She’s her source for local news, her confidant, her friend, her therapist, a fellow small-business owner…and NOBODY but Mikayla touches her hair, this is way too important to be left to some stranger! Much like a patient’s relationship with a primary care physician, people develop trusting long-term relationships with their hair stylist, beauty operator, or barber. And all are small businesses whose customers pay affordable cash rates; no middlemen required.

A beach isn’t a massive boulder, it’s billions of tiny rocks. An avalanche isn’t a mountain-sized ice cube, it’s billions of tiny snowflakes. And DPC doesn’t have to become a gigantic table around which we and our patients sit on the floor, while corporate/government middlemen dine in style, while we hope a scrap or two falls off if we click the right boxes. THAT is the system we left behind, and I for one WILL NEVER GO BACK.

And besides, let’s be honest, here. When words like “Medicare” are used in a sentence by a DPC doctor, they should only be used as a highly-offensive cuss word or insult. In fact, let me be the first (pardon all the profanity):

Vance: Dude, Doug, when’s the last time you showered? You smell like Medicare.

Doug: Go Aetna yourself! It’s you who reeks of a Prior Auth, you CMN-loving middleman!

Vance: Them’s fightin’ words! You wanna piece of me, you Big-Pharma data-manipulator?

Doug: That’s it big boy, I’m gonna tear you a new PBM!

[Fight ensues, Doug, a former boxer, wins.]

Doug: You know I’m way older than you, a foot shorter and just had my hip replaced, right?

Vance: Shut up. You’re buying lunch.