What If Occam Used a Safety Razor?

It is frightening how much of this society devotes itself to making things more complex than they need be.  Sure, a great portion of this is simple parasitic graft, legions of government employees, swarms of consultants, and the entire accounting industry whose economic survival depends on leaching cash out of those who earn it.  Yet beyond these are so many whose instinct is simply to complicate, muddy, obfuscate, gratuitously dissect, and gum up any modern pursuit.  Health care is a tropically warmed, sugar-lined Petri dish for this sort of infection.

Consider:   “Carolyn Engelhard, director of the health policy program in the department of public health sciences at the University of Virginia School of Medicine, said she is sympathetic to the challenges PCPs face, but she argued that the direct primary care model removes clinicians from the overall health care provider pool, thereby stressing already understaffed primary care practices.”  Well of course she would say that!  How much of her study, her department, and her paycheck would be rendered unnecessary by widespread DPC adoption?  But like all other “policy experts,” she wants control, and that means telling doctors what to do, and expanding the “provider pool” that can be ordered about.  Naturally, she will retreat to pleas that patients are too stupid, and too poor to access the “right” sort of DPC physician.  “There is no reason for a PCP to do everything,” said the Master of Public Health, “let a nurse practitioner or physician’s assistant do routine clinical activities and leave the more complicated situations for yourself.”  I just love someone who never did a residency or suffered a board exam tell me what I should do. 

In a new twist, Engelhard worries that patients in direct primary care, may not have their info “on a health information exchange that other health care providers can access.”  Wouldn’t that be horrible?  Wouldn’t it be lousy care for your DPC physician to actually pick up the phone to call your cardiologist, rather wait for the latter to look it up on some inefficient EHR? 

A 2018 JAMA op-ed complained that “Direct primary care is not a scalable model built on fundamental incentive drivers that shape physician and patient behavior to achieve systemic cost savings, promote equity in access, and yield improvement in population health outcomes.”  No, the journal’s parent AMA has supported NEGATIVE-incentive drivers like mandated EHR’s, SGR games, ICD/CPT shakedowns, MOC extortion, and of course, the ACA.  Their disincentive drivers have had primary care barreling toward the cliff’s edge for more than two decades.  One of their authors, Paul George, MD, MHPE (of course) whines that DPC is unaffordable and promotes health inequity.  Will DPC work in every locale?  Doubtful.  But how does this justify JAMA do-gooders trying to squash those who can do real good in other areas?  This article includes more DPC criticisms from a Brown University medical academician, and a Families USA activist.  Like Engelhard, their purpose is to complicate and control.  The Families USA rep worries, “We have seen that not all direct primary care physicians take time to explain that direct primary care does not meet the Affordable Care Act requirement of having insurance.”  (Psst, let me help you out with that one…DPC docs DON’T CARE about the damn ACA, as it is not their problem!)  “’We also want to make sure direct primary care practitioners aren’t only selecting healthy patients, since this could affect the risk models that are used to generate insurance premiums,’ she continued.”  And we don’t want to make Big Insurance uncomfortable, do we?

Nothing simplifies like a lawyer.  Barbara Zabawa JD, MPH (groan) opines that for DPC to meet the legal definition of insurance for small employers, it would have to provide “minimum essential coverage” to make the IRS and Public Health Service happy.  She does think that DPC would give large companies “more flexibility in their health plan design than the individual or small group markets,” and believes that “further legislative and regulatory work is needed to make direct primary care adoption less risky for employers and the providers who offer those services.”

Why should DPC be risky for employers or docs?  This perspective suggests a huge potential trap for DPC, wherein large corporations fearful of government penalty, are encouraged to meddle in the customer-DPC relationship.  That makes Acme, Inc. in effect a government agent, enforcing ACA stupidity in the DPC office, and providing another line of attack against the free association of patients and physicians. 

We cannot repeat this too often:  as DPC grows in popularity, Big Insurance, crony corporatism, and naked government force will increasingly combine to shut it down.  Complicating the simplicity of the DPC model is nothing but an effort to end it.