The ACP Should Know Better

It was with great sadness that I reviewed the American College of Physician’s (ACP) recent report about “Direct Patient Contracting Practices” (DPCPs).  This group of misinformed “ACP Medical Practice and Quality Committee” members apparently elected not to conduct the thorough literature search that they promised.  They failed to understand the critical legal distinctions between DPC, Concierge, and other forms of private medicine, and then proceeded to make many incorrect generalizations about DPC.  They used a condescending tone to imply that while they believe in the freedom to practice medicine in any manner that best serves the patient, DPC hints of unethical behavior.  In short – this group has a great deal (of ignorance) in common with the Governor of Montana.  Let us consider each of these three fallacies one by one:

1. They failed to conduct the “extensive literature review” that they promised.  

For any that might have been paying attention, I have attempted to make the literature review process easy by laying out the most relevant DPC related academic and nonacademic resources on DPC Frontier.  In case the authors were unable to locate my website (certainly forgivable due to lack of search engine optimization), many of these resources may be found with simple PubMed or google searches for the phrase “direct primary care.”

For this “academic” analysis the ACP Committee did the following:

- The authors managed only 32 citations for a roughly  10,000 word position paper (compare this to my manuscript in JABFM that was one quarter the length but contained more citations, and my citations were from reputable sources)
- Their only DPC citations were from 1) Forbes, 2) The Hill, 3) Kevin MD, 4) Time, 5) US News – no academic sources were used, and only one of these studies was authored by a physician.
- They failed to cite DPC articles already available from academic sources such as 1) Health Affairs, 2) Family Practice Management, 3) The Journal of Health Life Science & Law, and the 4) West Virginia Medical Journal.
- They failed to cite any works by published leaders in the DPC field including the 1) Direct Primary Care Coalition, 2) Family Medicine Education Consortium, 3) Brian Forrest, MD, 4) Garrison Bliss, MD, 5) Erika Bliss, MD, and only mentioned one small AAFP article rather than covering any of AAFP’s resounding endorsements of DPC
- They failed to cite any of the fourteen state laws discussing and often defining DPC
- Routinely cited outdated, inaccurate, and nonscientific web surveys from Concierge Medicine Today and the American Academy of Private Physicians
- Failed to mention any well-known DPC practices such as Access Healthcare or AtlasMD, but did mention long-deceased groups such as Health Access Rhode Island (a network that never took off the ground).  Why not do a basic google search?  Health Access Rhode Island doesn't even have a website at this stage!

2. Their DPCP Definition

Their definition of the brand new term that they have started “DPCP” is so broad that it is essentially useless.  It immediately lumps together DPC and Concierge medicine.  This is the worst mistake an author in this field could make.  

The authors could have used the following language to start their position paper in a more honest manner.   “We are ignorant about direct primary care.  We think DPC sounds like concierge medicine.  Concierge Medicine is unethical.  Therefore DPC is unethical.”

3.  A Few Thoughts About ACP's Ethical Commentary

If I run a DPC practice where I charge less per month than a cell phone bill and never ask anyone “what is your insurance” how am I excluding patients?  Am I not less exclusive than the average fee for service practice that elects to cap the number of Medicaid or Medicare patients it is willing to accept?  

Speaking of Medicaid patients, why did you neglect to comment on the 20,000 Medicaid patients that were seen in the DPC setting by Qliance?  You breezed right past this fact and barely noted this project at all.

If a physician has a panel of 3,000 patients and she sees each patient on average less than two times per year for an average of twelve minutes – is this actually considered the effective delivery of primary care?  Is it any surprise that these patients regularly rely on fragmented health care in the urgent care and emergency department?  Compare this to a DPC physician with a panel of 600 – 1,200 patients where she spends an average of at least thirty minutes with the patient over an average of four or more visits per year – THIS is actual medical care – and it is the reason these DPC patients do not need to waste time and money seeing other emergency and urgent care physicians.  

The insinuation that DPC practices select for healthier or wealthier patients is simply untrue. There is no data to support this, and anecdotally DPC physicians have reported the opposite in many case reports.  Patients with neglected chronic care issues are often the first to understand the DPC value proposition, and practices that convert routinely note that the patients that elect to remain a part of the practice come from many different financial backgrounds.

The ACP should be ashamed of this uninformed commentary.  It leads me to question their intentions.  Do they represent primary care physicians, or do they represent specialists that rely on the dysfunctional fee for service system to retain their inflated fee for service reimbursement rates?  To anyone at ACP that might be reading this, please read an informed manuscript in the Journal of the American Board of Family Medicine before commenting further.