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.”
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.”
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.”
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 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?”
DPC warns Congress: our patients are at financial risk; please spend $1.8B. DPC warns its patients? Nah.
Scene One. November 2019. In an open letter to Congress, the President of the Direct Primary Care Coalition explains that, under current law, payment of subscription fees to a DPC makes an individual ineligible to contribute to an HSA. Calls for passage of a legislative fix. Scene Two. March 2020. Discussing exclusion of the DPC/HSAContinue reading “DPC warns Congress: our patients are at financial risk; please spend $1.8B. DPC warns its patients? Nah.”
Why a policy wonk like Wyden might (and, perhaps, should) kill a DPC/HDHP fix for subscription medicine. Short version.
A 1.8 billion dollar subsidy to support subscription-model contraction of primary care patient panel sizes is a problematic policy in a country when there is a shortage of primary care physicians. I came to this trying to figure something out. We hear that Ron Wyden kept the DPC/HDHP fix for subscription fees out of theContinue reading “Why a policy wonk like Wyden might (and, perhaps, should) kill a DPC/HDHP fix for subscription medicine. Short version.”
There is no excerpt because this is a protected post.
October 20, 2019: 500+ word Open Letter to Members of Congress by DPC Coaltion President asking for support and co-sponsorship of the The Primary Care Enhancement Act. Missing words: telehealth, telemedicine, virtual, telephone, phone, text message, text, SMS. March 26, 2020: DPC Coalition laments exclusion of the bill from CARES despite being sold as “meansContinue reading “The “DPC is uniquely able to telemed” train has left the station. Everyone is telemeding now.”
Possibilities to think about: DPC members who lose employer coverage will have the ability to go to ACA-compliant marketplace plans. Many of these will reach the low income levels at which ACA provides robust cost-sharing reduction is available. The relative desirability of DPC will fall. Some DPC members who lose income will become Medicaid eligible,Continue reading “Pandemic effects on DPC enrollment”
Update 4/22/2020. This one was mostly reactive to Dr White’s DPCAlliance.com essay on DPC and COVID-19. That was dated 3/19/20. I wrote this mostly in reaction to unseemly opportunism, not so much by White as by Flanagan and Springer as discussed. In retrospect, what DPC Coalition tried to do here looks almost pathetic. Expressly pitchingContinue reading “Direct Primary Care & COVID-19: some takes on Dr. White’s piece on dpcalliance.com”
Dr. Lee Gross of Epiphany, a direct primary care leader, brags about the great discounts he gets for his patients on downstream procedures like advanced radiology. And, specifically, he proudly lets us know that a big part of this involves accessing advanced equipment during slack hours. This is, of course, the same strategy by whichContinue reading “Dr Priceline’s downstream cost reduction plan cannot simply be scaled up.”
I actually hope that many doctors who have engaged in policy advocacy were blinded by ideology, or simply lying.
I see so much bad analysis and arithmetic in policy advocacy by MDs, I have to hope that it’s a result of ideological blind spots, or even outright lying. I am frightened by the principal alternative explanation: that one can too easily become an MD despite the lack of basic analytical or arithmetic skills.
Claims of cost reductions need to look comprehensively at all costs. Consider this chart from an Iora presentation of some years ago. The net drop in spending would look a lot bigger if prescription drugs (the green bar) were not part of the picture. But, a lot of how primary care, direct or otherwise, worksContinue reading “Making cost reduction claims more honest and helpful to decision-makers — random thoughts.”
DPC docs uniformly recommend that their non-indigent patients have wrap-around insurance coverage. But for indigents, particularly for what are known as “Medicaid expansion adults” too many DPC docs are willing to push their state for an indigents’ program heavy on direct primary care coupled to, at best, skimpy coverage of downstream costs. They’re eager forContinue reading “DPC and Medicaid expansion politics.”
At 2019 Summit, Mike Tuggy, MD, FAAFP, presented this: What Have Primary Care Practices Provided to Employers Who Invested in Primary Care? The Results Speak for Themselves–Reports from Across the U.S.2019 DPCSummit62019 Direct Primary Care (DPC) Summit His presentation began with high praise for Qliance and others. He suggested that these models might be usedContinue reading “A moment of clarity about selection bias – at a DPC summit.”
When the third word of an article with a quantitative angle is hyperlinked to an article by the same author, an MD who also holds an MBA, and the linked article reveals that the author can not actually calculate “markup” correctly, look hard at both pieces. Behold Why direct primary care is the future byContinue reading “Dr Rice’s “DPC saves money” fantasy.”
Update: See additional considerations here. HSA owners have the privilege of using before tax dollars for medical expenses but they are generally barred from using HSA dollars to pay supplemental health insurance premiums. The HSA privilege itself is usually justified by the argument that more “skin in the game” or “financial stewardship” for patient/consumers breedsContinue reading “An HSA break for DPC monthly fees?”
When Brain Forrest MD, the founder of the Access Healthcare direct primary care clinic, does legislative advocacy at, for example, the United States Senate, he shows the data of the foregoing chart. It’s from a 2013 course project by three NC State post-baccalaureate management students. He advocates pro-DPC legislation, apparently telling policy makers that theContinue reading “DPC + Cat is not a good substitute for full ACA Medicaid expansion”
DPC practitioners seeking to recruit insured patients often tout that the cash costs for primary care services and/or for downstream services procured through the DPC entity (e.g., advanced radiology) might be lower than even the patient cost-share for the same services procured under the insurance policy, especially high deductible policies. Patients should, however, carefully considerContinue reading “A calculus of mOOP”
Health Programs Group, University of Wisconsin School of Medicine and Public Health, Population Health Institute. Direct Primary Care (DPC): Potential Impact on Cost, Quality, Health Outcomes, and Provider Workforce Capacity, A Review of Existing Experience & Questions for Evaluation, October 8, 2019. On-line publication. The thing speaks for itself, acknowledging potential and noting absence ofContinue reading “The only bona fide university study of DPC has a message: “There’s no data.””
In a May 2018 “Policy Position” for the John Locke Foundation, Kathleen Restrepo wrote the following: A study conducted by University of North Carolina and North Carolina State University researchers found that patients seeking treatment from Access Healthcare, a direct-care practice located in Apex, North Carolina, spent 85 percent less on total health care spendingContinue reading “Spin doctor says DPC saves 85%. Don’t bet on it.”
“A university study found that patients treated in one Apex practice enjoyed average 35-minute office visits, more than four times longer than the average visit in a more typical practice. They also spent 85 percent less money.” Kathlerine Restrepo, John Locke Foundation press release of March 22, 2017 As discussed in a prior post, Ms.Continue reading “Spin Doctor: DPC office visits are four times as long as PPS office visits. Don’t believe it.”
To put it baldly, if it’s a topic and area of study you know nothing about and after a few weeks of cramming you decide that basically everyone who’s studied the question is wrong, there’s a very small chance you’ve rapidly come upon a great insight and a very great likelihood you’re an ignorant andContinue reading “Marshall on Dershowitz; or is he talking about me on DPC?”
I am not an insurance company fan.
Paladina Health maintains a news and information page on its website. As of the start of 2020, Paladina’s most recent entry of favorable cost reduction results is entitled “Paladina Health gives Akron schools a cost-saving model” and links to this Crain’s business report of an 11% reduction in claims. There was no adjustment for selectionContinue reading “11% claims reduction, with no adjustment for selection bias, is pretty tame.”
1/13/2020 Update. See this post for some cost-adjusted data that suggests that direct primary care has net positive effects. My crude analysis suggesting that DPC might have worked, at least a little, maybe once, has since been firmly contradicted by actuarial evidence. Here’s a chronological list of posts relating to AEG/WP’s “Healthcare Innovations”.
Leave aside the specific critiques of the last twenty or so posts. The support for direct primary care in the report Healthcare Innovations in Georgia: Two Recommendations ultimately turns on the source material from which the report authors drew the key assumption that direct primary care reduces downstream care cost by 15%. That material comprisesContinue reading “A few brags from a few DPC companies is not a sound basis for public policy decisions.”
Total claims cost caution: when DPC is implemented primary care claims vanish. AEG/WP’s 15% estimate is not conservative in the least.
When the direct primary advocates toss out figures about overall claims cost reductions, it’s important to carefully separate overall cost, downstream care claims costs, and overall claims costs. For example, the authors of the AEG/WP pitch for DPC in Georgia, have assumed a 15% reduction in downstream care costs and claimed that it “represents theContinue reading “Total claims cost caution: when DPC is implemented primary care claims vanish. AEG/WP’s 15% estimate is not conservative in the least.”
A possible 11% reduction in overall care cost, adjusted for risk, is suggested by Union County’s 2018 report.
NEVERMIND! In Union County adoption of a DPC option cost the county money. So say actual actuaries. I’ll leave this post essentially intact, for the record (of my folly!) Here’s some data that shows plausible overall cost reduction from direct primary care even after adjusting selection bias. It comes from the Paladina-operated clinic in UnionContinue reading “A possible 11% reduction in overall care cost, adjusted for risk, is suggested by Union County’s 2018 report.”
To learn how much direct primary care can do, try it first in the ACA-compliant, full-benefit individual market.
If Georgia must mandate the availability of direct primary care, here’s how. For some future open enrollment period, the individual market will offer paired plans that differ only by how primary care is paid for and how it is received. Bigco, for example, offers Bigco Silver FFS and Bigco Silver Direct ; MajorCo probably offersContinue reading “To learn how much direct primary care can do, try it first in the ACA-compliant, full-benefit individual market.”
Every published claim that direct primary care makes a significant dent in necessary health care spending is dubious at best. See, for example, here, here, here, here, here, here, here, here, here, here and here. When the data from the Union County clinic — a Georgia Public Policy Foundation favorite — is age-adjusted, it indicatesContinue reading “Three bad ways to bet the health of Georgia citizens on direct primary care.”
AEG/WP’s chosen actuary did not validate the assumption that direct primary care reduces downstream care costs.
AEG/WP report declares that “[Nyhart, an independent] actuary determined that “(1) the modeling assumptions are reasonable for this type of analysis and (2) the illustrative projections and savings are reasonable outcomes based on the modeling assumptions and data inputs selected.” This statement sounds like powerful support for report’s key assumption that direct primary care bringsContinue reading “AEG/WP’s chosen actuary did not validate the assumption that direct primary care reduces downstream care costs.”
Bupkes. Nextera reported a claims cost reduction of $72 PMPM; subtracting a $70 fee, and AEG/WP’s billion dollar promises fall nearly 95%.
Asked for sources supporting their assumption of 15% downstream care claims cost reduction, the authors of Healthcare Innovations in Georgia — Anderson Economic Group and Wilson Partners (AEG/WP) — point to Nextera’s contract with DigitalGlobe, as reported in Nextera’s self-published study here. And here’s the exact table from that study showing claims cost reductions forContinue reading “Bupkes. Nextera reported a claims cost reduction of $72 PMPM; subtracting a $70 fee, and AEG/WP’s billion dollar promises fall nearly 95%.”
Nextera’s marketing presentation establishes huge selection bias, while revealing modest evidence that Nextera cuts cost for some of its patients. But the data set is tiny, old, and contaminated by results for fee for service patients!
The basic premise of AEG/WP’s advocacy for direct primary care is succinctly stated in “Healthcare Innovations in Georgia: Two Recommendations” at page 24. “Establishing a relationship with a doctor for a fixed monthly fee can induce and empower many patients to see their primary care physician regularly, which results in decreased healthcare expenses and reducedContinue reading “Nextera’s marketing presentation establishes huge selection bias, while revealing modest evidence that Nextera cuts cost for some of its patients. But the data set is tiny, old, and contaminated by results for fee for service patients!”
The two largest and most current AEG/WP examples of downstream cost reduction failed to adequately address selection bias.
Although the AEG/WP report does not support its key claim with data or citation, the report’s authors responded to my request for information by indicating their sources. One of them was an e-zine article about the CHI clinic. The other two were promotional brochures, denominated case studies used, by the DPC companies Paladina and Nextera,Continue reading “The two largest and most current AEG/WP examples of downstream cost reduction failed to adequately address selection bias.”
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