DPC, one year after receiving a heart transplant, prepares to have old heart reimplanted.

I’m old enough to remember pro-DPC advocacy focussed on the long, in person, face-to-face primary care visits, the very “heart of direct primary care”. Surely that’s what motivated Doctor Steve Springer when he proudly opened Southwest Louisiana’s first direct primary care clinic. I say this because it certainly wasn’t telehealth Springer had in mind. After all, he barely did any telehealth prior to two days in mid-March of 2020.

On those two days, though, he seems to have increased his telehealth practice by about 2000%, apparently going from about one virtual visit a week to about 40 visits per day. Here’s his tweet from 3/18/2020

I teased Springer for the obviousness of his opportunism in a reply tweet. Over the next few days, I watched the DPC advocacy community pull together a new spin in its long-standing pitch for DPC legislation, now presented as the definitive Congressional emergency response to the pandemic, even calling it “our bill . . . expanding virtual care to 23 million more Americans “. My favorite part of this effort was learning that the direct primary care movement had, much like Dr Springer, apparently had a sudden heart transplant, now proclaiming in near unison that “telehealth is the heart of direct primary care.”

Those 23 million Americans managed to get through the next 60 days without suffering from the lack of direct primary care’s Telehealth SuperPowers. By mid-May, as pointed out by the Larry A Green Center (a strongly pro-DPC health innovation think tank) 85% of all primary care providers of any stripe were using a significant measure of telehealth capability. Dr Springer was not the only one going from zero to sixty in a pandemic moment. Then, too, by mid-March 2021, in person visit rates had nearly returned to pre-pandemic levels.

Not that telehealth was just a flash in the pan. Some game-changing lessons for primary care were apparently learned, although not necessarily by the “traditional” direct primary care movement. One possible major development is underway at Amazon.

That company had been experimenting with providing its employees with primary care from Amazon employed or contracted doctors. The company was quick to start using telehealth during the pandemic. One thing they noticed was that the children of their employees were falling behind their vaccination schedules. They started a program of sending out vaccinators to employee homes. Then, the idea grew to embrace home delivery of many other services, like blood draws. It was, of course, particularly easy for Amazon to integrate home delivered medications and pulse-ox devices.

A year to the day after noting Dr Springer’s tweet, I saw a tweet from a national health care reporter that linked an announcement that Amazon was “expanding to bring virtual-first primary and urgent care to more Amazon employees, their families, and for U.S-based employers.” Backed by Amazon’s ability to deliver goods and services into the home, Amazon could well deliver a vastly more comprehensive “virtual-first” primary care package into the home that anything ever seen from any existing direct primary clinic.

Another staple of DPC advocate pride is the facilitation of discounted rates for downstream services like advanced radiology. But Amazon is potentially far more effective at “pricelining” MRIs and such than any network of small DPC practices, just as Expedia is more effective than private travel agencies.

And, while Amazon projects its service as “virtual-first”, the company also expects to backup with in-person sites.

The likeliest challenge facing Amazon’s service would appear to be in the area of establishing ongoing relationships between patient and a single primary care physician. Accordingly, within a few days**, I expect to hear from the DPC advocacy community that Amazon telehealth is just a shiny object of minor impact, but that what matters most are those long, in-person visits. Those visits will be born again as the heart of direct primary care.

Which is probably as it should be, because that premium, small panel service is the thing that small independent practices are likely to do fairly well. It actually makes very little sense for highly trained PCPs to spend their time drawing blood or chasing lab and MRI discounts. Whatever the semantics employed, small DPC is “concierge lite”. Premium small panel service takes a lot of valuable PCP time. That, in turn, requires DPC patients to pay significantly more money to their chosen PCP, even after insurance costs are squeezed out.

DPC docs should simply welcome that position in the health care world with, “We’re worth it!”.

** That was quick. Here’s a commentary from a DPC thought leader comparing efforts like Amazon’s to a venereal disease.

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