Founding and running Qliance taught me that Direct Primary Care (DPC) is the future of healthcare, and we must do all we can to champion it: for our patients, for the healthcare system, and for our own sake.
Direct Primary Care: Patient-Centered Healthcare
Instead of pulling patients into our orbit and holding onto them, physicians should be working to make ourselves unnecessary. Our ideal should be helping patients achieve and maintain health, so they barely need us at all.
As a Direct Primary Care practice, Qliance was able to make decisions that served our patients and our business while ignoring many of the irrelevant or harmful trends in healthcare. We were liberated by the fact that our patients paid us directly and worked with us without outside intervention.
In working with a broad scope of patients, we found many ways to improve patient care. Rebuffing detractors who have tried to pigeonhole DPC as elitist, or only appropriate for certain niche markets, we found it to be successful across the board, from individuals to employees from all types of industries, union members, insurance plan members, association members, and Medicaid enrollees. Our patients came from all walks of life, all ages, all backgrounds, and many language groups. Some patients were very healthy, and some were extremely ill. Still, every category of patient benefited and, constantly we heard them say:
“This is how healthcare should be.”
How DPC helps
A large amount of DPC’s success comes from slowing down the pace of work so physicians can get to know our patients. While it might sound simplistic, having enough time to know a patient is fundamental to providing proper medical attention. Every experienced DPC physician understands that walking into the exam room relaxed, looking the patient in the eye, and asking personal questions dramatically improves treatment. This “slowing down the pace” doesn’t mean DPC doctors’ work is any easier than before, but simply that we focus more on the patient while behaving less like a factory worker on a line that’s constantly accelerating. Much of medical success comes from understanding context and personal medical history, so we must know our patients.
Additionally, “getting to know” our patients is a dialectical experience which grows and develops the doctor’s skill over time. When doctors spend more time with patients, our care becomes more efficient since we can teach patients to manage their health, we fix causes instead of symptoms, and we can predict trouble before it strikes.
While no one cares if a factory worker improves their body of knowledge, skills, self-reflection, or powers of deduction, being a physician requires both intellect and wisdom. In the doctor-patient relationship, each teaches the other, learns from the other, and challenges the other to be better. Getting to know patients makes us grow more of the complex reasoning networks that underlie our work. Merely spending the time to “get to know” our patients makes us better scientists and more effective healers.
How Qliance Implemented DPC on a Large Scale
While the clash was fierce at times, Qliance was able to combine a startup’s need for rapid change with healthcare’s sluggish speed. After detaching from the system’s typical funding streams, Qliance had to become alert, creative, nimble, and tough. The environment constantly applies pressure, so we realized we had to adapt if we were to survive.
Originally, our staff was familiar with steady, stable, fixed environments where healthcare was predictable, formulaic, and driven by externally-imposed rules. While the larger, more fundamental changes will always be difficult (and some people had to step off the team along the way), we found that tactics like rapid, constant communication helped everyone adjust more quickly. And even though we got better at rapidly embracing small, incremental changes, we still had to actively manage our perspective so we could keep adjusting to the environment and push healthcare forward. It was not so much a revolution as constant evolution.
What Qliance has Uncovered
Ultimately, Qliance has helped me reflect on the deeper problems that plague our system. We’re battling with a fat-and-happy industry that doesn’t want to reform itself. (For reference, healthcare is 19% of GDP, while the defense industry is only ~5% of GDP, and imagine how difficult it would be to change defense!) So, while it can be easy for DPC doctors to be satisfied by our high patient satisfaction, cost savings, and high-quality care, my experience with Qliance has raised some of harder questions:
- Fundamentally, what is primary care’s domain, and which patients need which parts?
- How can DPC meet that need?
- How do we counter the ongoing push to fragment primary care into shards of sub-industries, such as segmenting off retail care, urgent care, telemedicine, and more?
These and similar questions have brought me to the following conclusions, which inform how we built Qliance:
- Public health is much more effective at improving well-being than medicine, and is a much more efficient use of money in promoting health.
- Since patients would prefer never to experience healthcare at all, the notion of a healthcare “consumer” is the wrong way to relate to patients.
- Although people may be fascinated by technology and advanced medicine, most people would rather stick to simpler, tried-and-true approaches if that is all they need to get and stay well.
- Most people don’t need any healthcare in a given year (and when they do, most healthcare needs can be met by some aspect of primary care).
- Not everyone wants or needs a doctor-patient relationship.
While perhaps unusual to hear from a physician, these conclusions are paramount for understanding how to improve health, and why health should be every physician’s first priority.
Systematic Barriers to DPC
Worldwide, peer-reviewed evidence has proven that healthcare systems require robust, accessible, universal primary care to deliver effective healthcare at a reasonable cost. Unfortunately, despite this data, the U.S. persists in merely providing lip service to primary care while sucking the life out of it. Our healthcare system says primary care is the most important aspect of medicine while starving it of resources. These flaws become even more highlighted when, instead of restructuring healthcare in general, policymakers only discuss insurance reform, a clear instance of the tail wagging the dog.
In the U.S., we have allowed moneyed interests to take over the discourse about health and healthcare completely. While in the U.S. money brings power and drives policy making, many other countries have found ways to moderate this issue by agreeing to a social contract and establishing basic requirements and standards to sustain it. In many of those countries, improved investment in primary care is, therefore, a practical matter, not even a grand humanitarian gesture, since a healthier, more productive population is cheaper to support, pays more taxes, and has fewer social issues. Instead, American interests continually obscure the view, twisting the discussion to make healthcare seem more complicated than it really is. As proven by Qliance and many other primary care organizations, good primary care saves money, gets people healthy, and does so quickly.
Since primary care and DPC, in particular, improves healthcare without requiring complicated systems or technology, why isn’t it more prolific? Why is it that when I tell an insurance company we can save them 20% on the overall cost of care, they run through excuse after excuse not to work with us? Worse, why does everyone we talk to, from the individual up to the highest reaches of government, say DPC is a great idea but fail to implement it?
I’m reminded of the movie “Concussion,” where a physician discovers the pathological proof that repetitive concussions in professional football cause severe and irreversible brain damage, leading to psychosis, depression, dementia, and suicide. Despite him finding solid proof of the link, the NFL refused to acknowledge the scientific evidence of this severe harm. Reeling from their response, the physician turns to his wife and says, “I am outraged.”
The DPC movement has found an intervention that saves lives, reduces disability, pulls people out of poverty, improves economic productivity, and saves enormous sums of money. Our problem is much larger than football player concussions, yet we’re moving much slower to fix it. People in our country are getting hurt and dying because of our inaction.
We should be outraged.
Fixing the System
While those problems sound woefully negative, I am optimistic. I truly believe that we can accelerate the pace of change if we take action to fix the healthcare system on the following fronts:
1. Insist on the Truth
Primary care is a proven solution to healthcare’s problems, and we must be relentless in insisting on this fact. DPC has also been around long enough (10+ years) to amass enough evidence showing it works brilliantly. When people ask for proof of DPC’s success, we should show them Qliance's data, Iora’s data, Vera’s data, and all the primary care research data from the last 30 years. We must continually challenge their objections because the data shows DPC works.
2. Be Bold in the Media
To get the message out, we must talk as much as possible about how the current healthcare system works against our individual and collective interests. We need to show Americans that successful innovations like DPC are improvements, but being actively ignored. The healthcare system is outrageous, so the public has the right to and should be outraged.
3. Take Legal Action
American social movements often succeed because of targeted legal action. Our constitutional and legal system has played a major role in the establishment of civil rights for women, minorities, the LGBTQ community, disabled people, and others. It has broken up monopolies and prohibited discriminatory practices in business, schooling, and housing. Our healthcare system is actively hurting people in this country, and legal action is required of us to become true patient advocates.
4. To Heal Healthcare, We Must Fight
As physicians, we love people, we love relationships, we want to help, and want to be liked, so we typically don’t take up arms. But we have a public health emergency, an economic emergency, and a social emergency in our country. We do a disservice to ourselves, our profession, and our patients by not fighting in every way possible. We must fight, both overtly and covertly, doing whatever it takes to fix healthcare, because lives literally depend on it.
Editing by Julian Wise