Ultimate DPC goal: capitation without accountability (rewrite)

Allowing an HSA holder to use pre-tax dollars to buy subscriptions only gets DPC operators so far. The HSA holders would still notice that their paid subscription fees will not actually make a dent in meeting their insurance deductible. DPC advocates will then reprise their perennial theme song, “Insurer’s conditions on payment interfere with the doctor-patient relationship.”

It is interesting to note how deeply this idea is invested with emotions: specifically respect for physicians, and disdain for insurers. But why, after all, should any physician have anything to say about an individual’s contractual relationship with an insurer?

This will play out in a multi-pronged DPC effort to interfere with the insurer-insured relationship. The effort will be tagged “free market reform”.

It will, of course, be demanded that insurers credit capitated subscriber payments on the same basis that they credit fee for service payments. Insurers might or might not accept that principle. DPCs will, if necessary, seek legislation to interfere with the insurer-insured relationship by requiring insurers to accept capitation, citing interference with the doctor-patient relationship and “free markets”.

Insurers that decide, or are forced, to accept capitation will naturally want to negotiate price and quality measures to protect themselves from the inherent incentive of providers receiving capitated payments to do too little and to push costs downstream. A satisfied insurer will declare some compliant DPC providers to be “in network”.

Among the non-compliant, a familiar cry will arise: “Insurer conditions and limits on payment interfere with the doctor-patient relationship.”

“Freedom” and “free markets” will be invoked: “only doctors and patients are needed to determine primary care value and pricing”. The freedom of an insurer and an insured to agree to the shape of an insurance policy will not play a part. In the name of “health care freedom”, DPC advocates will insist that insurance companies give full credit toward deductibles of every subscription dollar paid to any provider.

The foregoing thought exercise also gets to a question raised by certain DPC thought leaders’ statements that DPC clinic are naturally disinclined to employer purchases of DPC subscriptions for their employees, and would much prefer that employers simply offer their employees HDHP/HSAs in a post-PCEA environment.

But in such an environment, neither an HDHP carrier nor a self-insuring employer, would be obligated to credit the DPC subscription fee toward the deductible. Some HDHP/HSA holders might still resist DPC unless the DPC subscription fee counts toward their deductible. On the other hand, a direct DPC contract with the employer removes that barrier to DPC enrollment. Whatever they may say, DPC contracts with employers profit DPC substantially.

It has been evident for many months that a great many DPC providers are pushing hard for employer contracts despite a decade of complaint that third party payment is the source of huge evil. It is noteworthy that the tip of the spear is pointed at landing employers that are not likely to have truly savvy benefit managers — the type who might actually demand real accountablity through properly risk-adjusted performance data.

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