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 is 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.  Similarly, a presumption of DPC efficacy might be invoked to support a §1332 waiver for a limited benefit plan that could contribute to market segmentation by risk with undesirable, cream-skimming effects. See, for example, the piece by David Anderson here.


Why I stepped up this blog in early Winter 2020

In the late Spring of 2019, the Georgia Public Policy Foundation released a proposal by the Anderson Economic Group and Wilson Partners (AEG/WP). Busy with other matters,  I only caught wind of that proposal as Winter 2020 was approaching. One component of the AEG/WP report was that all large insurers in Georgia be required to offer at least one comprehensive, ACA-compliant health plan plan that substituted direct primary care for traditional fee-for service care.  That suggestion opens the door to a potentially valuable marketplace experiment that could be accomplished with no more than modest risk, especially if restricted to, say, a set of pilot counties of varying population density.

At the same time, the AEG/WP report all but insisted that large savings from direct primary care was a given. And, because Georgia is indeed pursuing  a §1332 waiver that would allow limited benefit plans build around DPC, the danger of market segmentation by risk mentioned above seems very present.  Quite apart from their influence, if any, on developments affecting the wider health coverage market, the extravagant promises of DPC cost-effectiveness from AEG/WP report are likely to reappear in arguments to reduce or limit Medicaid spending.

Over a dozen posts in the winter months addressed the AEG/WP report. After the most careful analysis of which I am capable, I concluded its billion dollar claims were not justified. In light of the Milliman report on DPC for the Society of Actuaries, the AEG/WP report looks even worse.

Where I was in Spring 2020

As my work on AEG/WP 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 how I was trained.

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.

And here’s where I was in late-Summer 2020

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 mid September 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 $100K); and the O.J. Simpson approach (e.g., our technology will soon reveal who the real cherry-pickers are).

No response so far presents new data that has been competently adjusted to remove selection bias. Might this be because the DPC community knows full well that DPC does not bring about cost savings?

I also await the day when a DPC professional says, “Yes, of course, our way IS more expensive, but worth it anyways.” I sometimes get the feeling that DPC advocates want 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. Maybe, despite the posturing, 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.  Maybe, all the anti-insurance rhetoric in DPC is just a cover story for a transfer of wealth from insurance rentiers to physician rentiers.


Who writes this blog? 


Gary Ratner. BS, JD, PhD.  I was a full-time law professor a long time ago. I taught “law and medicine” and tons of other stuff.  I was an adjunct professor at a very large medical school. Then, a lawyer whose practice tilted toward health care finance law; I represented — at one time or another — providers, consumers, and the federal government.

Before law, and after, I’ve been on an alternate life-track involving a math-heavy area of biomedical research; some statistics and a bit of bioinformatics were involved. At least in large part because of my time as scientist, I am better with numbers than most retired lawyers. When compared to other retired lawyers, scientific training has also — I hope — rendered me generally more interested in learning the truth than in winning some argument. 

As an investigator, I aspire to an approach that would make me worthy of having once been referred to as a person “associated with” the man who wrote this. That’s why the blog comes with both comment and contact capabilities. Go for it.

Oh, and this. Maybe it is simply the case that DPC does not save money, that it never has, and that it never will.

Let me anticipate three perfectly fair questions.

Q: Why the snark?

A: Lasting effect of being a lawyer.

Q: If DPCreferee is neutral, why do all the posts seem to argue against claims that DPC is 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 most typical DPC advocates were health policy naifs armed with a religious-like level of certainty that DPC is necessarily the answer to any question asked. But some are surely health policy knaves deliberately spreading falsehoods.

Consider this stunt:

“KPI Ninja conducted risk score analysis in partnership with Johns Hopkins’ ACG® research team [.]” KPI Ninja’s Nextera study, page 7.

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

On the other side, 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. At the same time, even respectful, careful commentary like this one by a university professor is described as a “hit piece” (read it for yourself).

Show me any one 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 I’ll affirm 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.”

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