Brain Forrest, MD
Despite his longtime DPC advocacy, Dr Forrest’s work has yet to receive proper respect. For example, even despite his having publicized its astonishing findings, many do not recall that Forrest directed a team of NCSU graduate business students in canvassing the entire Raleigh area to observe directly the amount of time FFS-PCPs were actually spending…
As important as overhead expenses are in the economics of PCP practice, measuring overhead costs as a percentage of revenue can be profoundly unhelpful.
After attaining a certain measure of success and a spreading reputation, an illustrator can vastly increase his prices and still sell his entire output, and do so without incurring added costs for pencils, paint, paper, other studio supplies or studio space. Revenue up; no change in overhead costs; overhead costs as a percentage of revenue…
Quick guide/recap for Brekke’s “Paying for Primary HealthCare” and my responses
In an e-book and blog about paying for primary care, Gayle Brekke presents an argument laced with actuarial theory and jargon, calculations, notes, and citations. An appearance of scholarly pursuit and mathematical precision is thereby created; in both blog and e-book Brekke makes clear that she is an experienced actuary who is also deep into…
The mathmatical core of Brekke’s “Paying for Primary Healthcare rests is not reasonably supported by the sources to which Brekke points.
Because paying for primary care with insurance incurs administrative costs not encountered in direct pay models, a case can be made that direct primary care should cost a patient less than insured primary care. But most DPC advocates are themselves PCPs and they have little to gain from offering discount pricing and much to gain…
In rural areas, decreased primary care panel size is a problem, not a solution.
Montana’s last governor twice vetoed DPC legislation. He was not wrong. Over the last month or so, DPC advocates from think-tanks of the right have trotted out the proposition that direct primary care could be “the key to addressing disparities in health care access in underserved areas of Montana facing severe shortages of primary care”.…
Try due diligence before betting the health of your employees on Lee-Gross-style Direct Primary Care
In his latest Direct Primary Care slide-show brag, attributing significant overall medical cost reduction for employees electing DPC over and FFS primary care alternative offered by the same employer, Dr Lee Gross insists that the favorable results do not reflect “cherry picking”. And yet, Dr Gross fails to compare the health status of the DPC-covered…
Including Primary Care in Health Insurance Policy Coverage with Insurance Is Reasonable
The missing part 5 of Brekke’s “Paying for Primary Care”, a comment. Under the traditional insurance model, patients receiving covered primary will indirectly pay significant administrative costs, but they may also gain compensating financial advantages that Gayle Brekke’s multipart “Paying for Primary Care” series fails to recognize, ignores, or minimizes. At the top of the…
Brekke’s “Paying for Primary Care”, Comment on Part 4
In the first three installments of her Paying for Primary Care series, actuary Gayle Brekke’s invoked actuarial principles and behavioral economics to scold coverage of primary care on the ground that the costs of primary care are “predictable, routine, likely events over which the customer has a great deal of control”. In her fourth installment,…
Brekke’s “Paying for Primary Care”, Comment on Part 3
In Part 3 of Paying for Primary Care, Gayle Brekke discourses on the behavioral economics of shared health cost arrangements to conclude that insuring primary care adds costs not seen in direct pay. These cost, she contends, simply add on to the 50% administrative cost burden of insurance she had already she had already declared…
Brekke’s “Paying for Primary Care”, Comment on Part 2
In Part 1 of “Paying for Primary Care”, actuary Gayle Brekke (mis)computed the provider side administrative cost burden of paying for primary care insurance at about 28%; in a response, I showed it likely that the true number was less than 9%, indicting that Brekke had inflated by more than three fold. Now we turn…
Brekke’s “Paying for Primary Care”, Comment on Part 1
In the winter of 2021, actuary Gayle Brekke penned a four-part-blogpost-series arguing that the cost of insurance primary care delivery in the insurance system is at least 50% higher the cost of delivering primary care through subscription model DPC. Notably, Brekke’s work was theoretical rather than empirical; she attempted to compute the relative costs of…
DPC, one year after receiving a heart transplant, prepares to have old heart reimplanted.
I’m old enough to remember pro-DPC advocacy focussed on the long, in person, face-to-face primary care visits, the very “heart of direct primary care”. Surely that’s what motivated Doctor Steve Springer when he proudly opened Southwest Louisiana’s first direct primary care clinic. I say this because it certainly wasn’t telehealth Springer had in mind. After…
Do economic forces lead to healthier patients self-selecting to member- funded DPC practice?
Yes. And, favorable selection to member-funded DPC is likely even greater than that already actuarially documented for employer funded DPC. [D]o economic forces lead to healthier patients self-selecting to a DPC practice? . . .. . . The value proposition for chronically ill patients– needing frequent visits and savings on ancillary services (labs, meds, etc.)–…
Fauxtrage
While strongly endorsing direct primary care, the AAFP’s May 25, 2018 position statement to CMS on direct provider contractor models invoked the structural risk that the prevailing fee for service primary care practice model incentivizes the provision of unnecessary primary care services. As yet, the fee for service primary care physicians who comprise the vast…
New DPC leader is incredible – unfortunately, not in the good way.
Let’s meet Cladogh Ryan MD, one of the new board members for DPC Alliance for 2021 who picked up the torch from some of those golden oldies. Dr Ryan cranked up a town meeting style event to recruit some of her Cook County, IL, fee-for-service patients into her new enterprise, Cara Direct Care. She layed…
KPI Ninja and bad faith.
KPI Ninja missed so many boats — a whole fleet really — in its Nextera report, you may wonder whether they come to analysis in good faith. Well, there’s one note in their favor. Sometimes, KPI Ninja’s inability to make important adjustments disfavors their DPC client. In their analysis of DirectAccessMD, for example, an induced…
Nextera and Paladina (Everside): a race to the top of Mount Brag
Updated 9/4/21 In 2015, Qliance still towered over all in the Direct Primary Care Bragging World with its claim of 20% overall cost reductions. Even that, of course, was quite a come down from the extravagant claims previously spewed under the Qliance banner; fond memories still linger of those heady days when the Heritage Foundation…
In rural areas, decreased primary care panel size is a problem, not a solution.
Montana’s last governor twice vetoed DPC legislation. He was not wrong. Over the last month or so, DPC advocates from think-tanks of the right have trotted out the proposition that direct primary care could be “the key to addressing disparities in health care access in underserved areas of Montana facing severe shortages of primary care”.…
Shorter KPI Ninja/Nextera SVVSD report
“We used a statistically valid risk measurement tool and determined that there was a a non-Nextera population had a 7.5% difference greater level of risk then our Nextera population. But don’t believe that result, because it was not statistically valid.” “We reduced inpatient hospital 92.7%. Want to know how great we are? Our statistically valid…
Nextera brags about THIS? Really?
In its recent report from KPI Ninja, Nextera Healthcare bragged unpersuasively about overall costs savings and reduced utilization of downstream care services. But they also bragged about the following utilization figures for a group of 754 members for whose primary care they were paid $580,868 in DPC subscription fees over the equivalent of a ten-month…
KPI Ninja/Nextera report: every single cost comparison has a 10% benefit design error.
In KPI Ninja’s “School District Claims Analysis” comparing claims costs under the Nextera plan and the competing fee for service (Choice) plan, the “Analyst” overlooked two major differences between the plans in how the “School District” pays “Claims”. Nextera members pay post-deductible coinsurance at a 20% rate and the district pays an 80% share. But…
KPI Ninja’s Nextera risk measurement charade
Abstract: The Nextera “study” by KPI Ninja misappropriated the prestige of a Johns Hopkins research team to support its risk measurement claims; relied on an undisclosed and unvalidated methodology for obtaining population risk measurements; obtained highly dubious risk measurement results; and sharply mischaracterized the significance of those results. In the end, because applying even their…
KPI Ninja’s Nextera analysis: more than enough problems.
Three major adjustments are needed, even without correcting the IP admit rate problem or arriving at a more reasonable risk adjustment. Comparing data from Nextera patients and non-Nextera patients in the SVVSD programs requires three major adjustments which KPI Ninja never attempted. Computations here. Because of the different benefit structures, the district’s claim costs for…
FFS primary care is higher quality than DPC. “Proved.”
One pet theme of most D-PCPs is, “Who can better determine quality better than my patient?”, a question invariably coupled to its speaker’s brag about a high patient retention rate. And yet, in the Union County employee DPC clinic study, the actuaries observed a huge risk selection bias against the DPC, enough to require a…
DPC’s narratives can be just as misleading as their quantitative studies.
Advocates for the DPC movement have many stories to tell the public about how great DPC is. Some of their most potent narratives, however, are as misleading as their slew of quantitative studies. One root cause is that DPC advocates seem unable to imagine anyone else being as clever as they are. The ur-brag of…
KPI Ninja’s Nextera study: a “single blunder” introduction
The KPI Ninja report on Nextera’s school district program claims big savings when employees chose Nextera’s direct primary care rather than traditional primary care. But the analysis reflects inadequacy of a high order. Here’s a starter course of cluelessness, actually one the report’s smaller problems. The report ignored the effect of an HRA made available…
Nextera did not reduce inpatient hospital admissions by 92.7%.
Abstract: KPI Ninja’s report on Nextera’s direct primary care plan for employees of a Colorado school district clinic claims profoundly good results: nearly $1000 per year in savings for every Nextera clinic member and a staggering 92.7% reduction in inpatient hospital admissions. Both claims rest on the proposition that a population of middle-aged. middle-class, white-collar,…
Nextera’s Next Era in Cherry-Picking Machine Design
Note: revised and redated for proximity to related material. Original version June 27, 2020. In June of 2020, Nextera HealthCare had a hot new brag: These results were not risk adjusted. But they desperately needed to be. The St Vrain Valley School District had this health benefit structure for its employees during the period studied:…
Medi-Share gives its Christian take on DPC downstream cost savings: $31 — a year.
Christian Care Ministry (“Medi-Share”), whose 400,000 members account for more than a quarter of health cost sharing members nationally, recently acted to allow some of its members to receive credit for their entire direct primary care membership fees up to $1800 per year. That there is a certain synergy between DPC and health cost sharing…
HSA breaks for DPC defeat the purpose of HSA breaks
HSAs are intended to encourage more cost-conscious spending by placing more of the health care financing burden on out-of-pocket spending by the users of services, as opposed to having the costs of those services incorporated in payments shared over a wider group of plan enrollees regardless of service use. H/T Blumberg and Cope. HSAs are…
DPC from 30,000 feet, on September 2020
Even with all the overhead reductions that come from not taking third party payment and/or from not billing on a fee for service basisEven with those reductions transformed to increased primary care access that results in clear reductions on ED visits and other urgent care needsStill, Direct Primary Care with panels of 600 patients per…
Helping those patients most dependent on DPC means defeating the DPC/HDHP/HSA “fix”.
Plus, two more reasons to reject the “fix”. Direct Primary care clinicians and advocates often point out, accurately, that they serve a broad socio-economic range of patients. The range is well illustrated by a pair of oft-appearing themes, “concierge care for the middle class” and “affordable care for those who fall between the cracks”. In…
DPC is way different than you paying Neflix. Notes
The State of New York has the financial capital of the country (arguably the world), has the most insurance companies in the country, and was the biggest state for the longest time. For these reasons it is generally looked to for leadership in the law on financial subjects primarily governed by state law. Here’s their…
DPC subscriptions transfer financial risk.
Identifying DPC nonsense does not require a law degree. Watch out. Near you is a direct primary care advocate begging a legislator or regulator to make his medical practice less accountable. He is stomping his feet very, very hard and he’s shouting “This is not insurance”, “There is no risk being transferred”, or “My practice…
DPC cherry-picking: the defense speaks. Part 2.
Update: In the fall of 2020, KPI Ninja released the first study that relies on it’s new risk information technology. I find it sadly opaque. Recap of Part 1 The direct primary care community has long tried to support claims that DPC reduces overall health care costs by 20% to 40% with non-risk-adjusted cost-reduction data…
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,…
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,…
Ultimate DPC goal: capitation without accountability (rewrite)
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 the…
Loading…
Something went wrong. Please refresh the page and/or try again.
DPC Referee 