Post Index (reverse chronological)

Nextera’s SVVSD brag has many deep flaws. This one is a real doozy.

If you truly believe a population of healthy teachers about forty years old and their families have an IP admissions rate of 246 per 1k, call me. I have a bridge you might like to buy. In their path-breaking report on Direct Primary Care to the Society of Actuaries, the team from Milliman Actuaries describedContinue reading “Nextera’s SVVSD brag has many deep flaws. This one is a real doozy.”

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 areContinue reading “HSA breaks for DPC defeat the purpose of HSA breaks”

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”. InContinue reading “Helping those patients most dependent on DPC means defeating the DPC/HDHP/HSA “fix”.”

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 theirContinue reading “DPC is way different than you paying Neflix. Notes”

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 practiceContinue reading “DPC subscriptions transfer financial risk.”

DPC cherry-picking: the defense speaks. Part 2.

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 drawn from employment health plans that allowed employees to elect between DPC and FFS primary care options options. But the first and, so far, onlyContinue reading “DPC cherry-picking: the defense speaks. Part 2.”

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?

At the moment, there does not appear to be a snowball’s chance in hell of the DPC/HDHP/HSA fix of the “Primary Care Enhancement Act” passing Congress. But let’s explore what DPC advocates would demand after PCEA passage Allowing an HSA holder to use pre-tax dollars to buy subscriptions only gets DPC operators so far. 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.”

No huge win for DirectAccessMD when employer DPC option data is compared with non-DPC cohort.

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 “No huge win for DirectAccessMD when employer DPC option data is compared with non-DPC cohort.”

On induced utilization in direct primary care, Milliman replied. I rebut.

In a prior post, I suggested that Milliman’s use of downstream claims data in assessing utilization in Union County’s employee health plans may have been distorted in favor of DPC because that downstream data had not been adjusted to reflect the effects of the County’s cost-sharing design on utilization. In a footnote to a recentContinue reading “On induced utilization in direct primary care, Milliman replied. I rebut.”

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.”

Nextera’s Next Era in Cherry-Picking Machine Design

Nextera HealthCare has a hot new brag: These results were not risk adjusted. But they desperately need to be. The St Vrain Valley School District had this health benefit structure for its employees during the period studied: The school district’s 10% coinsurance rate for the PPO predates the arrival of the Nextera option. The schoolContinue reading “Nextera’s Next Era in Cherry-Picking Machine Design”

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.”

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. But then, a failure to realize an important prerequisite for performing thatContinue reading “The mixed bag of Milliman earns a final grade: B”

The raw downstream cost claims data fed into Miliman’s “isolation” model were imprinted with Union County’s (likely pro-DPC) model of downstream cost-sharing.

Note. The foregoing post was essentially completed and copied to Milliman in late May or early June 2020. In a footnote to an internet essay at the end of June, two members of the Milliman team presented new material addressing the issues raised below. I will address this new material in a new post. InContinue reading “The raw downstream cost claims data fed into Miliman’s “isolation” model were imprinted with Union County’s (likely pro-DPC) model of downstream cost-sharing.”

Did Ratner Industries uncover the secret of health care cost reductions?

To kick off our open enrollment period two years ago, we at Ratner Industries held a company wide employee meeting. There we dusted off our brand new offering of a high deductible plan option. To get a rough idea how many employees planned on electing each option we offered free bags of M&Ms to employeesContinue reading “Did Ratner Industries uncover the secret of health care cost reductions?”

Attn: AEG/WP. Milliman study implies 12.6% downstream care cost reductions for DPC.

The AEG/WP plan still isn’t likely to work. A $95 PMPM fee, increasing at the same rate as other medical expenses, and coupled to a 12.6% reduction down stream would evaporate all of AEG/WP’s claimed billion savings. “Healthcare Innovations in Georgia:Two Recommendations”, the report prepared by the Anderson Economic Group and Wilson Partners (AEG/WP) forContinue reading “Attn: AEG/WP. Milliman study implies 12.6% downstream care cost reductions for DPC.”

Milliman’s valuation of DPC health care services at $8 PMPM rests on faulty data.

If I were a direct primary care practitioner, I’d be mildly miffed at Milliman’s reducing what I do to a series of CPT codes. I’d be more worried by Milliman’s team setting the value of my health care services at $8 PMPM. The $8 PMPM figure Milliman declared as the health care service utilization toContinue reading “Milliman’s valuation of DPC health care services at $8 PMPM rests on faulty data.”

ATTN: Milliman. Even if Union County had not waived the $750 deductible, the County still would have lost money on DPC.

The lead actuary on Milliman’s study of direct primary care has suggested that the employer (Union County, NC, thinly disguised) would have had a positive ROI on its DPC plan if it had not waived the deductible for DPC members. It ain’t so. Here’s the Milliman figure presumed to support that point. It is trueContinue reading “ATTN: Milliman. Even if Union County had not waived the $750 deductible, the County still would have lost money on DPC.”

Risk adjustment, and more, badly needed for KPI Ninja’s Strada-brag

Amended 6/26/20 3:15AM The Milliman report’s insistence on the important of risk adjustment will no doubt see the DPC movement pouring a lot of their old wine into new bottles, and perhaps even the creation of new wine. In the meantime, the old gang has been demanding attention to some of the old wine stillContinue reading “Risk adjustment, and more, badly needed for KPI Ninja’s Strada-brag”

DPC is uniquely able to telemed: a meme that suffered an early death.

An update to this post. Larry A Green Center / Primary Care Collaborative’s Covid-19 primary care survey, May 8-11, 2020: In less than two months, clinicians have transformed primary care, the largest health care platform in the nation, with 85% now making significant use of virtual health through video-based and telephone-based care. Larry A GreenContinue reading “DPC is uniquely able to telemed: a meme that suffered an early death.”

The Nextera/DigitalGlobe study design made any conclusion on the downstream effect of subscription primary care impossible.

The study indiscriminately mixed subscription patients with pay-per-visit patients. Selection bias was self-evident; the study period was brief; and the study cohort tiny. Still, the study suggests that choosing Nextera and its doctors was associated with lower costs; but the study’s core defect prevent the drawing of conclusions about subscription primary care. UPDATED JUNE 2020.Continue reading “The Nextera/DigitalGlobe study design made any conclusion on the downstream effect of subscription primary care impossible.”

Iora’s Las Vegas experience is an inapt model for DPC, and shows no real cost reduction.

While DPC Coalition features an Iora Clinic in Las Vegas as a data model of the joys of direct primary care, it is simply not representative of a general population. That clinic focused on a very high need population, every member chronically ill. We are looking at people with $11,000 claim levels at 2014 prices;Continue reading “Iora’s Las Vegas experience is an inapt model for DPC, and shows no real cost reduction.”

Why is subscription DPC the precise hill on which self-styled “patient-centered” providers have chosen to make a stand?

A subscription model is not the most patient-centered way. Consider this primary health care arrangement: Provider operates a cash practice no insurance taken no third party billed Provider may secure payment with a retainer balance is carried refreshed when balance falls below a set threshold Provider may bill patient for services rendered on any basisContinue reading “Why is subscription DPC the precise hill on which self-styled “patient-centered” providers have chosen to make a stand?”

DPC Alliance manifesto steps on its own foot attempting to prove that DPC saves money.

On May 13th, the Direct Primary Alliance published a manifesto: Building the Path to Direct Primary Care. It was signed by every officer and board member of the largest membership organization of direct primary care physicians. In so many words, it said: FFS primary care practice is being destroyed, financially, by the Covid-19 pandemic. DPCContinue reading “DPC Alliance manifesto steps on its own foot attempting to prove that DPC saves money.”

dpcreferee’s 2017 op-ed on Union County’s failure to save with DPC proved to be almost spot on.

In February 2017, I sent the op-ed piece below to the Charlotte Observer. It was not selected for publication. But it has been proven accurate in a detailed, independent study by team of health care actuaries from a firm of highly regarded actuaries known widely for its health care work. The study was prepared forContinue reading “dpcreferee’s 2017 op-ed on Union County’s failure to save with DPC proved to be almost spot on.”

That “DPC is working while FFS is failing financially because of COVID” meme takes a big hit; proof furnished by DPC Alliance.

Reality: while it is may not be a pretty picture, no one has a clear view what the pandemic’s ultimate effects on primary care practices, FFS or DPC, will be. On May 13th, the Direct Primary Alliance published a manifesto: Building the Path to Direct Primary Care. It was signed by every officer and boardContinue reading “That “DPC is working while FFS is failing financially because of COVID” meme takes a big hit; proof furnished by DPC Alliance.”

DPC advocates: an undoubtedly small number of individuals can be as high as 23,000,000.

Summer 2019 DPC advocates argue against a $1.8 budget score for their pet DPC/HPHP/HSA fix. They argue the impact is zero, and they cite a study by The Moran Company that says: The number of individuals presently barred from HSA participation solely by reason of DPC enrollment is undoubtedly small. March 2020 DPC Coalition glumlyContinue reading “DPC advocates: an undoubtedly small number of individuals can be as high as 23,000,000.”

DPC: “Unlike FFS, we’re keeping our doors open, except when they’re not.”

Ahem, indeed! The thrust of the vox.com article cited by Dr. Edwards is that primary care physicians are losing in-person visits and telemedicine visits return fewer dollars. It’s key sentence: “Doctors and other health care providers have seen a precipitous drop in the routine visits they depend on for revenue, and experts fear many officesContinue reading “DPC: “Unlike FFS, we’re keeping our doors open, except when they’re not.””

DPC and the pandemic: more capable than FFS? Or less?

DPC advocates are talking a lot these days about how a pandemic shows the superiority of direct primary care. Today, I learned this. Along with individualized medicine and the flexibility of fewer patients, however, comes one negative side effect: as Dr. Donohoe puts it, “the biggest roadblock to more people doing Direct Care pediatrics isContinue reading “DPC and the pandemic: more capable than FFS? Or less?”

Loading…

Something went wrong. Please refresh the page and/or try again.

%d bloggers like this: