DPC cherry-picking: the defense speaks. Part 1.

Jump to Part 2. Within days of the Milliman report warning of the “imperative to control for patient selection in DPC studies [lest] differences in cost due to underlying patient differences [] be erroneously assigned as differences caused by DPC”, the first rumbling of resistance from the DPC advocacy community emerged. This was a suggestion,Continue reading “DPC cherry-picking: the defense speaks. Part 1.”

Milliman: A $60 PMPM DPC fee buys an employer a zero ROI.

An actuarial study brings employer direct primary care to a turning point. Milliman’s actuaries insisted that DPC cost reduction data without risk adjustment is essentially worthless. A second prong of Milliman’s analysis suggested that the direct primary care model is associated with a 12.6% over-all reduction in health services utilization*. Then, working from that number,Continue reading “Milliman: A $60 PMPM DPC fee buys an employer a zero ROI.”

DPC ultimate goal: capitation without accountability?

Allowing an HSA holder to use pre-tax dollars to buy subscriptions only gets DPC operators so far. The HSA holders would still notice that their paid subscription fees will not actually make a dent in meeting their insurance deductible. DPC advocates will then reprise their perennial theme song, “Insurer’s conditions on payment interfere with theContinue reading “DPC ultimate goal: capitation without accountability?”

Downstream consequences when employers fall for non-risk-adjusted data brags.

Do you remember when Union County’s three year DPC commitment for 2016-2018 was claimed to be saving Union County $1.25 Million per year? So why did Union County’s health benefits expenditure rise twice as fast as can be explained by the combined effect of medical price inflation* and workforce growth? For the first year orContinue reading “Downstream consequences when employers fall for non-risk-adjusted data brags.”

Medicare, dual coverage, and opt-out. The cherry on top of the cherry-picking machine for employer-based direct primary care.

In 2016, the share of people between 65 and 74 who were still working was over 25%. Any of them working at employers with more than twenty employees covered by group health plans are required by law to be included in the employer’s plan. They may also enroll in Medicare Part B. Some employer plansContinue reading “Medicare, dual coverage, and opt-out. The cherry on top of the cherry-picking machine for employer-based direct primary care.”

Two new DPC brags failed to show bona fide risk-adjusted savings; together, they make clear that DPC brags rely on cherry-picking.

Two recent DPC brags fit together in a telling way. Nextera Healthcare reported non-risk-adjusted claims data indicating that employees of a Colorado school district who selected Nextera’s DPC option had total costs that were 30% lower than those who selected a traditional insurance option. But that employer’s benefit package confers huge cash advantages (up toContinue reading “Two new DPC brags failed to show bona fide risk-adjusted savings; together, they make clear that DPC brags rely on cherry-picking.”

Nothing huge, but a possible small win for DirectAccessMD cost reduction claims.

The DirectAccessMD clinic that serves the employees of Anderson County, SC, is run by a tireless advocate for, and deep believer in DPC, Dr J Shane Purcell. Here the employer, with Dr Purcell’s apparent support, has taken steps that seems to have somewhat mitigated the selection bias that is baked into most other direct primaryContinue reading “Nothing huge, but a possible small win for DirectAccessMD cost reduction claims.”

Do bears sh. . .ake cherries out of trees? Selection pressure is built into DPC choices for any population with a normal deductible.

At last, it dawns on me. Selection bias is baked into virtually every DPC cake.* Direct primary care usually comes with a significant price and a package of financial incentives revolving around primary care (and, sometimes, around some downstream care). For some, the game may be worth the candle. The incentives, typically the absence ofContinue reading “Do bears sh. . .ake cherries out of trees? Selection pressure is built into DPC choices for any population with a normal deductible.”

Epiphany. Dr Gross’s risk adjustment metholodogy for direct primary care stands contrary to contemporary understandings of how to assess the relative expected costs of differing populations.

Dr. Lee Gross’s Epiphany Healthcare provides DPC services for some of the employees and some members of of some of their families at a hospital in Florida. Some hospital employees decline Epiphany; they and some members of their families receive instead traditional insurance based primary care. Unusually for such arrangements, a recent assessment of theContinue reading “Epiphany. Dr Gross’s risk adjustment metholodogy for direct primary care stands contrary to contemporary understandings of how to assess the relative expected costs of differing populations.”

CHANGED GRADE: The mixed bag of Milliman earns a final grade: B+

Skillful actuarial work on risk adjustment. A clear warning against relying on studies that ignored risk adjustment. Implicit repudiation of a decade of unfounded brags. An admirable idea on “isolating the impact of DPC model” from the bad decisions of a studied employer. Milliman should have recognized that the health service resources that go intoContinue reading “CHANGED GRADE: The mixed bag of Milliman earns a final grade: B+”