Featured

Why a policy wonk like Wyden might (and, perhaps, should) kill a DPC/HDHP fix for subscription medicine. Short version.

A 1.8 billion dollar subsidy to support subscription-model contraction of primary care patient panel sizes is a problematic policy in a country when there is a shortage of primary care physicians.

I came to this trying to figure something out. We hear that Ron Wyden kept the DPC/HDHP fix for subscription fees out of the CARES Act. DPC Coalition’ s Jay Keese flatly indicated that this was because Wyden was confused about the relationship between DPC and concierge. Because Wyden is a pretty wonky guy, and his wonkiness extends especially to health care policy, I just don’t believe that his concerns are so simple they can be addressed by explaining that “DPC is not concierge”; I’ll bet he understands the differences as well as anyone.

Differences do not always make the difference. Sometimes the similarities matter more.

It matters not how much DPC and concierge differ on some or even most possible variables, if DPC and concierge are, at the same time, similar on one or more of a set of decisive variables.

Most likely, Wyden’s biggest concern is to avoid using the tax code to support subscription fees that buy, in large part, exclusionary access to PCP services that are in short supply.

700 member patient panels at DPC clinics literally exclude the 701st and all additional patients. If there were plenty of PCPs to go around this fact would be less significant. DPC cannot be sufficiently scaled for everyone, or even most people, to have DPC in any near future. In fact, if every PCP goes to a 700 person panel today, tens of millions who had a PCP yesterday would not have a PCP tomorrow. This is precisely what subscription based small panel DPC shares with concierge practices: more attention for some comes at the price of less attention for others.

Why should taxpayers subsidize that?

One can image basing a possible answer to that question on real data to demonstrate that the cost-or-health effectiveness of DPC creates off-setting value. But, as far as I can tell, and this blog closely follows the barrage of brags by DPC advocates, there is as yet no independent, peer-reviewed study to support the proposition that DPC is cost-effective, not even for its own members. Not one.

Even if what is needed is a larger pool of PCPs, why not directly subsidize primary care practice. A tax fix for subscription fees is a roundabout way of getting that result, and compounds this issue of access inequality with issues of wealth inequality. See this in-progress, longer version of this post.


If one wishes to determine what the law should do about ________,he can approach the question in either of two ways: by definition or by analysis.

Dworkin, Roger B. (1973) “Death in Context,” Indiana Law Journal: Vol. 48 : Iss. 4 , Article 6.
Available at: https://www.repository.law.indiana.edu/ilj/vol48/iss4/6

The article by Roger Dworkin explains why it is problematic to try to solve real problems simply by invoking definitions. In this context, that means it is hard to resolve the issues by saying that “DPC is by definition not the same thing as concierge” Here, the reasons which apply to denying public financial support to concierge practices apply in the same general way, if to a lesser degree, to DPC subscription fees. To solve policy problems, decision makers to look at broad effects, not mere words.


Featured

The “DPC is uniquely able to telemed” train has left the station. Everyone is telemeding now.

October 20, 2019: 500+ word Open Letter to Members of Congress by DPC Coaltion President asking for support and co-sponsorship of the The Primary Care Enhancement Act. Missing words: telehealth, telemedicine, telephone, phone, text message, text, SMS.

March 26, 2020: DPC Coalition laments exclusion of the bill from CARES despite being sold as “means of expanding virtual care to 23 million more Americans with HDHP/HSA plans.”

Fortunately, all 23 million HDHP members dodged that bullet when a huge swatch of FFS primary care docs (along with DPC docs willing to code) stepped up to virtual care practically overnight.

It is likely that on a single day or two last week, (3/23 to 3/27) the number of FFS PCPs who learned to telemed exceeded the total number of DPC docs present in country. By April 1, there should be many fold more telemeding FFS docs than telemeding DPC docs. [Heck, one or more U.S. Senators bet a month ago.]

Featured

DPC + Cat is not a good substitute for full ACA Medicaid expansion

Adapted from B. Matthews, C. Crafford, and C. Queen, Direct Pay Medical Model at Access Healthcare. Presentations of a course project at Poole College of Management, North Carolina State University, Chapel Hill, NC, August 23 & September 13, 2013.

When Brain Forrest MD, the founder of the Access Healthcare direct primary care clinic, does legislative advocacy at, for example, the United States Senate, he shows the data of the foregoing chart. It’s from a 2013 course project by three NC State post-baccalaureate management students. He advocates pro-DPC legislation, apparently telling policy makers that the NCSU students found that, over a ten year period, Forrest’s patients’ total costs of care were lower than even than the lowest of the selected industrialized countries, and had remained flat at $2200 a year through Forrest’s ten years in direct pay practice.

That $2200 figure is composed from an estimate of the annual fees for subscription members of Forrest’s DPC clinic coupled with a catastrophic coverage insurance policy priced at $1750. After passing through the hands of Forrest’s allies in the public policy arena, this soon became a proposal by the Georgia Public Policy Foundation for an alternative to Medicaid expansion, for about 400,000 low-income Georgia adults, that would provide each of them with a catastrophic coverage insurance policy and a direct primary care subscription. The Foundation prices this “patient-centered” option at between $2000 and $3000 per year, a fiscal conservative’s dream when compared to the $5370 per so-called “expansion adult” projected for 2018 by CMS’s chief actuary.

But even $3000 does not come close to providing adequate funding for the health care needs of the Medicaid expansion population. The Foundation’s model, like Forrest’s claim that his DPC patients pay the lowest amounts in the industrialized world, seemingly rests on a massive error. The calculations Forrest presented reflect a patient population that carried high-deductible catastrophic policies but paid not a penny of cost-sharing for any downstream care. It is absurd to suggest that any typical patient panel will have a similar result.

Some DPC advocates seem to believe that there is some sort of “true catastrophic coverage”, under which anything beyond primary care is a “true catastrophe” for which an insurer will pay all or nearly of the total cost. Such policies do not seem to actually exist. If they did exist, the premiums would likely be quite high, comparable to those of platinum policies on ACA exchanges. In any event, a fantasy of this sort provides a foundation for the delusion that “DPC + a cat” can meet the health care needs of indigents.

To get some idea what health care for indigents might actually cost, we can start with looking at catastrophic policies as they exist, today, in Georgia. A 42 year old (average age for expansion adults) Atlanta resident can have catastrophic coverage for $3200 per year; it comes with a deductible of $8150.

It has an actuarial value of less than 60%; so, annual cost-sharing would average at least $2133 for each covered person. Adding the cost-sharing and the premium, annual expenses for a covered person of average age and with average experience would come to $5333.

Even a $3000 version of the Foundation’s program would be insufficient to pay the premium of a catastrophic coverage policy for an indigent adult of average age. And even with a “cat” policy in hand, and primary care prepaid, an average indigent patient would still need massive financial assistance to meet an average patient share of downstream care costs.

If there were sound evidence that direct primary care can actually produce net cost savings, the care of that average expansion adult might be brought below $5333. Since there is no sound evidence that direct primary care can do that, however, Medicaid expansion at $5370 completely reasonable.


Bonus Segment 1. The cost of DPC+Cat were not flat for ten years.

It is quite unlikely that the costs for Forrest’s patients at Access Healthcare, even just those for DPC fees and catastrophic premiums, stayed constant from 2002 through 2013. Medical cost inflation, per the Bureau of Labor Statistics rose about 50% over that period. An insurance policy comparable to one that cost $1750 in 2013 should have cost only $1167 in 2002.

As to the direct primary care fees at Access Healthcare, the students found that the average member in 2013 had 3.7 clinic visits, for which he would have paid $473. Dr. Forrest himself has published rates for his own practice in 2002 that would have priced 3.7 visits at $285. Forrest’s 2013 fees were actually 65% greater than his 2002 fees; he was raising fees even faster than the general rate of medical cost inflation.

Forrest’s patients’ cost curve flexes upward, like those for every country shown.


Bonus Segment 2. The $1750 premiums in the Forrest calculation reflect the exclusion of those with pre-existing conditions.

The relationship between 2013 catastrophic policies to those in 2020 is less straightforward. Above I used a $3200 policy from 2020; had it existed, the same policy if deflated to a 2013 value (using BLS information as in the previous segment) would have cost about $2600, $900 more than the $1750 in Access Healthcare Calculation.

The difference between the policy pricing is that the 2013 figure of $1750 is pre-ACA and would have been underwritten; risky customers were broadly excluded or, if allowed, were subject to exclusions and waiting periods.

Presumably, a program of healthcare for indigents requires significant parity of access for the individuals at all risk levels. One way or another, the costs of risky indigents has to figure in. Realistic “cat” pricing in 2013 would have been $2600 for a community rated policy, or would have averaged $2600 for a series of underwritten policies covering all ages/risks level in separate pools.


Bonus Segment 3. The United States’ series line in the chart above is not representative of either Forrest’s patients or the Medicaid population.

The charted figures for total healthcare cost of various nations shown above include basic medical care for the particularly expensive aged population, as well as the cost of custodial long term care for those, old or young, who receive it. In the US, these items are paid for in systems that are essentially separate from either the target Medicaid expansion population or Forrest’s patient panel.


Bonus Upshot of Bonuses.

  1. Adjust Forrest’s patients’ cost curve upward so it no longer excludes downstream care costs born by real patients;
  2. Further adjust Forrest’s patients’ cost curve upward so that it includes the cost of catastrophic insurance for the full range of real, non-aged patients, including the risky;
  3. Adjust the curve of the United Sates downward so it reflects the non-Medicare population and excludes long-term care expenses;
  4. Give the correct upward curving form to Forrest’s patients’ cost curve; and
  5. Viola — Forrest’s patients’ cost curve will look a hell of a lot like everyone else’s.
Featured

The only bona fide university study of DPC has a message: “There’s no data.”

Health Programs Group, University of Wisconsin School of Medicine and Public Health, Population Health Institute. Direct Primary Care (DPC): Potential Impact on Cost, Quality, Health Outcomes, and Provider Workforce Capacity, A Review of Existing Experience & Questions for Evaluation, October 8, 2019. On-line publication.

The thing speaks for itself, acknowledging potential and noting absence of proof.

Also makes clear that how much my own analyses misses a hell of a lot.

Not more than a quick look at this, for example, made me realize that old comparisons of OOP for DPC primary vs FFS primary – such as the one mentioned in this previous post – were likely to be shifted significantly in more recent years even further in favor of FFS because of the ACA rule barring application of cost-sharing for a list of designated preventative services. Note, too, that the bar applies to high-deductible plans.

Featured

Spin Doctor: DPC office visits are four times as long as PPS office visits. Don’t believe it.

“A university study found that patients treated in one Apex practice enjoyed average 35-minute office visits, more than four times longer than the average visit in a more typical practice. They also spent 85 percent less money.” 

Kathlerine Restrepo, John Locke Foundation press release of March 22, 2017

As discussed in a prior post, Ms. Restrepo is spinning more than a little bit in sourcing this information to a “university study”. In this post, however, we primarily address the substance rather than the provenance of her claim of four fold increases in patient visit times.

The work to which she refers on visit length is part of an unpublished course project by three post-baccalaureate management students from NC State: Ben Matthews, Chad Crafford, and Charles Queen. Mr. Queen has told me that only the 35-minute figure came from actual field research; the eight minute figure used for comparison came from one or more publications.

It is easy to find printed anecdotes about eight minute primary care appointments, frequently in the form of recollections from a physician explaining his migration to direct primary care. There are also diatribes about how all the time of a visit does not count when the doctor looks at a computer during some of the time during that visit. But there appears to be no published research that demonstrates that eight minutes, or anything approaching it, is the average time spent by the patient with the physician during an appointment at typical primary care practices.

Instead, there is fully documented and broadly accepted survey work from the professionals engaged by the respected Centers for Disease Control that shows that the average primary care visit around the period covered in NCSU work was 23.5 minutes. This measurement is essentially identical to that attributed in the AAFP’s Family Practice Management issue reporting on AAFP’s Family Practice Profile for 2015. That measurement would suggest that appointments at the Apex clinic are a bit under 50% longer than typical primary care visits. That’s still a feather in the Apex practice’s cap; it is also, as we will see, a fairly plausible outcome for an insurance-free practice.

What is not plausible is that any direct primary care clinic, even the one in Apex, actually delivers a four-fold increase in patient visit duration over traditional practices.

DPC advocates place their ability to deliver longer patient visits on their ability to reduce overhead. But how much overhead is there, and how much can it be reduced?

A 2014 quantitatively detailed, peer-reviewed academic study of “Billing and insurance-related administrative costs in United States health care” concluded that billing and insurance-related costs in physician practices amounted to thirteen percent (13%) of gross revenues. This works out to be about 22% of the estimated 60% overhead expenses (see here and here) for family practice physicians. 

So, while a traditional practice would divide $100 of revenue into $60 of overhead and $40 for the practitioner, eliminating all billing and insurance would increase the funds retained by the practitioner from $40 to $53. That would allow an average physician to boost appointment duration by about one-third (1/3).

That boost would bring average patient visit duration above 31 minutes, a number that might reasonably taken as confirming the 35 minute visit duration determined by the NCSU students for the no-insurance clinic in Apex.

Still, pro-DPC activists regularly assign a much higher percentage of overhead to billing and insurance costs; at least one advocate suggests that as much as two-thirds (2/3) of overhead goes to billing and insurance. Let’s look at some possibilities that I’ve developed with the aid of a spreadsheet.

Assuming that half the overhead of a practice can be eliminated, then the amount of funds left for the practitioner would increase from 40 cents to 70 cents on the dollar. Doing so would let the practitioner spend 75% more time with her patients without a loss in revenue. And, while that might be a considerable achievement, it comes nowhere close to quadrupling visit lengths.

Even were it possible to eliminate all overhead, the effort would not generate visits that were four-fold longer.  A practitioner who gets to keep 100 cents on the dollar instead of 40 cents can still only spend two and one-half times as long with her patients.

To spend four times as long with his patients, an average practitioner would have to reduce overhead by 200%. A physician would have to “keep” 160 cents on the dollar to get that result. Instead of the physician paying $32,000 per year for an assistant, the assistant pays $32,000 per year to the physician!


A physician could, one supposes, reach 160 cents on the dollar by increasing patient charges. So keep in mind that Ms. Restrepo asserts that the Apex practice manages, not only to quadruple normal visit times but, to lower patient prices by 85%.

Featured

Spin doctor says DPC saves 85%. Don’t bet on it.

In a May 2018 “Policy Position” for the John Locke Foundation, Kathleen Restrepo wrote the following:

A study conducted by University of North Carolina and North Carolina State University researchers found that patients seeking treatment from Access Healthcare, a direct-care practice located in Apex, North Carolina, spent 85 percent less on total health care spending and enjoyed an average of 35 minutes per visit compared to eight minutes in a nondirect-care practice setting.

https://www.johnlocke.org/policy-position/direct-primary-care/

Can you imagine that?

Did Restrepo imagine it?

Let’s carefully address her sourcing and find out.


Restrepo misrepresented the provenance of the 85% claim.

If you thought that Restrepo’s hyperlink from the word “study” to an article in a peer-reviewed academic journal would take you to an academic report of the study by a team of academic research professionals, you were wrong. Restrepo’s statement is not your ordinary reference to a piece of peer-reviewed academic research.

Restrepo gives a fourth-hand account of unpublished material by medical students and business school students engaged in course work projects. The published article by Eskew and Klink, to which Restropo provided a rather misleading link, gives a third-hand account of the research Restrepo describes; the second-hand account of that particular research comprised less than three minutes and three powerpoint slides in a meeting presentation by Dr. Brian Forrest.

The business school students’ part of the work was never compiled into a manuscript, although the students made slides and presented them in several closed-to-the public venues (personal communication with Charles Queen, one of three business student authors named by Forrest ). Forrest’s talk also included a thirty second summary of separate work by an unstated number of unidentified medical students.

Along with the identity of the originators of any work referred to, the very fact of publication and the details of publication are, of course, important initial indicators of the credibility of cited research. Even high-school students are taught to fully and accurately represent the provenance of the material they reference. Restrepo knew that the relevant work was enitirely by students (see her earlier policy piece), but eschewed revealing that telling detail to those she sought to influence. More importantly, even though the Restrepo-cited Eskew and Klink article plainly stated that the actual research was unpublished, Restrepo disguised that unpublished research by dressing it in the garb of a peer-reviewed published article.


Restrepo did not accurately convey the content of the article she cited; and that article had not accurately conveyed the content of the source it cited.

High-school students are also taught that they must accurately represent, not just the provenance of claims on which they rely, but also the substance of the material to which they refer. Yet it seems that Restrepo’s fourth-hand account may have failed even to accurately convey what was said in Eskew and Klink’s third-hand account. Eskew and Klink (“EK”) say the study showed that DPC patients “spend 85% less out of pocket for their total cost of care compared with the same level and amount of care in a traditional setting.” Restrepo offers instead that DPC patients “spend 85% less on total health care spending”. These seem to mean quite very different things. Dr. Eskew has confirmed to me that he was referring to primary care cost sharing for insured FFS patients. But primary care costs are only a part of “total health care spending”, referred to by Restrepo.

Perhaps Procrustes could fit Eskew, Klink, and Restrepo on the same page. If so, that page should be the Forrest presentation that Eskew and Klink identified as their source. But neither Restrepo’s fourth-hand account nor Eskew and Klink’s third-hand account accurately reflects Forrest’s representation of what the research team itself had to say about comparative savings cost savings for DPC versus traditional patients.

The 33rd minute of his talk was the only point at which Dr. Forrest referred to comparative cost savings of DPC versus traditional patients as determined by NCSU business students. For this, he showed a slide by those students which made exactly one cost comparsion: that of the employee share of premium for various employer sponsored insurance policies versus the full premium of a catastrophic policy ; the students computed a differential of 33%.

The 18th minute of his talk was the only point at which Forrest referred to any specific work by UNC medical students. There was no slide, but he said this, and this alone: “In fact, some work by some UNC medical students showed that people who were commercially insured actually came out of pocket 7% cheaper for the year when they came to our practice versus ten other local practices that were in the traditional model that were in network.”

Neither a 7% difference in OOP nor a 33% difference in insurance premiums bears much resemblance to the 85% reductions in whatever it was Eskew, Klink, and/or Restrepo (EKR) had written about. No 85% figure was tied to any student research finding anywhere in Forrest’s presentation. Somehow, the entire EKR trio found themselves in contradiction to the very report that announced the existence of the studies to which they referred!

Nothing could better demonstrate why it is broadly agreed that referrers should carefully examine the material to which they refer. This is precisely why the rules of citation prioritize primary reports of research results. Indeed, even when citation of secondary reports is allowed because, for example, the original source reference was physically unavailable for inspection, these rules nonetheless require full details of the original source.

The value of sharing research by citation turns on accuracy in describing both the provenance and the content of the material cited.


The 85% claim badly needed to be masqueraded as high quality research – because it is literally incredible.

Eskew and Klink’s 2015 article in the Journal of the American Board of Family Medicine declared that unpublished work by post-baccalaureate students who studied a certain direct primary care clinic in 2013 “demonstrated” that the average fee for clinic members was 85% less than the cost-sharing paid by traditionally insured patients for the equivalent care.  The 85% claim is preposterous.

The American Academy of Family Practice and affiliated groups regularly lament that 8% or less of health care costs are spent on primary care, and hold up 12 or 13% as an aspirational model. In 2013, the overwhelming majority of traditionally insured patients were covered by employer sponsored plans. These plans had an average premium of $5884 for a single adult and an actuarial value of about 87.5%, indicating average total health care costs of about $6725. Even if we apply AAFP’s aspirational 13%, the amount spent for primary care by insurers and insureds combined would be less $875. Reducing that by 85%, would mean that the direct primary care practice in question was receiving fees of less than $132 per person per year. That’s not credible.

As the NCSU students showed, however, the average member of the subject DPC practice paid fees of $473 per year.  But, in that case, 85% savings would imply that primary care spending in traditional FFS practices was $3,153, about 47% of total health care costs. That’s AAFP’s aspiration more than tripled. That’s not credible either.


And then there is Katherine Restrepo, who gilded the 85% lily by assigning that huge reduction to total health care costs, not merely primary care costs. That would mean that the DPC patients had total health care costs of $1009 dollars.  Subtracting the $473 they pay for primary care, that leaves $536 dollars for all downstream care.  But for average FFS insured, even the aspirational 13% allocation for primary care leaves 87% for downstream care – $5851. Dividing $536 for downstream care of those DPC patients by $5851 for downstream care for FFS patients suggests that the Apex DPC’s patients saw a truly miraculous 91% reduction in downstream care costs. Nowhere near credible.


In a separate post, I explain that Restrepo’s suggestion that DPC office visits can be over four times as long as traditional office visits, is equally incredible. For now, keep in mind that Restrepo apparently expects the public to believe that DPC both has vastly lower costs and delivers hugely longer visits.


If you are a doctor choosing a pharmaceutical for your sister, feel free to rely on third-hand and fourth-hand reports of literally incredible results of unpublished pharmaceutical research by Master’s level students, some unnamed. If, instead, you are treating my sister, make sure you’ve paid your malpractice premium.

Please approach the design of healthcare systems that serve our brothers and sisters across the country with some concern for credible evidence.

Nice try!

October 20, 2019: 500+ word Open Letter to Members of Congress by DPC Coaltion President asking for support and co-sponsorship of the The Primary Care Enhancement Act. Missing words: telehealth, telemedicine, telephone, phone, text message, text, SMS.

March 26, 2020: DPC Coalition laments exclusion of the bill from CARES despite being sold as “means of expanding virtual care to 23 million more Americans with HDHP/HSA plans.”

Fortunately, all 23 million HDHP members dodged that bullet when a huge swatch of FFS primary care docs (along with DPC docs willing to code) stepped up to virtual care practically overnight.

Why a policy wonk like Wyden might (and, perhaps, should) kill a DPC/HDHP fix for subscription medicine.

Drafty fuller version

Click me for shorter, more polished version which you may (a) prefer and/or (b) have already seen.

A 1.8 billion dollar subsidy to support subscription-model contraction of primary care patient panel sizes is a problematic policy in a country when there is a shortage of primary care physicians.

I came to this trying to figure something out. We hear that Ron Wyden kept the DPC/HDHP fix for subscription fees out of the CARES Act. DPC Coalition’ s Jay Keese flatly indicated that this was because Wyden was confused about the relationship between DPC and concierge. Because Wyden is a pretty wonky guy, and his wonkiness extends especially to health care policy, I just don’t believe that his concerns are so simple they can be addressed by explaining that “DPC is not concierge”; I’ll bet he understands the differences as well as anyone.

Differences do not always make the difference. Sometimes the similarities matter more.

It matters not how much DPC and concierge differ on some or even most possible variables, if DPC and concierge are, at the same time, similar on one or more of a set of decisive variables.

Most likely, Wyden’s biggest concern is to avoid using the tax code to support subscription fees that buy, in large part, exclusionary access to PCP services that are in short supply.

700 member patient panels at DPC clinics literally exclude the 701st and all additional patients. If there were plenty of PCPs to go around this fact would be less significant. DPC cannot be sufficiently scaled for everyone, or even most people, to have DPC in any near future. In fact, if every PCP goes to a 700 person panel today, tens of millions who had a PCP yesterday would not have a PCP tomorrow. This is precisely what subscription based small panel DPC shares with concierge practices: more attention for some comes at the price of less attention for others.

Why should taxpayers subsidize that?

One can image basing a possible answer to that question on real data to demonstrate that the cost-or-health effectiveness of DPC creates off-setting value. But, as far as I can tell, and I closely follow the barrage of brags by DPC advocates, there is as yet no independent, peer-reviewed study to support the proposition that DPC is cost-effective, not even for its own members. Not one.

Even if what is needed is a larger pool of PCPs, why not directly subsidize primary care practice. A tax fix for subscription fees is a roundabout way of getting that result, and compounds this issue of access inequality with issues of wealth inequality).


If one wishes to determine what the law should do about ________,he can approach the question in either of two ways: by definition or by analysis.

Dworkin, Roger B. (1973) “Death in Context,” Indiana Law Journal: Vol. 48 : Iss. 4 , Article 6.
Available at: https://www.repository.law.indiana.edu/ilj/vol48/iss4/6

The article by Roger Dworkin explains why it is problematic to try to solve real problems simply by invoking definitions. In this context, that means it is hard to resolve the issues by saying that “DPC is by definition not the same thing as concierge” Here, the reasons which apply to denying public financial support to concierge practices apply in the same general way, if to a lesser degree, to DPC subscription fees.


A DPC/HDHP/HSA fix also entails multiple issues of wealth inequality


Likely, Wyden’s concerns may be rooted in multiple elements held in common by DPC and concierge such as the validity of a subscription model, the segmentation of health care by risk or income/wealth, and the fostering of exclusive access to a goods in short supply .

There are not enough docs to do this for everyone, and this will barely make more total docs in anything less than a term of decades. It is not simply “shopping to get the best price”.

To sell yourself — not others like a nurse practitioner, nurse, or another doctor you might not know — as being available in a timely manner and to guarantee a highly personalized relationship implies that the number of patients a direct primary care physician can reasonably care for goes way down, in some estimates to only one-third or one-quarter the number a traditional primary care doctor can care for. That does not define a transformative innovation in a country that has serious primary care access problems.

Hoff in Stat

Compare this with Congress agreeing to extend HDHP tax break to OTC menstruation products. It was in same section of an eartly version of CARES, but was kept in rather than cut out. The supply of menstruation products is ample. HDHP members using more menstruation products does not necessitate that others use less. But more HDP plan members spending on “subscription model small panel primary care” does indeed significantly and negatively impact the supply for non-members.


Early draft was building from this:

This evolving post supplements my prior post on proposals for a DPC/HDHP fix. I’m trying to look at thing from a perspective that compares DPC and concierge care in the specific context of granting tax privileges. I’m wanting to incorporate/assess in my new analysis some/all of the things listed below. This raises some big questions. See Rawls et al. and watch this space.

  1. there is a substantial cost to the fix: CBO says $1.8B ten-year.
  2. in the context of progressive taxation, tax breaks are regressive, promoting wealth inequality,
  3. so a tax break for dpc contributes to wealth inequality
  4. also, at a whole other layer of regressiveness, low income people are just less likely to even be in HDHPs even if everything is on a tax equal basis. : DPC election will still strongly correlate with income/wealth level, because the lower ones incomes the harder it is to bear a high deductible.
  5. And even among those who can afford a high deductible plan, the lower one’s income income is, the lower one’s ability to meet the expense of the subscription fee.
  6. At the same time, the effect of dpc is to allocate more of a resource ( doctor attention from small panel), to some than others (admittedly those who buy it) than others, so as to definite health care access inequality. (All resources are finite, and doctor time is looking very much scarce in the COVID moment.)
  7. the health access inequality that DPC entails is linked to wealth inequality even if DPC membership isn’t subsidized by a tax break, and moreso if it is subsidized.
  8. In regard to separating a group who gets more PCP access and a group that gets less, there is an important equivalent of concierge care, even if the effect is somewhat diminished in scale.
  9. Why would we subsidize a process that compounds health access inequality with wealth inequality. A process in which wealth inequality will be not ony reinforced (those with better incomes save more in tax $$) but will receive this reward will be for giving themselves better health care access? Why would we subsidize with a regressive tax break a process through which the better off sequester a disproportionate share of primary care access for themselves?
  10. Does this line of thought explain why the DPC/HDHP fix was excluded from the COVID #3 rescue package?
  11. Even if DPC contributes concurrently to wealth and access inequality, it could be worth the cost, if DPC had the evidence of its own cost-effectiveness – i.e. -if deployment of DPC increases the total resources available, it could still be a justified to, say, a Benthamite or Rawlsian.
  12. Thus, DPC cost-effectiveness or countervailing value is a necessary condition for validating the acceptability of a DPC/HDHP tax preference; you cannot make a case for DPC/HDHP fix unless you can make the case for DPC cost effectiveness.
  13. Elsewhere in this blog, I address many of the claims by DPC advocates that DPC has proven its cost-effectiveness. The upshot is that it has not.
  14. Comparison: CARES act did extend an HDHP fix to OTC menstruation products. Regressive, yes. But, as there is no scarcity of such products, this part of the CARES act will not have the effect of sequestering menstruation products for an enhanced access. But note if supply of menstruation products was limited, then driving access in regressive way would be questioned, right?

This is sort of an aside, but not entirely. In COVID-era sensibility, do both DPC and concierge, looks a little like hoarding of the scarce resource of PCP medical attention. As things are playing out in real time, we see a lot of DPC docs explaining how well off their patients are because the panel size is small all while other part of the system are rationing care. Not “hoarding”-hoarding, but keep in mind that scarce resources are requisitioned, i.e., forceably reallocated in times of crisis.

In any case, the pandemic is amplifying the effect of a PCP shortage; but the shortage will remain when the pandemic-fueled amplifaction is turned off.

Please use comment section if you have something to say.

Pandemic effects on DPC enrollment

Possibilities to think about:

  1. DPC members who lose employer coverage will have the ability to go to ACA-compliant marketplace plans. Many of these will reach the low income levels at which ACA provides robust cost-sharing reduction is available. The relative desirability of DPC will fall.
  2. Some DPC members who lose income will become Medicaid eligible, especially in expansion states.
  3. Some states that have not done so yet will accept Medicaid expansion, reducing the number of those whose health plan was “DPC + hope.”
  4. A high percentage of DPC members have HDHP plans (technically illicit). HDHP plans have bigger advantages for higher income people. A general downward slide in income coupled to an opportunity to change plans if group coverage is lost due to job loss will likely see a shift out of HDHP plans. Even if those shifting don’t see incomes low enough for the robust cost sharing, they will have less incentive for DPC.
  5. Some DPC members will not be able to keep up their monthly payments. Some of them, especially those with relatively low utilization in the past, are going to be upset if they are discharged from the practice.
  6. More people will hit, or expect to hit, full amount of deductibles or MOOPs, reducing the relative value of DPC membership.
  7. For a while at least, there will be less and less “high-touch” medicine of any kind. This reduces the relative value of DPC subscription model.

More to some. Use comments to tell me of other issues.

Based on the above, I expect DPC clinic to lose subscribers this year. A DPC/HDHP fix, if part of Covid-stimulus, would have moved the needle somewhat toward more subscribers; it did not happen.

Direct Primary Care & COVID-19: some takes on Dr. White’s piece on dpcalliance.com

Next post will be linked here, then new post likely will be pinned near top of blog. Not sure yet the degree to which the next post will supplement, incorporate, rearrange, just replace this one, maybe none of these.

This one is mostly reactive to Dr White’s DPCAlliance.com essay on DPC and COVID-19. That was dated 3/19/20. Four days earlier, DPCAlliance’s current head had posted a piece that piqued my interest in regard to its discussion of DPC members who demand COVID-testing that might not have been appropriate; I left that aside (and may never return to it) because White’s piece demands more attention.


I don’t think this a good moment for the usual coupling of disparagement of traditional practice with praise for DPC. The White article, which when published became the public face of DPC Alliance on the subject of COVID, does very little more than say , “OUR DPC patients and physicians are going to be fine; the other guys, not so much”

However, whether it be 24/7 telemedicine, emptier waiting rooms, faster response times, healthier patients more able to survive an infection, more personal knowledge whatever, isn’t every one of the cited advantages for DPC in a time of COVID equally held by FFS/concierge? Isn’t this about the panel size, not payment model?


If a pandemic mandates anything for doctors, it’s that each handle more patients, not fewer.


What about descending on Congress with a general pro-DPC agenda disguised as a crucial pandemic policy? I hope that isn’t what’s going on. But there’s more than hint of that in some quarters. One of the first DPC practictioners replied to a tweet of Dr White’s essay suggesting just that. And a recognized leader of the DPC community, chimed in, ” It’s already happening.” Here’s the tweet, the reply, and the chime in.

undefinedundefined

Are DPC’s lobbying crew going all in on the idea that DPC is a “proven solution” — for COVID? That making DPC happen now for more patients is a COVID strategy?

Springer: “I’ve spent two days doing virtual visits to which I was largely unaccustomed; let’s tell Congress that’s a COVID plan that only DPC can do.”

Then there’s this from another group of DPC activists: https://dpcaction.com/never-let-a-crisis-go-to-waste. In which they (DPC Action) urge that “during this time of National Emergency” Congress must pass their favorite DPC/HDHP fix.


While a DPC/HDHP fix might be justified, pandemic surge needs are not that justification.

I won’t, as such, have any objection to the principle of attaching DPC/HDHP fix legislation to any other legislation that’s moving, unless something more important in COVID-19 Package #3 is taken as a hostage to getting a DPC/HDHP fix.


Still —

A DPC/HDHP fix should rise or fall on its own merits, which may have little to do with pandemic policy going forward.

A boost to telemedicine should rise or fall on its own merits, which may have a lot to do with pandemic policy going forward.

Boosting access by lowering cost sharing should rise or fall on its own merits, which may have a lot to do pandemic policy going forward.


Pandemic COVIDcare going forward now seems likely to be optimized by”telemedicine” and “lowered cost sharing” at least at the diagnosis and early treatment stage. But these can be achieved in FFS settings, as being shown in real time at hint.com by actual DPC leaders actively recruiting actual DPC docs for FFS-based telemedicine. Arguments for surge-telemedicine are arguments for surge-telemedicine, and are best met by legislation that promotes surge-telemedicine. Surge-based arguments for low cost sharing are surge-based arguments for low cost sharing, and are best met by lowering cost-sharing where this helps deal with the surge. COVID related legislation has already moved these needles and will likely do so to an even greater extent. Telemedicine and cost barrier removal can be and is being facilitated in a very big way directly for everyone (insured, public supported, uninsured) through DPC, FFS, or other practices, for the duration of COVID-need (or even for freaking ever), all at the snap of a handful of federal and state government fingers.

Once the pandemic/public health case is made for boosting access by lowering cost sharing and practicing telemedicine, and such efforts properly funded, there’s no public health/pandemic rationale for a DPC/HDHP fix for DPC monthly fees.

At the same time, that kind of fix for DPC monthly fees is (a) limited to only those for whom HDHP plans are otherwise worthwhile and (b), even then, is only a roundabout way to upscale telemedicine and lower-cost sharing for pandemic services. In DPC, freedom from usage based cost- sharing must be purchased with monthly and even initiation fees, fees that can in themselves might act as barriers to care. But from a pandemic/surge perspective, it makes more sense to just exempt COVIDcare from usage-based cost-sharing so that, even in FFS medicine, COVIDcare goes forward. Some states have already mandated this, even for those in HDHP plans. Again, from a pandemic perspective, why try to drive HDHP plan members toward desirable telemedical care by the indirect route of offering a tax-break, useful only by some and then in varying degrees, in the hopes that some of those some will buy subscriptions for DPC? Instead, telemedicine by FFS, DPC, or anyone else can be directly facilitated as part of cost-sharing-free COVID care, by direct subsidy, by relaxation of any restrictions, whatever.

Accordingly, whether or not a DPC/HDHP fix might be justified for other reasons, no cautious policy maker would consider pandemic surge needs a significant argument for a fix; and no reasonable policy maker would let pandemic surge needs be held hostage to a DPC/HDHP fix.


White’s piece repeatedly and primarily stresses small DPC patient panels. This is an odd thing to emphasize at a moment when what the crisis is likely to produce is a community need to have all hands on deck for relatively brief interactions with relatively very large numbers of patients.


Which do you think will save more lives next Monday: 33 ten minute focused COVID-related encounters or 11 thirty minute encounters? The ten-minute visit, usually scorned by everyone, could well be just the thing here in late March of 2020.


I would far rather have seen a DPC Alliance article that said: “We have small patient panels and we usually focus on their long-term care goals; in the current context, that luxury needs tempering in the face of community need; fortunately, Congress and has passed emergency legislation which will allow us to accept uninsured patients for COVID-19 screening and appropriate primary care; we eagerly embrace that opportunity.” As noted both above and below, some DPC have chosen to do that.


At its best point, White’s article hails telemedicine. But even that useful bit is tainted with White’s apparent belief that DPC necessarily does telemedicine better than anyone else. Still, at least White acknowledges that other forms of practice do have telemedicine capability; over at Twitter, White’s article is re-tweeted with favorable comments by DPC-friendlies who seem to write as if DPC has a monopoly on telemedicine. (Ironic, considering that one of the first tweet responses to White’s piece was the one shown above, from a DPC doc who made clear that he had just just gone a year without a significant number of virutal visits.)

I have some familiarity with the dominant large health systems in three major cities . Despite “FFS”, the large players there have robust, sophisticated, effective patient portal systems.

And every day in this middle of March 2020, we are seeing wide-scale “tele-operations” being successfully implement by schools, businesses, religious institutions, etc. In a political campaign nearly ten years ago, I learned first hand how a small group of co-workers could conjure up major telecom initiatives on the fly with a few simple software tools, net access, some lap tops and cell phones.

Certainly COVID may at some point overwhelm these systems by sheer volume. That’s not a fault in FFS-based medicine and it will not reveal a unique virtue of DPC. To the extent that individual DPC practices do not become overwhelmed, it will be because of small panel sizes, i.e., they will be doing no better than an FFS based concierge practices and doing that well for largely the same reason – small panel size. Not payment model, just small panel.

Who thinks there should be an HDHP fix for concierge fees?

And, more specifically in response to the White essay, none of DPC’s presumed advantages in a time of COVID flow from the payment model. Whether it be 24/7 telemedicine, emptier waiting rooms, healthier patients more able to survive an infection, whatever, every one of the cited advantages for DPC in a time of COVID is equally held by FFS/concierge; it’s about the panel size, not the payment model.


The more highly staffed any system is, the more headroom it will have before it break under pandemic stress. But the payment model by itself does not determine the staffing level. A far more important determinant, for example, are physician expectations of what they should be paid.

Granted, squeezing out insurance related overhead presents a good opportunity to buy some more physician bang for the medical buck. But, as I discuss elsewhere in this blog, it has yet to be shown DPC is generating the huge savings so often promised. Nextera Healthcare, mentioned above, is sometimes included as a poster child for effective DPC; but its own, current, publicly available marketing material claims overall net savings of less than 15%. That’s marginal, not revolutionary.

And even that data and analysis lacks rigorous vetting by independent professionals.

Moreover, that data compares Nextera to FFS primary care in the context of employer health plans. If the benchmark here is who can do better in the recently created Congressional COVID care for the uninsured, or in supplementing stressed networks by a streamlined telemedicine program at the diagnosis stage, that kind of work will likely have modest administrative costs. Coding geniuses will not be required, or even useful.

And that’s precisely why “Hint” is comfortable being all over the intiative mentioned bth above and below: FFS telemedicine for DPC doctors.


Department of Credit Where Credit Is Due

Better late than never, this is what DPC Alliance lead post on COVID should have been about:

In a conference call 800PM EST 3/19/20 organized by hint.com, its leadership announced an intiative to put lots of DPC’s MDs to work doing telemedicine when and where needed. They’ll hook docs up to reach into communities whereever needed. There are emergency licensing arrangements to facilitate.

Now cue the Department of Irony. This work will involve even working hand in hand with FFS-tainted entities, coding , and submitting claims for governmentally supported third-party payments.

This seems, for now, exactly what’s needed from DPC docs. Not a payment model; not 30 minute face-to-visits. And making it happen did not depend, at all, on a DPC/HDHP fix.


Dr Priceline’s downstream cost reduction plan cannot simply be scaled up.

Dr. Lee Gross of Epiphany, a direct primary care leader, brags about the great discounts he gets for his patients on downstream procedures like advanced radiology. And, specifically, he proudly lets us know that a big part of this involves accessing advanced equipment during slack hours. This is, of course, the same strategy by which discounters like Priceline are able to book last minute hotel rooms at big discounts.

As long as marginal costs of production are met, vendors are happy with discounts for inventory that would otherwise become unsalable. But, Dr. Gross, the total of all sales prices has to exceeed the total of all costs of production; else there is no profit. Discount after-hours bookings for MRIs will be available at, and only at, the margins.

The broader world of downstream care pricing will not likely be remade by direct primary care practices applying Dr. Gross’s Pricelining technique. If there is any real value to be extracted by, for example, off-peak MRI scheduling, health insurers and large provider systems will be better equipped to exploit that opportunity than direct primary care clinicians who choose to sacrifice face time with their patients to spend telephone time as downstream care brokers.


Come to think of it, is there any legitimate reason for direct primary care physicians — who pride themselves on long, probing patient visits — to spend their precious time acting as downstream care brokers? How exactly has the DPC MD who delivers meds to your office, or opens her surgery for a Sunday meds pickup become a symbol of cost-effective care?


Doctor Gross plainly understands that a seller of MRI services is willing to provide lower cost services at below average prices so long as marginal costs are met. But many of his compatriots describe accepting Medicare and Medicaid patients at payments lower than average fees as “losing money”, even when that amount of price discrimination can add to a practice’s bottom line. And I don’t hear them grousing about how Gross’s patients are not paying their fair share of MRI costs, even as I hear them make the equivalent complaint about Medicare and Medicaid patients.

I actually hope that many doctors who have engaged in policy advocacy were blinded by ideology, or simply lying.

I see so much bad analysis and arithmetic in policy advocacy by MDs, I have to hope that it’s a result of ideological blind spots, or even outright lying. I am frightened by the principal alternative explanation: that one can too easily become an MD despite the lack of basic analytical or arithmetic skills.

Making cost reduction claims more honest and helpful to decision-makers — random thoughts.

Claims of cost reductions need to look comprehensively at all costs.

Consider this chart from an Iora presentation of some years ago.

The net drop in spending would look a lot bigger if prescription drugs (the green bar) were not part of the picture. But, a lot of how primary care, direct or otherwise, works is by getting people on the right meds, then getting them fully compliant. When you spend money to save money, you need to look at a net change.

Perhaps the most widely cited claim of cost reductions is Qliance’s 2015 press release claiming overall reductions of about 20%. But their analysis did not cover drug costs. It seems highly probably that somewhat higher drug costs for Qliance’s is a major driver of the reductions in other categories of care. In that case, their overall cost reduction is probably significantly below the 20% they claimed. (And, lest we forget, the Qliance data made no attempt to examine the possibility of selection bias.)

Similarly, consider that Qliance’s 2015 data omitted a category that had been included in their own earlier internal analysis, specifically, surgeries. Qliance’s 2015 evaluation of “overall costs” did not include surgeries. If Qliance patients had just as many surgeries as non-Qliance patients, incorporating that result would lower overall savings. And, just as the case with prescription drugs, there’s some chance that Qliance’s success in reducing other costs might even come from its patients having more surgeries.

So, to generalize, a proper demonstration of success at overall downstream care cost reduction needs to consider all downstream costs to fairly reflect the achievement of direct primary. Cherry-picking of selected reported categories that show improvement gives a misleading picture. Several studies have, to their credit, used comprehensive measures of all downstream cost.


Ideally, studies are repeated at a fair interval or extended for an ample single period. A single snapshot or short-term study, if high or low, will likely regress to the mean when repeated or extended.


A study of a single start-up period may be distorted. It may take more time for the full effect of DPC to develop its full value. On the other hand, there is good reason to expect that a start-up period will pull in a disproportionate share of enrollees who have never had an prior primary, in which case there might be a first year bonus of discovered problems.


Claims about the efficacy of direct primary care providers have a lot more credibility when they report data from direct primary care providers and not from concierge practices. MDVIP is not a direct primary provider and neither is White Glove Health. Yet, they have appeared in pro-DPC advocacy repeatedly.


Study by bona fide independent investigators is much preferred to self-reported brags, for the simple reason that self-studies that don’t favor the self-student are buried. Ultimately, the studies that best show real success are the studies that are designed to show the truth, whether that be success or failure.