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 need to look at broad effects, not mere word formulas.


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