Board of Directors Letter (May 2018)

Dear DPC Alliance Members,

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First, we wanted to thank you for being a member of this young organization. There has been a significant amount of work in laying the foundations for future growth, but we have been working steadfastly behind the scenes. Many of you are already helping in those efforts. Thank you.

This is the first of our Board of Directors letter which is planned to be quarterly-ish. We feel that several topics need to be addressed promptly so this will be a bit longer than future BOD letters.


CREATING RESOURCES & TEAMS

We have formed some organizational structure and outlines for future member resources and projects; an updated “Resources” page on our website reviews much of those plans. We have formed a number of teams for projects. Many more are in the pipeline. We will have a more formal list of those opportunities available soon. If you are eager to get more involved, the DPCA Slack page is a great place to start.

DIRECT VS. CAPITATION MANAGERS

Although the Alliance’s main focus is giving our members’ tools to help grow their practices, we also serve as an advocate for an authentic version of independent DPC practice. To do that, we must understand how the system around us is changing. Many of these things may influence the operations of DPC practices and our larger goals.

As our movement has grown and gained legitimacy, many outside parties-- people other than you and your patients-- are starting to recognize the amazing potential and far-reaching impact of the DPC model. These entities take many forms, including employers, organizations, brokers, consultants, managers of all sorts, insurance companies, and government agencies. Some of them are merely cheerleaders of our cause; while others are engaging in business directly with DPC practices.

Recently, a number of companies are attempting to connect large groups of patients with DPC practices; typically through larger employers or collections of employers. The basic function of these companies is to manage a portion of these healthcare dollars and subcontract out primary care services through networks of DPC practices. Structurally, these management companies are very similar to a traditional Managed Care Organization (MCO, e.g. Aetna or Coventry), but restricting their management to primary care. We don’t yet have a label for this type of company, but “Primary Care Management Organization” (PCMO) seems an apt description.

So what does this mean for DPC practices? In the next couple years, we will undoubtedly be given sales pitches of “We can bring your DPC practice 500 new members!” Sounds like a great way to grow a practice, but in the midst of these discussions, we must remember the core principles of Direct Primary Care and what truly distinguishes us from the status quo managed care system.

The essence of the DPC model has always been about putting our patients back in control of their health care, including their dollars. As much as we applaud PCPs being freed from red tape and bureaucratic distractions, just as importantly, DPC empowers patients. As a patient chooses us freely on our own merits and value, It’s the ultimate “engagement” tool that has long been missing. This direct, transparent partnership has tangible benefits that people not in the exam room often can’t comprehend or measure.

Given the modern nature of primary care, moving away from fee-for-service payments is a good thing. But the Direct Primary Care model is much more than clinics charging a flat monthly fee. In the purest version of DPC, a practice works exclusively for the individual patient as individuals; not for an outside company or plan managing the health care dollars of those individual patients, especially when these individuals are grouped together on a plan.

Historically, the latter is called capitation and not a new idea whatsoever.  Whether they be private (e.g. HMOs) or government organizations, capitation arrangements have traditionally been fraught with problems for primary care. Despite this, capitation proponents claim the next iteration will be better; promising to properly value primary care and minimize the administrative hassles.

Even if you are trusting enough to believe that, the PCMO concept is fundamentally adding a layer of management and cost to the simplest version of DPC. Some would argue it is not Direct Primary Care at all. Regardless, attempts to organize patients and practices through PCMOs is well underway.

CMS “DPC” PROJECT

CMS recently unveiled a “Request for Information” (RFI) for a potential “DPC” project. Unfortunately, CMS retooled the DPC acronym as “Direct Provider Contracting”. The warping of the DPC acronym was frustrating, but the content of the document was also met with much consternation and concern.

The RFI heavily references an existing Medicare payment model (Comprehensive Primary Care Plus, or CPC+) which is a partial capitation payment to PCPs. The payment methodology with CPC+ is complicated (120 pages) but slowly moving towards nearly full capitation with adjustments for “performance” (presumably via reported metrics).

In this context, CMS described their version of DPC as, “CMS would pay these participating practices a fixed per beneficiary per month (PBPM) payment to cover the primary care services”. The RFI also mentions “an opportunity to earn performance-based incentives for a total cost of care and quality.” If you are wondering how this description is much different than CPC+ program, so are we!

Further, the RFI discusses how the CMS version of “DPC” could or should (?) be combined with Accountable Care Organizations (ACOs). If you are not familiar with ACOs, the basic concept is that all providers and companies involved assume financial responsibility for a population of patients. If it sounds complicated to organize such a thing without red tape and moral hazards, that’s because it is. The adoption and promised savings of ACOs are falling way short of expectations despite heavy investments from the federal government.

In the 9 pages of the RFI, there is only one brief mention of “direct primary care”; described as “where physicians or practices contract directly with patients for primary care services.”

Although the tone and content of the RFI were disappointing, the CMS project is still in the early stages of formation. We will continue to engage in this process to make sure your voices are represented and encourage our members to do the same. In the coming weeks, we will be sharing a full detailed response to the RFI, including suggestions to create truly patient-centered options for people to choose innovative models like DPC.

ADVOCACY & PROFESSIONALISM

As the Alliance and DPC community engages in advocacy within a changing landscape, we want to affirm that the Alliance believes in collaboration and professionalism per the ABMS standards. We recognize and respect that our members have many different views on matters related to DPC and other issues. Our passion and diversity of views can cause friction at times among each other and when interacting with other organizations.

Even when not officially representing the Alliance, we encourage our members demonstrate that we are esteemed, educated, compassionate, and thoughtful professionals. We must remain mindful that unprofessional behavior can be destructive to the Alliance and the DPC movement’s larger goals.

PRIMARY CARE ENHANCEMENT ACT & LOBBYING

There are many individuals and organizations still pushing for the Primary Care Enhancement Act  (HR 365) to be passed in the U.S. Congress. This Act will clarify a few matters regarding Health Saving Accounts (HSA) and membership in a DPC practice. The bill now as 30 cosponsors in House and remains bipartisan.

The DPC Alliance is not a political or lobbying organization but we recognize many of our members will engage in such activities as individuals or as part of other organizations. We encourage members who desire to be involved with legislative process around Direct Primary Care (including HR 365) to inform themselves about options for involvement through organizations designed for such activities. A few of these options that have lobbied on behalf of DPC matters include state medical societies, DPC Coalition, AAPS, AAFP, ACOFP, AID, AMAC, PWT, and NFIB.


Sincerely,

DPC Alliance Board of Directors