How it started
Does direct primary care have real value in reducing , when compared to traditional fee-for-service primary care, the overall costs of care? That specific question, cost-effectiveness, was worth looking into for several reasons. The stakes are high, the health of my fellow citizens. The core idea of controlling the cost incurred because of the presence of insurers and other third parties is profoundly attractive. And alternatives to fee for service medicine have had some successes controlling costs abroad, and even at home.
What first brought my attention to direct primary care was a concerted effort by fiscal conservatives connected to the Georgia Public Policy Foundation to lower Medicaid spending by transferring recipients into DPC. I generally support public financial assistance for healthcare for those who need it and, because of that, I am not ordinarily a fan of fiscal conservatism. But if DPC actually could lower the cost of bringing care to the low income population, make the money go farther, and earn fiscal conservative support to broaden care for those with low incomes, I’d be very happily on board.
The GPPF’s specific DPC for Medicaid proposal was built on the expectation that direct primary care could cut the per person costs of healthcare by more than half. That I did not immediately dismiss that claim as beyond belief was probably the result of something I share with DPC physicians: a disdain for health insurance companies, although in my case this is grounded in support for publicly funded healthcare.
Leaning away from both insurance companies and fiscal conservatives put me in a good place to referee a debate in which two antagonists of publicly funded healthcare would fight over how best to support publicly funded healthcare. Fun!
As for seeing primary care physicians themselves as combatants on these issues, “There are fine [doctor] people on both sides.” Over 98% of these fine doctor people practice fee-for-service medicine. I admire those in small, independent practices regardless of the payment model under whichever payment model they operate.
As to those docs who have elected DPC, I admire their senses of urgency and insurgency. I am happy for them to have found a practice setting in which they are comfortable. As a group, they seem to be doing their best and bringing quality primary care to their relatively small patient panels. If I was a PCP, I would likely choose this mode of practice. And, I would seek a direct primary care physician for myself, if I could afford one.
If DPC offered a significantly better than break even proposition for overall costs, a Medicaid program bringing DPC’s ‘lite’ version of concierge care to current Medicaid patients might well sail through any legislature in America. After a short trial period, however, we can count on fiscal conservatives shrieking in rage at unlimited half-hour visits for Medicaid people, then cutting the monthly fees paid DPCs by Medicaid— even if the program actually was cost-effective.
I started this blog reviewing direct primary care with an open mind, ready for probing analysis of available data or carefully designed experimentation in the healthcare marketplace. I still remain open to any serious attempt to investigate the cost-effectiveness of direct primary care. But, after four years of best efforts, including examining every piece of DPC advocacy I can find, I see scant evidence to support claims of significant cost-savings and very much evidence to the contrary.
The most popular ur-narrative of DPC cost efficiency is that deep savings on insurance overhead allow PCPs to net the same income with three times smaller patient panels, resulting in three times longer visits, and radically lowered ED utilization. But insurance overhead is simply not large enough for tiny panels with tripled visit times, and the shortfall needs to be made up by the DPC clinic receiving significantly more revenue per DPC patient than traditional PCPs receiving. To make a dent in overall costs, therefore, direct primary care must outperform traditional models in downstream care cost reduction by a significant margin.
As of Winter 2021, only the single study by Milliman actuaries came anywhere near making a plausible argument that the direct primary care model results in meaningful net savings. That study was not subject to pre-publication peer review; nor did it appear in a forum open to letters and comment. For reasons I explain here, I think that study’s suggestion of even modest saving contains a glaring flaw.
As they say, however, your mileage may vary. I really hope it does. The best way for me to test my analysis is to devour contrary opinion and evidence with gusto. That’s how I was taught to get at the truth. Use Comments. Use Contact. Give feedback.
In the late Winter 2020, Covid-19 stimulated a lot of pro-DPC advocacy. A principal element of that advocacy was an opportunistic grab for privileged tax treatment for direct primary care subscription fees. There was, as well, a massive round of premature pandemic-related self-congratulations by direct primary care practitioners. Both phenomena pointed my inquiries beyond the cost-effectiveness issues to explore a broader range of healthcare policy implications of direct primary care.
Looking at the bigger picture brought the realization that beating down public financing of health care is not the only mischief that over-rating DPC can do. For example, DPC providers dangle unsupported visions of cost savings in front of self-insuring employers in an attempt to win business, risking employer cancellation of other programs that may give many employees better choices. Similarly, purveyors of substandard, “non-insurance”, health cost sharing contracts team with DPC to offer consumers a shiny, but problematic, health care path.
In May of 2020, the game-changing Milliman study came along. Finally, the tools of actuarial science were brought to bear in an independent investigation on the cost-effectiveness question. That study made apparent that most and, perhaps all, of what DPC advocates report as cost savings are the results of selection bias.
The blog has tracked how the DPC community is handling the Milliman’s report’s exposure of the role of selection bias in creating an illusion of cost-effectiveness. The responses though July of 2021 included: outright lies (e.g., “Milliman validated the Qliance study!”); ignoring the problem (e.g., “Cherry-picking, what’s that?”); defiance (e.g., “No one can prove that OUR clinic cherry-picks, without spending lots of money.”); and a profoundly underbaked attempt at risk measurement (e.g., “We did it, but under own own secret rules and with our fingers crossed; then, we ignored the result because actually applying it would have reduced our brag.”).
Perhaps, someday, a DPC professional will say, “While our version of concierge primary care is not cost-effective, we’re worth it.” Some DPC advocates surely yearn to say just that, but refrain because political support for DPC might be lost if it was widely believed that direct primary care was nothing more than a way to extract a larger share of economic rent resulting from a PCP shortage by offering queue-jumping to the well-to-do.
Is all the anti-insurance rhetoric in DPC is just a cover story for a transfer of wealth from insurers to physicians? That’s not necessarily a bad thing. Nor is it necessarily a good thing. Just a thing that warrants critical examination to see where the public interest lies.
My name is Gary Ratner. I have some arguably relevant training and experience. In this blog, I largely eschew “the argument from authority” and I entirely eschew making any argument from my own authority. I aspire to the analytical approach linked here. That’s why the blog comes with both comment and contact capabilities. For anyone who cares to take issue with any matter on the blog, I will be happy to have a live or asynchronous, private or public discussion on Zoom or other social medium, audio, video, smoke signal, in print, anywhere, anytime, any participants, any audience.
Who am I? It does not matter. The analyses in this blog have to stand on their own.
If you insist on “credentials”, see here.
Let me anticipate four perfectly fair questions.
Q: Why the snark?
A: I am, or arguably “was once”, a lawyer.
Q: If DPCreferee is neutral, why do all the posts seem to argue against claims that DPC works wonders?
A: I used to think that this was merely an artifact of insurgency. I do my best to respond to claims from whereever they may come. Pro-DPC advocates are advancing a novel position and necessarily make a lot of claims; in doing so, some claims will allege wonders that seem to be too good to be true, often as a result of self-serving confirmation bias.
More than just a few DPC advocates are health policy naifs operating far beyond their expertise. One of the biggest DPC brags, coming from a DPC Alliance Board member and proclaiming DPC savings of over $2000 per member per year, is a stunning example of unfamiliarity with the basics of the insurance market. And one DPC thought leader, who has been proclaimed in that community as one of its foremost policy experts, recently “rebutted” the fact that average ACA market premiums fell three years in a row by singling out increases in the price of benchmark silver. (Count yourself as a health care naif if you do not know what silver loading is; then read this).
Also, some are health policy knaves with variable levels of attenuated senses of good faith and/or veracity.
Then, there are double talkers like these “policy experts” who insist that both parties benefit financially from a fixed-price direct primary care requirements contract no matter how much or little primary care the patient may require during the contract term. Is this fraudulent nonsense, or merely ignorant nonsense?
Q: Why do some posts seem to labor tediously to rebuild known phenomena from near scratch?
A: (1) I don’t write well. (2) as I age, it gets worse. (3) “What I cannot create, I do not understand.”
Q: How can you claim to be neutral when you’ve actually filed multiple false advertising complaints about some DPC providers?
A: I think that those primary care providers, including direct primary care providers, who do not tell wild lies about how great they are should be protected from unfair competition from those direct primary care providers who do tell wild lies about how great they are.
More broadly, only accurate information is actually useful for figuring out how to attain a set of declared goals, in this case, the noble goals claimed by DPC advocates. Misinformation is useful primarily to promote the hidden agenda of the misinformer.