CMS Quietly Launches an Offensive Against Direct Primary Care

Our healthcare system is self-destructing, a fact made more obvious every single day.  A few years ago, a number of brave physicians who were fed up with administrative burden, burnout, and obstacles to providing care for patients started a movement –known as Direct Primary Care (DPC.)  This is an innovative practice model where the payment arrangement is directly between a patient and their physician, leaving third parties, such as insurance or government agencies, completely out of the equation. 

The rapidly growing number of DPC physicians have organized into a group called the DPC Coalition (DPCC); suddenly, the Centers for Medicare and Medicaid (CMS) is paying attention.  As of February 2018, there are 770 DPC practices across the United States with new clinics opening each week as brave physicians leave the “system” behind, never looking back. Breaking free from the chains of insurance and government, this group is restoring the practice of medicine to its core, a relationship between a physician and their patient.    

CMS understands there is a problem with the way Medicare services are being delivered to tax payers; it turns out their idyllic version of “high quality” care is not as affordable as they predicted.  All evidence indicates the DPC model is not only capable of generating significant cost reduction, but also saving the federal government billions if administered on a large-enough scale.  As fewer physicians accept Medicare and convert to DPC practices, CMS wants a piece of the pie. 

CMS has chosen to hold focus groups in four cities, two meetings occurred in Boston and Dallas this past week; two more will be held in Denver on February 19th and 20th, and in Seattle on February 21st and 22nd.  One day is for independent FFS physicians and the other is for DPC physicians.  Last week, questions for the groups were reportedly: “what do you think is wrong with Medicare,” “what needs to change,” and “what will make it better?”  I find this approach patronizing as the majority of DPC docs (and many FFS) have OPTED OUT of Medicare entirely.

Two physician organizations supporting the DPC model are the American Academy of Family Physicians (AAFP) and the Direct Primary Care Coalition (DPCC.)  Representatives from both organizations were secretly present at the “listening sessions” last week, however neither organization openly disclosed the CMS meeting to their general membership.  These organizations should work to preserve and protect physician autonomy rather than invite the government to the table and conceal that fact from their membership. 

DPC physicians already opted out of government control.  Why on earth would DPCC and AAFP entertain inviting a third party back into the fold? While some members of AAFP or DPCC might be interested in a Medicare program that incorporates DPC, the vast majority of the small independents are vehemently opposed to this approach. 

Sun Tzu once said all war is based on deception.  Wise commanders take measures to force opponents to react only to the wrong circumstances. Diversionary attacks, feints, and decoys are effective tactics.  CMS has incorporated a new one, raising the false flag — an ancient ploy where ships were permitted to fly the enemy flag, so long as they raised one with their true colors just prior to attacking their foe.

One year ago, CMS introduced their “value-based” care model at the listening session I attended.  Now, CMS insinuated themselves into the leadership at the AAFP and the DPCC before unveiling their Direct Primary Care Prototype pilot program.  DPC physicians are satisfied with their practice model, who asked for a pilot program?  CMS has realized they need one.  They have designed a prototype which requires that physicians re-enroll in Medicare (capture), accept pre-determined payments of $90-120/monthly based on patient age and complexity (control), and entails submission of patient data for payment (capitulation.)   What appears on the surface to be a DPC-friendly endeavor will destroy the system from the inside. 

The DPC movement offers the first successful and innovative alternative health care approach to emerge in years.  CMS is focusing on physician capture, control, and capitulation, yet should not underestimate the fortitude of independent physicians.  We are steadfast, experienced in trench warfare, and refuse to succumb to their demands.  We will continue to fight relentlessly against mounting administrative burdens which interfere with the provision of patient care.   CMS will raise the flag with their true colors before long.  If you own a DPC or micro-practice, do not be fooled by this wolf in sheep’s clothing.  Stand strong and remain resolute.  Government, insurers, and hospitals will try to silence us, but physicians are absolutely essential to the delivery of proper healthcare.  Make no mistake, CMS is the enemy of independent physicians everywhere and our best defense is to have a good offense – leading with transparency to our patients and the public. 

If you are a physician who has been invited to these clandestine CMS listening sessions, have information to share, or wish to anonymously assist Denver or Seattle physicians who have not been invited to attend, please reach out on Twitter to me @silverdalepeds, or contact @IndDrs (Association for Independent Doctors), @IP4PI (independent physicians for patient independence), or @PPA_USA (Practicing Physicians of America.) 

This post was authored in collaboration with independent physicians who wish to remain anonymous.  May the force be with you all in the challenging days ahead.

Niran Al-Agba (@silverdalepeds) is a third-generation primary care physician in solo practice in an underserved area in Washington State who blogs at peds-mommydoc.blogspot.com.

14 replies »

  1. It seems y’all are talking about cost, but what about the benefits of healthcare access? In my DPC in rural Colorado, I learned that there are small employers that don’t offer any insurance to their employees, except healthcare spending accounts and DPC subscription.

  2. I’d like to see Medicare embrace DPC model, but I’m just a DPC patient, not a doctor.

    I’m self-employed. I have an exceptional employer insurance now, but I dont like to use that insurance because I don’t trust the profit motives of the conventional hospitals/clinics. So I purchased a family membership to a DPC.

    I quite like the care. I’ll soon buy a policy on the exchange, and boy do I wish it covered DPC membership because I pay twice for primary care. Thinking about going for an HSA plan. But, doctor tells me HSA funds can’t be used for DPC membership. I’d reallybprefer to buy Medicare with a primary care option for DPC.

    I don’t have any health conditions, but I trust my doctor’s motives in a DPC model, and I feel his care has all been medically necessary – all his advice was simple and involved over-the-counter solutions. More is not better, in my view. I feel medically unecessary care could cost me more money. My membership for my family is $160/month.

    DPC is really the closest replacement I’ve found to Kaiser Permanente (without the great automation Kaiser offers), which isn’t available in my rural town. I don’t get bills. I don’t get overly proactive doctors that see me as revenue. I don’t mind waiting for some care because when I do I can trust it, though I haven’t yet had to “wait.” I do know my doctor sees some pretty sick people (small companies that dont offer insurance), or so he says. That actually makes me feel good – that I’m part of a solution for those that can’t afford care.

    DPC is a godsend! And, I’d love to have Medicare because of its large network: my insurance provider has a terrible network in other states where I have family. I seriously can’t visit my family without worrying, “what if my son needs to go to ER.” Medicare is accepted everywhere.

  3. Chronic patients care requirements are different when compared to regular patients. For chronic patients, the provider should create a care delivery model to accommodate various healthcare requirements. A solution like HealthViewX Chronic Care Mangement will help providers provide quality care for their patients.

  4. 1.Niran is right that health care is getting worse daily.

    2. DPC works for docs in high income areas and creates a two tiered system- those that can afford”membership” in a medical practice as well as their insurance Most of us- and I am a PCP- cannot even afford our insurance. I cannot afford to use it, and I can barely afford the 892.00 a month. I am an MD. I am not going to also purchase membership in my doctor’s office!
    3 it is widely felt that the AAFP and most of our professional societies have failed us Funny that independents were “invited” to these mtgs .I never heard about it.
    4 DPC docs are hardly brave, they are tired- yes , frustrated- yes,,but not brave.Oh please.
    Here in rural MAine were I to ask a patient even to pay for forms to be filled out, paperwork, 15.00 I get RAGE.
    we need simple affordable insurance that can be used anywhere As Uwe Reinhardtxeplained and I have seen, the cause is- its the prices stupid (he said)The prices of drugs, IV fluids, devices etc drive everything up. I do not believe there is any hope frankly.There will be change only when one of two things occurs- one- massive marches in the streets, or PCps going on strike. Good luck with that.

  5. I interview 50 doctors for my book, “I Have Been Talking with Your Doctor: Fifty doctors talk about the healthcare crisis and the doctor patient relationship”. It is very frustrating to me that the perspectives of our doctors are not heard. I don’t understand how we can possibly have reform without their input. That is, if we are still interested in having doctors.

  6. “However, a colleague who retired a few years ago and moved to FL from NYC told me that she had some difficulty finding a primary care doctor who would accept new Medicare patients in the Naples, FL area”

    Yes Barry, FL seems to be a problem for Medicare patients as my wife’s mother has had trouble in the Clearwater area, as did her father when he was alive. I think there are so many Medicare residents in FL that it could be all of a practice, not that that would bother me as single-pay would be the same.

    I’m for shifting money from specialty to primary care to attract more PCPs.

  7. Peter, I don’t know what percentage of doctors support a single payer / Medicare for all health insurance system but those who do implicitly would also support accepting Medicare payment rates from all comers. I suspect there are quite a large number of primary care doctors who currently find Medicare’s documentation requirements, including electronic records requirements, unnecessarily burdensome.

    The CEO of Medtronic was quoted in an interview published in excerpted form in the WSJ recently stating that the payment world is moving rapidly toward payment for value and away from straight fee for service. The prescription drug industry is moving in the same direction especially for expensive specialty drugs. That’s as it should be, at least for drugs and devices. Perhaps the value concept doesn’t lend itself quite as well to physician services and hospital based care because of the difficulty in defining and measuring quality and value.

    Like you, I also have no trouble so far accessing high quality care as a Medicare beneficiary though I have a supplemental plan to go along with my regular FFS Medicare. However, a colleague who retired a few years ago and moved to FL from NYC told me that she had some difficulty finding a primary care doctor who would accept new Medicare patients in the Naples, FL area but had no trouble finding an orthopedic surgeon to perform a hip replacement presumably because Medicare pays acceptably well for that procedure. Apparently, a lot of the primary care doctors are saving Medicare slots for their long established payments so they can continue to be seen as they age into Medicare while keeping their overall payer mix acceptable to them.

  8. When are you going DPC Niran? Would it work in your community?

    Those patients who like DPC will sour when new arrivals realize the local DPC doc client list is full, maybe also all the other docs in the area.

    Like Barry said, high need, high usage patients will find it an advantage, people like me with low need will not. I don’t even have a Medicare Advantage supplement.

    “CMS understands there is a problem with the way Medicare services are being delivered to tax payers; it turns out their idyllic version of “high quality” care is not as affordable as they predicted.”

    As a taxpayer who has used (uses) Medicare I find this statement not true. I’ve had nothing but high quality care through Medicare as the payer. Who doesn’t like Medicare are docs who want more money.

  9. Thanks for the summary which makes a lot of sense to me. I also think your estimate of 2% of the population that might be attracted to a DPC model sounds reasonable. If it’s accurate, then even if these DPC docs can save money for the healthcare system, it probably won’t be anywhere near enough to move the needle on healthcare costs.

    While I personally could easily afford to join a DPC practice and I have some longstanding health issues, mainly heart disease, I haven’t so far because I have a traditional primary care doctor that I’m happy with and a cardiologist who I think is fantastic. I also don’t know if there are any DPC practices in my area though I haven’t made any effort to find out.

  10. Many, if not most, of these folks also have high deductible, health insurance.
    It seems that there are three groups of people, who as a whole, seek healthcare. One group is attracted to the DPC model, somewhat a throwback to the idealized family doctor of 50-60 years ago. Mostly, this group appreciates the level of trust that can occur, especially in an emergency. A second group uses a handful of specialists to assure that they get the best “scientific” healthcare. And, finally, the third group uses an urgent care center and an occasional specialist by referral from any number of resources, e.g., employer, emergency room, internet search, neighbor or friend at work.

    Men tend to populate the third group, women tend to populate the second group, and families with children or Medicare-eligible folks with stable health tend to populate the first group.
    The DPC model would fit with the first group but not under the usual array of accessibility issues that exist for 20-30% of our citizens (who often end up periodically in the second group for serendipitous reasons). I would guess that about 2% of our nation’s population might use the DPC model.

    I wonder what Niran and her DPC colleagues would say about all of this.

  11. While I understand how much many doctors like the DPC business model and I hope Medicare stays out of their way and doesn’t complicate their lives, I remain skeptical about how many patients would actually embrace it if given a chance and how many doctors could afford to offer it in their service area.

    I know of a woman in the Washington DC area in her 60’s that pays a $1,700 annual subscription fee for her DPC practice. She can afford it and she’s very happy with it. However, she, of course, needs comprehensive insurance on top of that to cover medical needs, including hospital based care and prescription drugs, that can’t be provided by a DPC practice. The subscription fee must be age based as noted by Niran because there is a huge variance in medical costs between older and younger people.

    I know that Rob Lamberts now has a very successful DPC practice in the Atlanta and I’m happy for both him and his patients. However, with all due respect, it’s considerably less expensive to do business in Atlanta than in NYC, DC, Boston, SF, LA, and Seattle. There are huge areas around the country and within most major cities where many people simply can’t afford the DPC subscription fee and wouldn’t be able to join such a practice even if they wanted to.

    For basically healthy people who rarely need to see a doctor, it just doesn’t look like a very good value, especially if you’re 50 or older. The subscription fee amounts to primary care insurance with a deductible equal to the subscription fee and then 100% coverage after that coupled with better access to the doctor and longer patient visits if needed. For those with a chronic disease or condition or complex patients with multiple co-morbidities, it’s a much better value. However, I don’t envision it ever being more than a niche offering along with traditional healthcare that must deal with third party payers.

  12. from “Inside Bureaucracy” by Anthony Downs (Rand Corp)

    Since most organizations have both functional and allocational rivals, the possibility that a bureau all be destroyed by its enemies is a real one. Its functional rivals are other agencies whose social functions are competitive with those of the bureau itself. […] In government, all bureaus supported by the same fund raising agency (such as Congress) are allocationally competitive. In the private sector, allocation competition is usually indirect. […] A bureau’s infancy, therefore, nearly always involves a fight to gain resources in spite of this latent hostility.

    If the new bureau has strong functional rivals, or if it is designed to regulate or inhibit the activities of powerful social agents, then it will be severely opposed from the start.

  13. It seems odd, what ever its motives might be, that CMS would reach out to DPC given the substantial deficiencies that nationally exists in the equitable availability of Primary Healthcare, community by community. The issue affects all age-groups and not just the Medicare eligible segment. The oddly conceived struggle within our nation’s healthcare reform seems to lurch periodically to the latest new idea. Congress should relegate CMS to its most important central function, ‘getting out of the way’ for the healthcare of Medicare-eligible citizens.
    By the way, ALTARUM published their preliminary analysis of our nation’s Health Spending during 2017 on February 12, 2018. They estimate that our nation’s health spending in 2017 increased by 4.7%. This compares to a 4.3% projection of increased GDP during 2017. So far, there is little to support the belief that there has been any population based improvement in the cost and quality of our nation’s healthcare during 2017. Remember again, that the other, 34 OECD nations devote @13% or less of their GDP to ‘health spending’. For our nation’s GDP in 2017, the difference between 18% and 13% represented $991 Billion.
    No amount of hand-wringing over outlier issues will solve that problem. No matter how you might try to reconfigure a variety “what if” propositions to re-orient our current reform trajectory, there is still no hope for solving its basic cost and quality problems. I perceive we are moving to an increasingly precarious national economy. Procrastination, veiled as new ideas by CMS, reflects a mindset to ignore the HEALTH reality of most citizens beyond the beltway.

  14. Optimistically, I say that CMS is trying to lure those who may want to do DPC but are too risk averse to do it on their own. It is a positive step away from FFS, right? We’ll see. This sounds like a wolf in sheep’s clothing. In the DPC world (of which I am a 5-year veteran), we’ve heard rumblings of CMS wanting to pilot a program, but the near universal response from the DPC docs was “hell no!!” Getting out of the tyranny of third parties in the exam room, looking over your records, and determining your “quality” is one of the biggest benefits of DPC. Very few of the docs already in DPC are likely to go (having tasted the fruit of freedom), but again, I wonder if this will lure docs away from FFS into a hybrid model. Would that work? Time will tell.