Do You Enjoy a Good Debate?

Please check out the current edition of AAFP's Family Practice Management.  

Edmond S. Weisbart, MD, wrote an argument against DPC by citing manuscripts like the ACP thoughts of Bob Doherty (rebutted here) and an 11 year old concierge medicine study.  He certainly did not cite an academic manuscripts about DPC, or even any policy focused (less academic) DPC manuscripts.  I had a manuscript defending DPC in the same edition of Family Practice Management.

Dr. Weisbart's first argument that DPC exacerbates the physician shortage is the most common (and logical) policy attack against DPC.  I addressed this in full in my FPM comments, so I will not restate those here.  

In his second argument he states that DPC is unregulated insurance (citing only Missouri's law) and that it is just another form of capitation without necessary patient protections.  This is untrue. Many state DPC laws contain explicit patient protections, and those that do not include these directly have them elsewhere within the state code.  I have rebutted this in my manuscript in FPM and have an extensive legal treatise on the "not insurance" topic pending publication elsewhere with all the appropriate legal citations. 

At the end of his second argument was one of the stranger comments "pure DPCs operating completely outside of the insurance industry are not as constrained by parts of HIPAA, the Health Information Technology for Economic and Clinical Health (HITECH) act, and the Affordable Care Act that protect patients' confidential medical information. In fact, there is little preventing DPCs from selling patient data to marketers."  Any cash-pay practice (DPC or otherwise) can build an argument that it is not a HIPAA covered entity.  Selling patient data is always forbidden by state privacy laws.  The P in HIPAA stands for portability (not privacy). I expect that your data is much more secure with a pure DPC practice that will refuse to share it with an insurance company (or anyone else) without explicit permission from the patient.

His third point was that DPC relies on an erosion of medical benefits.  He stated "An employer who offers a high-deductible plan coupled with paying the retainer for a DPC has essentially locked their employees into a defined practice. For parents who prefer their children to see a pediatrician, a woman who prefers to receive care from a gynecologist, or someone who travels frequently, belonging to a DPC practice may feel more restrictive than an insurer's narrow provider networks."  So let me get this straight - if I - as a family physician (willing seller)- offer a great price for comprehensive primary care - and a patient (willing buyer) decides that my care is such a good price that she no longer wants to see outside (more expensive) specialists, I am supposed to feel bad that she is no longer willing to spend lots of extra money to see a specialist?  Any patient is free to spend all of her own money elsewhere. DPC is not the arranged marriage of capitation - it is a marriage of free will and the patients and physicians can end the relationship if need be.  DPC creates narrow networks that patients WANT to be in because they are high quality, low cost, and designed in a natural and effortless manner by their primary care physician rather than a clueless out of state administrator who's only skill is negotiating third party payment rates.

The author's fourth attack was that DPC worsens disparities in care on both financial and racial grounds.  "Although the evidence is still emerging, DPCs may be choosing to locate in areas most able to financially support the model. Studies have suggested that DPC physicians have smaller proportions of African-American, Hispanic, and Medicaid patients and see smaller proportions of people with diabetes."  His citation was a study of concierge practices published in 2005.  He did not cite any DPC studies.  The mapper indicates that practices are all over the country in rural, urban, suburban, poor, and wealthy areas.  For those that enjoy a little latin - res ipsa loquitur.