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The Origins of Direct Primary Care: Transformation, Simple Ideas, and Trojan Horses

The Origin of DPC:
Transformation, Simple Ideas, and Trojan Horses

I’m a proud Direct Primary Care pioneer. I founded the Direct Primary Care movement and was Qliance’s Chief Medical Officer, as well as a past president of the American Academy of Private Physicians.

Today, I’d like to share with you my experience of DPC’s origins, as well as some simple ideas that have driven my work in DPC. I like to think of DPC as a Trojan Horse poised to transform the entire U.S. health care system.

 

My Transformation

Although I could write forever about DPC’s origins, I’ll focus today on the source of my own transformation. I was always interested in medical care design and ethics, but if it were not for my son Michael, neither I nor any other DPC doctors would be here.

Having a son with a brain tumor altered my perspective in ways that cannot be undone. Through caring for him, I saw the effort, commitment, and ability of care providers. I also saw their remarkable lack of critical knowledge, poor service, and the ignored needs of both patients and their families.

 

Starting my Journey

After over a month of continuous vomiting from a presumed gastroenteritis, Michael was seen by a pediatrician with an oncology background. The pediatrician did a CT scan and identified Michael’s cerebellar ependymoma. The day after this was removed, Michael awoke without nausea and with an appetite for bacon. His nurse said the kitchen was willing and able to supply this, but that she couldn’t give them an order until the doctors finished their rounds. I was a practicing physician with experience with this quaint ritual, but I did not understand why my son’s needs and desires had to wait for the ritual to conclude. The nurses, doctors, and hospital felt otherwise.

This experience started my 30+ year inquiry into what works and doesn’t work in health care. I redesigned my own medical practice so it focused on my patients. I intricately modeled primary care systems. My conclusions and this new structure allow for:

  • More time with patients,

  • More room for urgent care,

  • Clearer promises, and

  • Better patient experiences

 

Moving into Subscription medicine

Two of my partners from my original practice eventually left to set up MD2, the first monthly fee practice in the US. At $1000 per member per month, MD2 was also the first ridiculously priced primary care practice, so it attracted comments in the press about concierge care and boutique primary care.

When I looked at financing an optimized primary care system, I was attracted to the monthly fee concept. Primary care is a fixed-cost business, so a monthly fee could replace the fee-for-service insurance model, with its foolish incentives and toxic costs.

I calculated the lowest monthly fee that could support a 600-800 patient panel at $30-50 per patient per month (depending upon age). It worked both as a care model and business model, so Mitch Karton and I launched the new Seattle Medical Associates in 1997, filling our practices in just over a year.

 

DPC: A National Movement

Roughly 3 years later, I moved on to supporting a national movement through a board position in the American Society of Concierge Physicians, started by Dr. John Blanchard, which later became the Society for Innovative Medical Practice Design, and eventually the American Academy of Private Physicians.  

In 2007, I co-founded Qliance, along with my cousin Erika and brother-in-law Norm Wu. We hoped that this would be the first scalable venture-backed model of Direct Primary Care. To allow us to open Qliance, we passed legislation in Washington State creating the new term “Direct Primary Care.”  

Since then, I helped establish the Direct Primary Care Coalition to incorporate DPC into the Affordable Care Act. We accomplished this with the help of Jay Keese, who remains the Executive Director of that lobbying organization.

The DPC Coalition has been instrumental in passing laws in 23 states defining DPC and clarifying that DPC is care, not insurance. We have active current bipartisan legislation in both the House and Senate that would remove two massive roadblocks to DPC by defining DPC as a legitimate deductible medical expense in the IRS code and as something that can be purchased with an HSA. These bills would open this care to millions of employed Americans. There was a recent hearing in the Ways and Means Committee of the House of Representatives featuring our bill as a strongly bipartisan piece of legislation.

Thousands of other individuals have put their shoulder to the DPC wheel and moved it into the thriving organism it now is. I wish that I could thank them all personally.

 

Simple Ideas, Trojan Horses, and the Future

In my time involved with DPC, I’ve learned many simple, impactful ideas. Direct Primary Care can be the Trojan Horse that infiltrates health care and fixes it from the inside.

 

12 Simple ideas:

1. Doctors’ actions matter, for better and for worse.

As physicians, our tools are powerful. Our ability to both help and injure our patients is growing.

2. At some point you must decide whom you work for: a payor or a patient.

This decision determines whether you go to a job or a mission. I recommend a mission. A mission is more fun.

3. Business models matter.

A business model can reinforce or destroy your mission. Pick one that won’t destroy it, such as DPC. Then, no matter your model, do only what works for your patients.

4. If you want to understand why any business fails its customers, you will find it in the business model.

This includes government, health insurance, health care, brokers, and pharma.

5. The point of medical care is not the destruction of disease, but rather the promotion of health.

Doctors have barely begun to explore and understand how this can be done. By aiming at the target of health, we will create better patient lives.

6. It is more important to operate from promises to patients than from rules suggested by textbooks and committees.

While you must prepare to do both, always keep in mind which one has priority.

7. When you walk into an exam room, know what you plan to do.

Is it diagnosis, coding, treatment or something else? Myself, I always strive to have every patient leave the room better equipped to create their own health.

8. Chose empowerment over dependence.

Before you tell a patient what to do, you need to know what they want and need. Then, you can give them the tools to care for themselves.

9. Share the truth with your patients about what medicine can and cannot offer.

You don’t have to be the Wizard of Oz. You can be real and transparent.

10. Live outside of yourself as much as you can.

Worry less about you and more about your patients.

11. Join the DPC movement and help further its mission.   

By participating and inspiring each other, we’ll improve health care. Connect with other DPC docs at the Hint Community. Come to next year’s Hint Summit and the DPC Summit. Give advice and get advice. We need all the help we can get.

12. Walk away from the class warfare in medicine.

Infighting, such as between DPC and concierge, destroys our credibility and deprives our patients of options they need to know about.

 

Our 2 Trojan Horses

1. Primary care has much more power than it realizes or wields.

We do most of the referrals in health care and our patients trust us. In every case, we can work with on our patients’ behalf, or we can be the gatekeepers or financial enablers of a dysfunctional health care system. The choice is ours.

2. Almost nobody thinks that primary care can fix health care, but…

If you look at what Qliance, Iora, R-Health, Nextera, and others have been able to do to right the ship of health care, you will discover what’s possible for this movement.

 

The Future

1. We can work together, or we can stay disorganized and powerless.

2. We can fight over our relative purity and perfection, or we can understand that we possess neither and that there are many ways to serve our mission.

There are many business models as yet undiscovered that can promote and defend our mission while expanding our reach and ability to serve patients.

3. Today is the end of this movement’s beginning.

I do not expect to see the culmination myself. Today, I am passing the baton to you, the next generation. Use it wisely.

 

 

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