Keep Your Options Open, and Principle is Optional by Pat Conrad MD
“The ‘winning’ side would have paid you much better.” ~ Capt. Louis Renault
In the beginning of October, a month for scary stories, we are reminded that most of them feature a fall guy, a sap, a patsy, a doormat, the bag man with his hand out, his eyes veiled, and his ears closed. The great mob movies, spy thrillers, and classic tales of terror usually feature some schmo out to score some nice coin, selling out his own values, and collapsing into a scapegoated heap of bones, lies, entrails, accounting mishaps, failure, and ruin.
Is John Bender, MD such a mark? We can’t tell yet, because he is fence straddling, and I’ve watched enough post-apocalyptic shows to know that those can be the most dangerous types, the ones who scream for freedom even as they finger the next ones to get the cuffs. Dr. Bender has written about “The rise and fall of the patient-centered medical home” for Medical Economics, and we can take it from him. Ol’ JB is thinking of quitting his PCMH accreditation, calling it “basically a marketplace decision.” It seems like the increased payments from his handlers just …don’t …quite…make up for all “the care coordinators on payroll, …externally reporting from my large data registry, and all the other trappings” for which Bender must earn extra to support. Bubba, quit bitching: Renfield worked for flies.
Bender prevaricates that he is in an ACO, and so might need to stay on the PCMH team because of “the Medicare shared savings I hope to see in third quarter 2016.” He does note that the PCMH model “has never has never caught on with the top five (soon to be three) national commercial payers at a level that is truly sustainable.” Carlo Rizzi tried to play both sides until Michael Corleone gave the word. How many of the Joker’s henchmen had orders to kill their co-workers, and never suspected a double-cross until they heard the click behind their left ear? On “The Walking Dead” both Milton and Andrea tried to work with the Governor, for the greater good y’know, and it bit ‘em hard. Even Captain Renault read the writing and flipped after Bogie shot the Nazi major at the Casablanca airport.
Okay, so am I being a little too hard on kindly ol’ Doc Bender? After all, he is warning us, right? Well yeah, NOW he is. But seven years ago he tells us, “I was …one of the first 10 practices in my state to gain National Committee for Quality Assurance (NCQA) Level III PCMH recognition (the highest available) under the original 2008 standard. I even worked as a senior physician reviewer for the NCQA, reviewing physician practice applications for recognition.” So he liked the idea, and helped to encourage others into it.
(If only PCMH’s had laudanum…)
Bender starts this article cautioning colleagues to be neither first nor last to implement a new therapy, establishes his credibility using PCMH, then uses it to warn against Direct Primary Care: “DPC has almost a cult following. Its numbers are growing rapidly…
– “…has the potential to become the dominant form of primary care reimbursement…”
– “…payers have not been willing to make those payments in the amounts or attribution levels physicians hoped for…”
– “As more and more physicians adopt the DPC payment model, the lower costs of the model become a disruptive innovation, bringing lower healthcare costs.” Isn’t that what we want?
In his conclusion, Dr. Bender notes that DPC has quality issues to overcome, despite any contrary evidence, and does honestly note that no evidence has ever shown higher quality in the PCMH model. He signs off with confident advice for the would-be Direct Primary Care physician: “You neither want to be the first nor the last to try a new payment model.”
Translation: You’re treading water in a very cold ocean. And that really is a John Williams soundtrack you hear rising in the background, but don’t get into the boat yet. It might have a leak, and the mayor said it was safe to swim.
If DPC is left alone, it will dominate primary care within 5 years.
However there are a few obstacles as DPC grows.
DPC may be hijacked by government who does not truly understand it.
DPC may be slowed/thwarted by insurers who try to roll out their own DPC plan, but it won’t be DPC as it will come with all the headaches of third parties.
DPC may be hijacked by industry who will try a top down as opposed to bottoms up approach to control it.
So in the future, DPC must stay true to its roots, and have the doc and the patient in full control. Otherwise it will be a slippery slope down the path we have already been with managed care.
Bender’s a whore, no more, no less.
I think the DPC practices may really score a victory over PCMH ones with the rollout of the Obamacare policies with high deductibles. The PCMH practices have been accustomed to getting substantially more from third party payors for routine office visits–patients paying out of pocket may not perceive a good reason to pay more for services which are no better and are often delivered with the finesse of an industrial assembly line. Down coding will probably be impossible to do in large practices where the EHR determines the level of service. Patients who are already angry about their $6000 deductible will get little consolation by paying $150 or more out of pocket for Junior’s sore throat or Dad’s bad back.