Some DPC thought leaders seem barely able to engage in a good faith discussion. In a twitter thread in May 2020, one in which seven DPC Alliance leaders participated and argued that DPC was enduring COVID far better than FFS, I pointed out that documents linked on DPC Alliance’s own website showed that DPC docs had taken PPP loans at a 67% higher rate than their FFS counterparts. One of those Board members replied:
All I can say is none of the 20 or 30 DPC docs I’ve chatted with in last m (sic) 6 weeks have had any financial issues. In fact, they are all adding patients. But that’s probably not scientific enough for you. The Alliance hasn’t heard from any DPC docs to date struggling due to COVID
https://twitter.com/docshanep/status/1264261183495901184?s=20
Less than six weeks previously, that same fellow’s own two doctor clinic had taken its own six figure PPP loan. Over half of the DPC docs participating in the thread had done likewise, swearing under penalty of law that economic uncertainty required the loan to maintain operations.
But it gets worse, a lot worse.
In early 2017, Paladina’s Union County clinic bragged a $1.28 Million, 23% annual DPC savings. It emerged just in time to take to become the principal poster child of the DPC movement. In May of 2020, however, the game-changing Milliman brought the tools of actuarial science, risk adjustment most prominently, to bear in an independent study of the cost-effectiveness of that very clinic. The results were not pretty.
The Milliman study kicked firmly to the curb ALL prior studies, including the prior Paladina study, for want of proper risk adjustment. In fact, the Milliman study found that a claims cost adjustment of 36% was required to account for the health differences between the studied Union County populations, more than enough to swamp Paladina’s 23% savings claims that had been based on raw unadjusted data. The Milliman team made plain as day its estimate that Paladina’s Union County clinic program had not produced any significant cost savings for the county.
The Milliman team admonished that:
It is imperative to control for patient selection in DPC studies; otherwise, differences in cost due to underlying patient differences may be erroneously assigned as differences caused by DPC. Grzeskowiak and Busch, What our study says about Direct Primary Care
This admonition might have had a useful, if sobering, effect on direct primary care, if the DPC community were actually interested in advancing the movement based on the skills of its medical doctors rather than on the proficiency of its spin doctors.
A few months after the Milliman report was published, Nextera blazed an interesting path in coping with the risk-adjustment imperative.
“KPI Ninja brought in the Johns Hopkins research team that has significant expertise in what is called population risk measurement. . . . We took that extra step and brought on the Johns Hopkins team that has this ability to run analysis. It’s in their wheelhouse and they applied that . . . [The] Johns Hopkins Research Team did the risk analysis[.] Nextera presentation at 2020 Hint DPC Summit meeting.
Ah, but:
“We were not directly involved in this analysis.” Associate Director, HopkinsACG.org.
Not only was there no academic team involved in Nextera’s deeply flawed study, which fraudulently bragged at the 27% level, no risk adjustment was actually performed. It was an heroic charade.
Paladina understood at once that they had to launch their own charade, which appeared on its website a few months later. After coupling Paladina’s own lip service regarding risk adjustment to performative praise of the Milliman study, Paladina’s spin doctor went on to declare that “Paladina Health’s Union County client, the employer case study featured in the Milliman report, also prospered from adopting the direct primary care model. . . . Union County taxpayers saved $1.28 million in employee health care costs . . .. 23% . . ..” No matter that the Milliman team had actually exploded that very conclusion.
DPC Referee 