Data Efforts, DC Policy Update, Qliance, AL = #22

This post will focus on three topics: 1) DPC data accumulation efforts, 2) the new HHS (Trump) policy proposal favoring DPC, and 3) my thoughts about a recent news story covering the Qliance closure.  Thanks to Governor Ivey's signature today Alabama is now the 22nd state to pass DPC legislation (it will likely be mentioned here in the next few days).  Maine is the only state with active legislation remaining in the 2017 session.  Videos from the Hint Summit have been posted. 

Data Accumulation - Dr. Benson, Dr. Corba, and Ms. Restrepo have asked that I forward along this DPC practice survey to the rest of the DPC community.  The survey takes around two minutes to complete.  

I am working on an independent medical malpractice study and I would be grateful if DPC physicians would be willing to participate.  At this point it is only data aggregation.  If the actuarial numbers are as favorable as we expect then a much lower priced (truly customized rather than merely volume discounted) DPC malpractice insurance plan could be designed.   

Trump Policy Proposal - I have not read the full 108 page document, but Dr. Tom Price likes it and views it as a step in the right direction away from rising health insurance costs.  Page 4 of the document states:

"Achieving the President’s goals to reform Medicaid will require providing States with more flexibility to improve healthcare delivery to meet the needs of their unique populations. Direct Primary Care practices, in which physicians offer primary care services to patients at a set price, generally without payer or insurer involvement, are a mechanism to improve physician-patient relationships. Some State Medicaid programs are already testing this innovative care delivery model. HHS will explore opportunities for States and providers to further expand Direct Primary Care, which will support improved health outcomes for Medicaid populations." 

Page 62 of the same document goes on to describe the "Medicaid Direct Primary Care Initiative."  This initiative states that "DPC arrangements have the potential to improve Medicaid in the following manner: 1) Increasing Access, 2) Supporting Positive Health Outcomes for Medicaid Patients, and 3) Putting Patients and Doctors in More Control of Healthcare."  

We all know that the devil is in the details.  The health savings account hurdle was not directly mentioned in the Trump plan.  In any event additional discussion of direct primary care at the federal level by either party should be a positive development, since educated policymakers from both sides routinely favor DPC.

Qliance - As I mentioned in the May 2017 Newsletter, their closure will be discussed for some time.  This recent discussion from "State of Reform" was well meaning, but the author's comments highlight a continued societal misunderstanding about primary care.  Here is a sad quote from the article:

"[L]ong term care workers, MSWs, PAs and ARNPs are doing a great deal of good primary care work.  They can’t handle the full load of primary care demands, but they are taking on an increasing share of the actual care delivery.  This shift increasingly means that the primary care physician (PCP, MD or DO) has lots of competition for throat swabs and sutures.  Where the PCP has highest value is as the care coordinator among specialists, Rx, behavioral health integration, and inpatient/outpatient transitions."

Basic 3rd year medical student urgent care work does not equal family medicine.  Family physicians need to re-educate patients about this at every turn.  We have too many complacent family physicians that watch their scope narrow at every turn, accepting their boring employed roles, spending time reading paperwork from specialists rather than spending the time completing independent workups.  Patients have started to pick up on this, and they rightly begin to assume that there is little reason to schedule an appointment with a family physician that will merely point toward other offices.

Differentiating a viral upper respiratory infection from a Group A streptococcal infection requires about 0.1% of our knowledge base, and for those that are clinically well trained the diagnosis often does not require a throat swab or culture.  If the pretest probability is high then you are treating automatically to limit the patient's risk for post strep glomerulonephritis or rheumatic heart disease.  If you want to know what a good family physician is capable of doing, follow your grandma to her office appointment in a rural community.  A (DPC) family physician will be carefully titrating her third hypertensive medication while screening her for obstructive sleep apnea, counseling her about reducing her carbohydrate intake and using metformin and glipizide because they are affordable and she prefers to avoid insulin, all while trying to reduce her knee pain by performing bilateral kenalog knee injections to reduce her chronic NSAID use (NSAIDs such as ibuprofen stress her kidneys and worsens her CHF and HTN); treating foot ulcers secondary to her diabetic neuropathy, and doing a difficult and detailed neuro exam in an attempt to see if she has parkinsons disease like her father.  This all happens along with preventive medicine screenings where a FIT stool test is performed, a mammogram is scheduled, a urine sample is obtained and examined by the family physician with his microscope in the office due to a concern about blood in her urine with smoking history (hint: high bladder cancer risk), a baseline chest x-ray and EKG are taken, and a lesion concerning for possible squamous cell is removed via excisional biopsy off the patient's back.  

If the above scenario sounds unrealistic - if you thought that this patient would need to see dermatology for the skin biopsy, cardiology for the CHF, nephrology for the falling GFR (kidney disease), an orthopedist for knee injections, a neurologist for a neurologic exam to evaluate for parkinsons, and an endocrinologist to discuss options beyond metformin and glypizide for her escalating HgA1c - then you simply don't know what good family medicine is capable of doing. If you are aware that a family physician can manage these conditions and insist on traveling around town from one specialist to the next, then do not complain when you overpay for healthcare and waste your time in fee for service settings where there is certainly no clinical evidence of superior quality care.