Why did I start this blog?

Does direct primary care have real value in reducing , when compared to traditional fee-for-service primary care, the overall costs of care?  There may be good enough reason to suspect that DPC could reduce overall costs to warrant probing analysis of currently available data and carefully designed experimentation in the healthcare marketplace. I am wide open to serious investigation of direct primary care, no matter which way it points; by the same token, I am bothered by advocacy that is not supported by reasonably solid evidence — very much so, when the stakes are as high as the health of my fellow citizens.

If direct primary care actually does not actually reduce the overall cost of providing care, but merely gives that appearance, advocacy for direct primary care could do real mischief.  For example, a presumption of a very high level of DPC efficacy has appeared in the political marketplace as part of a plan to reduce Medicaid spending. Or, a self-insuring employer who has experimented with a DPC option may misconstrue selection bias artifact as proving DPC cost effectiveness, and cancel effective programs that give many employees better choices. Or, purveyors of  substandard “non-insurance” health cost sharing contracts may team up with DPC  to offer consumers a shiny, but dangerous, health care path; Velveeta looks like cheese but is (a) not cheese and (b) not good.

In over a dozen posts in the winter of 2019-2020, I addressed a lengthy report prepared for the Georgia Public Policy Foundation. After the most careful analysis of which I am capable, I concluded its billion dollar claims about DPC were not justified. In light of the Milliman report on DPC for the Society of Actuaries, the GFFP report looks even worse.

Where I was in Spring 2020

As my work on GFPP came to a close with a firm doubt in the ability of DPC to reduce the costs of publicly funded health programs, I increased my efforts to find new data that would challenge that conclusion. That’s a good way to perform analysis.

While that effort was continuing in late Winter 2020, Covid-19 stimulated a lot of pro-DPC advocacy on the legislative front. Investigating that advocacy, particularly that in support of privileged tax treatment for direct primary subscription fees, led me to a second focus on the broader health policy implications of direct primary care.

Then, 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.

I feel I am close to the point of having both heard and actually listened to everything DPC advocates have to say on behalf of their movement. The most active current subject for which it seems worth tracking new movement is how the DPC community will weather the impact of Milliman’s exposure of the role of selection bias. The responses though late November 2020 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); the O.J. Simpson approach (e.g., our technology will soon reveal who the real cherry-pickers are); and, most recently, 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, some day, a DPC professional will say, “Yes, of course, our way IS more expensive, but worth it anyways.” Some DPC advocates surely yearn to say just that, but refrain because the unpopular implications of that conclusion, given a shortage of PCP physicians, will cost the movement political support. After all, someone might think that direct primary care is simply a way to extract a larger share of economic rent resulting from a PCP shortage, by offering services to those who can afford to pay well for convenience.  Like concierge care, but for younger doctors who have a smaller “installed base”? Maybe 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 idea; but who gets hurt in the process?

Who writes this blog? 

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 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 where ever 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, especially when the claims originate from self-interested providers. I’ve come to believe that many typical DPC advocates are health policy naifs armed with certainty that DPC is necessarily the answer to any question asked. But I also know some to be health policy knaves and deliberate spreaders of falsehoods.

Then, there’s this stunt:

“KPI Ninja conducted risk score analysis in partnership with Johns Hopkins’ ACG® research team [.]” KPI Ninja’s Nextera study, page 7. In multiple editions, predating 10/20/2020, thereafter recanted.

“[KPI Ninja] brought in the Johns Hopkins Research Team that has significant expertise in what is called population risk measurement”. Nextera presentation at meeting.

“We took that extra step and brought on the Johns Hopkins Team that has this ability to run analysis. It’s in their wheel house and they applied that [.] Nextera presentation at meeting.

“We were not directly involved in this analysis.” Associate Director, HopkinsACG.org.

How little one must think of one’s own work to feel the need to dress it in borrowed academic robes?

Outside the DPC advocacy community, most people in the health care advocacy and academic health policy community more or less ignore direct primary care. I’ve not found many strong opponents of direct primary care. But even respectful commentary like this measured piece from an eminent scholar is called “shameful” — by a young man who spent this last summer working side-by-side with the very man who executed the foregoing Johns Hopkins charade.

I do not find it easy to work with people like that. But it’s not for want of trying. In fact, I have even developed a test bed and other ideas that KPI Ninja itself can use to improve its way of measuring DPC performance, and then use to have its core methodology validated by a neutral party.

Show me anyone making dubious claims that derogate direct primary care and I’ll analyze those, too, with enthusiasm (and snark). Show me a claim that seems too good to be true, but is actually true, and my test bed or related ideas may even help you prove it. Use the contact form. Use the comments. Publish elsewhere and send me a link.

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 recently filed multiple false advertising complaints targeting a particular DPC?

A: I think that direct primary providers who do not tell wild lies about how great they are should be protected from unfair competition from direct primary care providers who do tell wild lies about how great they are. I think wild lies do not help direct primary care; they imperil it.


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