DPC and the pandemic: more capable than FFS? Or less?

DPC advocates are talking a lot these days about how a pandemic shows the superiority of direct primary care.

There are aspects they don’t talk about.

The Milliman study’s survey — the same survey DPC advocates turn to when emphasizing, for example, how much telemedicine DPC clinics do — indicated that over a third of responding DPC practices do not do adult immunizations.

Then, too, some DPC clinics found themselves too thinly capitalized to provide COVID-19 testing for their uninsured patients even though federal legislation provided that coverage without cost-sharing even for the uninsured. At the same time, any DPC patients who had ordinary (or even high-deductible) insurance were eligible for free testing through their insurance plan and outside the DPC, even as many DPC clinics were treating appointments for COVID-testing as a billable extra not covered by the subscription charge.

I’ve commented elsewhere that much of the “we’re good for pandemics” bragging being done by DPC advocates ultimately rested on the value to DPC physicians and their lucky patients of small patient panels. I’ve noted that even in ordinary times, a shortage of primary care physicians means that greater access for some comes at the expense of lesser access for others; that resource allocation problem is a public health issue and ethical issue in its own right.

Add a pandemic and the key role of testing and vaccination to a now-aggravated resource allocation issue, and one can start to build a argument that direct primary care is in a uniquely POOR posture for a near future dominated by COVID-19.

Survivors of COVID-19 have been having a markedly unpredictable range of significant sequelae of yet unknowable intensity and duration. Pricing the primary care needs of such survivors into a subscription model involves a very high measure of risk, while the overwhelming majority of DPC practices have low capitalization and a low tolerance for risk. Fee-for-service payment models are likely to prove significantly more flexible than subscription models in helping physicians meet an unknown future.

Early DPC brags about how superior to FFS it was during an emergent pandemic focused on telemedicine. But within a week or two, FFS practices largely closed that gap. At the same time, social distancing has left DPC practices no longer well-positioned to return to their longer-standing emphasis on how small panels result in lengthy in-person visits. But with FFS telemedicine moving toward a par with DPC telemedicine, FFS docs will themselves be able to increase in-person visit times.

An officer of DPC Alliance posted this brag/unbrag sequence on April 27, 2020.

More about @Dr_A_Edwards’s twitter post here.

Is there any advantage left for DPC? Well, it will remain true that squeezing out a good measure of insurance/billing overhead could result in DPC being more cost-effective on that particular front than an insurance dependent counterpart. But this leads us back to this blog’s on-going attempt to assess the DPC community’s on-going claims of overall cost-effectiveness. And on THAT score, despite a surfeit of DPC advocate brags, there is still no independent investigation that shows that DPC delivers any value at all.

To the contrary, there is a constant flow of extravagant claims that are easily debunked. Here’s one, about three years old, that a DPC advocate, Lee Gross, MD, regularly re-flogs. It claims potential 86% savings for a family of four over ten years by combining direct primary care with a short-term, limited benefit wrap-around plan.

To realize those savings though, all four patients would have to go for a decade without exceeding the limitations of the plan. And one can glean a sense of how likely that is simply by looking at the premium the article assumes for the plan’s wraparound coverage: $2136 per year for a family of four for all downstream care. That’s low, even for these plans, despite their being underwritten, excluding pre-existing conditions which will soon include whatever Covid-19 sequelae emerge, and often having benefit caps. And these plans do not guarantee renewal, so however low a first year premium might be for a family in perfect health, the likelihood of any family seeing a full decade of clean-slate pricing is about zero. For a family of average health, 86% savings is nowhere near credible.

In fact, about two month before the article claiming 86% savings, Consumer Reports published a broad analysis of short-term plans and warned against using them on an extended basis. Moreover, that article pointed out that an average annual premium for these plans was $3,096 for a family of four – 45% higher than Gross claimed.

Will DPC advocates press forward with internally generated efficiency data. I’ve already heard an analyst followed with fervor by some in the DPC world declare that Covid-19 has closed down the generation for a long emergency period; evidently, fee for service primary care utilization is down across the board, so DPC brags about reducing overall costs have been largely blunted by reality. Meanwhile, independent academics or other analysts with the chops to mount careful, serious study of health care finance and cost-effectiveness will find that the pandemic, the associated economic plunge, and federal relief legislation have generated matters for study that are both more interesting and more pressing.

There may or may not be major reorganization in regard to delivery of health care in general and primary care in particular. If direct primary care has all along been everything that its advocates claim, it will be simply sad if DPC is excluded from that upheaval simply because DPC’s own advocates failed to marshal credible evidence.

I am no lover of insurance companies. Maybe that’s why I’ve always thought that direct primary care had significant potential for realizing its promise. Instead of developing and publishing meaningful evidence of effectiveness (particularly evidence with appropriate measures to account for selection bias), however, DPC advocates have spent years relying on brags ranging from thin, unvetted internal studies downward to complete and utter fabrication. That failure by DPC’s advocates may well cause them — and the rest of us — to real opportunities for important primary care reform.

A personal favorite: a tweet by a DPC marketing director saying , “Every dollar spent on direct primary care now saves $13.”

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: