My Full Commentary to Medical Economics (Updated)

I'm often asked for my commentary in a variety of media sources.  On May 18, 2017 I was asked to provide comments for a untitled Medical Economics Article.  I provided detailed commentary and few of those comments were used in a manner that might lead readers to believe I am pessimistic about the DPC movement.  This is not the case!  I am happy to report that the Medical Economics article has since been updated and now fairly presents my commentary.  As a reference I am leaving my full thoughts below.

1) Size can be a disadvantage when it comes to direct primary care.  Small practices can grow organically at a manageable pace and by design they are customized to fit the interests and experience of the founding physician.  Most physicians start with sources of revenue from other work outside the DPC practice and slow growth allows for a transition into a full time DPC role.  When larger groups take on millions of dollars in equity this funding comes with pressure to grow rapidly. DPC patient panels can be filled up quickly when you work with a Medicaid managed care company, a Medicare Advantage company, or a large employer.  When you work with these large groups retaining the "selected marriage" effect of DPC rather than morphing to the "arranged marriage" of capitation can be a challenge.  Large groups rightfully expect data, and often they expect it in a format that can be difficult to obtain.  When these processes are put in place to obtain the data they can erode the efficiency of the DPC model. 

2) Their closure means that one of the most important hypothetical questions in the DPC community remains unanswered: can the DPC model be scaled?  We already know that small and independent DPC practices can be financially sustainable.  There are general business and administrative economies of scale that happen as a practice grows, but the quality and patient outcomes are ultimately up to the physicians and nurses providing the care to the patients.  Being a great DPC physician is more difficult than being a great urgent care physician, and not all physicians are willing to put in the time required to thrive in the DPC model.  I believe the model can be scaled if the group has the right physicians working with the right patients & employers.

3) I am concerned that the DPC movement appears to be growing at a linear rather than exponential rate.  Most of the growth is happening in the form of smaller stand alone DPC practices and greater than 90% of them appear to remain open.  This reflects some stability in an obviously unstable American health system.  My greatest concern is that too few family physicians are willing or interested to practice broad scope family medicine, and too few patients are willing or aware that they should be holding their physicians accountable to this higher standard.  Family physicians have grown complacent over the years and allowed their referral rates to balloon. Family physicians should be learning new procedures and conducting medical literature reviews.  These efforts make us better physicians and allow us to offer more value to our patients for their DPC dollars. Too many patients see direct primary care and think 'I already have a cardiologist, endocrinologist, and neurologist, but I never see my family physician so I would never use DPC.'

4) I would tell those that are concerned to do their homework and learn the full history of DPC.  Remember that when you have seen one practice, you have only seen one practice.  DPC is too diverse to fail en masse.  Turntable Health was just one part of Iora Health and the majority of Iora Health practices are still open.  It remains to be seen what will happen to the DPC physicians and patients at Qliance. Many will likely follow in the lead of Garrison Bliss, MD.  Dr. Bliss was previously at Qliance but has his own thriving independent DPC practice called BlissMD.  I suspect many Qliance patients will follow their physicians into smaller independent DPC practices, so the closure of Qliance might not result in the loss of any DPC physicians from the movement if they each launch their own practice.

5) Stay diversified.  Most small businesses take a few years to reach profitability and DPC practices are no different.  If you are starting a DPC practice keep your moonlighting options open to avoid a cash flow crisis.  If you still have free time spend it marketing your practice to the community.  If you take a laissez-faire attitude it will show.  Being a DPC physician empowers you to be a great doctor, maybe even a "doctor's doctor."