The Debate Rolls On!

In a recent ACP Blog post several questions were posed to me (and other DPC physicians).  To those new to this discussion, you might want to start by reading things in this order:
1) My JABFM manuscript
2) The ACP's "Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices"
3) My response to the ACP's position paper
4) The ACP's most recent rebuttal
5) My response below (you might also find my general Defense of DPC interesting when contrasted with another physician's opposite viewpoints)

Who should oppose DPC?  Hospital systems and specialists that are highly paid in the traditional fee for service setting, largely due to the fact that they get to hide their outrageous prices until after the service has been provided.  Insurance companies benefit from these inflated prices as well, since their percentage cut is now taken from a higher denominator. DPC physicians shine a "transparency" light on this health care cartel - and they don't like it.   

How is DPC generally opposed?  Our opponents (typically motivated by one of the three groups above) attempt to confuse policymakers about DPC.  They label us as concierge practices.  Unlike concierge groups, DPC physicians do not "double dip" (charging both a periodic fee and still billing FFS insurance companies).  DPC practice overhead is generally much lower and this is typically reflected in our lower prices to patients.  

Price - "At what point, does the monthly fees charged by DPC practices make them concierge?"  Price is not a component of the definition of a DPC practice - not in the Affordable Care Act - and not in any of the 17 states that have passed legislation.  Prices do tend to be trending lower - Check out Millcreek MD (which ranges from $10-35 per patient per month).

Ethical attacks - "we accordingly urged physicians who are considering DPC... to consider steps, like waiving or lowering monthly fees for patients who can't afford them, to mitigate any potential impact on under served patients."  DPC physicians routinely discount fees for patients of limited financial means.  In fact, many comment that this is part of the joy of being a DPC physician by contrasting this flexibility to their old "job" at a "nonprofit" (i.e. non-taxpaying) hospital system that forbid them from offering patients discounts or seeing them for free.

Literature Search - The ACP did not find or chose not to cite the following 18 academic references and of these additional 45 references they only chose to cite five news articles.  This was why I chose to use the word "ignorant" in my original reply to their position paper.  Was this a harsh choice on my part - maybe, but I still feel that the use of term was accurate.  I would not have used the word "ignorant" if the ACP had published their opinion three years ago - when there was a greater paucity of DPC discussions within the medical literature, news, legal, and policy arenas.  I chose the word "ignorant" to motivate the ACP to do the right thing - to rewrite a position paper that actually focuses on DPC rather than attempting to brand it as synonymous with concierge and increase confusion among policymakers.  

More Research - Asking for more research at the end of your manuscript is a practical close to any manuscript, and is the most common way to end any paper these days.  I am in favor of more research and have been contributing to the DPC research community as much as anyone. The ACP was not "ignorant" based on its request for more research.  Characterizing my opinion otherwise is inaccurate.

Motivations - I am happy with the "DPC evangelist" label, and I would estimate that most of my colleagues enjoy that label as well.  I'm glad that we have moved from the DPC pioneer phase to the evangelist phase.  DPC is the best chance at saving primary care in our country and with the eventual development of ACA-wrap plans it has the potential to save the ACA's exchanges as well. Democrats and Republicans support DPC.  In multiple states DPC legislation has passed without a single nay vote! It's none of my business what the ACP ultimately decides about whether they support or oppose DPC - I'm not a member.  I do want the ACP to be honest about its motivations, and I have attempted to point out where they have left off information that was inconvenient to their argument.  ACP's membership of 148,000 may well be made up of many specialists - a cohort that could see their incomes fall as a result of a renewed focus on comprehensive primary care triggered by the DPC movement.  Some of their members likely have single payer aspirations.  These individuals often pretend to support the ACA, secretly wanting it to slowly (not quickly) fail, thus justifying the passage of single payer laws.  They might feel threatened when a simple solution like DPC turns up - especially since DPC has the flexibility to save primary care in our country either with or without the ACA.  I suspect that the ACP authors had trouble discrediting DPC on its merits, so they lumped DPC with concierge and then proceeded to attack both sets of practices based on the failings of concierge practices.

My Three Wishes for the ACP:
1) Publish an actual DPC focused position paper - you could even use some of your research funding to contribute something original to the medical literature.  Given your ethical concerns you might survey known DPC practices in attempt to establish the amounts of charity care they provide.
2) Publish an actual concierge (fee for non-covered service) focused position paper - it is clear that ACP has deep ethical concerns with this practice model.  I have no interest in defending concierge practices.  They have created their own set of problems.  I'm weary of these groups creating political hurdles for DPC practices to their benefit and our detriment.  
3) Disclose your motivations - I'm a family physician and I make no attempt to hide this fact. The AAFP and ACOFP represent family physicians and understand that the DPC movement is one of the best ways to reignite interest in family medicine - thus their support of the model. Is the ACP focused on the interests of outpatient primary care internists?  Maybe, but I would speculate that much of their membership is made up of hospitalists and specialists, groups that might see a dip in the amount of services they provide once more family physicians adopt the DPC model.