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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.

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Angela AkridgeHealthViewXJ Antonucci MDprothbaum@gmail.comPeter Recent comment authors
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Angela Akridge
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Angela Akridge

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… Read more »

HealthViewX
Guest
HealthViewX

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.

J Antonucci MD
Member

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… Read more »

prothbaum@gmail.com
Member

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.

Peter
Member
Peter

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… Read more »

Barry Carol
Member
Barry Carol

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… Read more »

Peter
Member
Peter

“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… Read more »

Barry Carol
Member
Barry Carol

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… Read more »

pjnelson
Member
pjnelson

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… Read more »

Barry Carol
Member
Barry Carol

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… Read more »

Angela Akridge
Guest
Angela Akridge

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.

William Palmer MD
Member
William Palmer MD

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… Read more »

pjnelson
Member
pjnelson

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… Read more »

Rob Lamberts
Member

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… Read more »