1:50

Primary care is an innovative, alternative

1:53

path to insurance driven health care. Typically,

1:57

a patient pays their doctor a low monthly

1:59

membership and in return,

2:01

builds a lasting relationship with their doctor

2:03

and has their doctor available at their

2:05

fingertips. Welcome

2:07

to the My DPC Story podcast, where

2:10

each week, You will hear the ever so

2:12

relatable stories shared by physicians who

2:14

have chosen to practice medicine in their individual

2:16

communities through the direct primary

2:18

care model. I'm your host, Marielle

2:21

Conception, family physician, DPC

2:24

owner, and former fee for service doctor.

2:27

I hope you enjoy today's episode and

2:29

come away feeling inspired about the future

2:31

of patient care, direct primary

2:34

care. Now

2:38

you guys are walking into this amazing

2:40

conversation that has already been going on for a few

2:42

minutes, but I am joined with some amazing

2:44

people. Some of you listening already

2:46

met them at DPC summit, so

2:48

please, my esteemed guests, can

2:51

you please introduce yourselves? Dr. Garrison

2:53

Bliss, we'll start with you.

2:54

Garrison Bliss. I am a retired

2:57

direct primary care doctor, but

2:59

my major distinguishing feature

3:01

is I was the first one. So

3:03

I have been in all the trenches with many

3:05

of you and I was brought

3:08

here to sound elderly, which

3:10

is easy.

3:11

And in most recent times, he's also been known for

3:13

being an assumed pickleball player. So if

3:15

you play pickleball, you, you are amongst

3:18

great company and Dr. Eskew, we'll

3:20

turn the mic over to you now.

3:22

Phil Eskew, a family physician and attorney

3:24

been practicing in the drug primary care space as

3:26

soon as I could, which was as soon as I finished family

3:28

medicine residency in 2015, done

3:30

that in the onsite space. Also got a correctional

3:33

medicine background, been working with Jay Keese

3:35

and the coalition now for 10

3:37

years too, which is great. It's

3:39

just flown by. And it's been a lot of fun.

3:42

Amazing. And you are the counsel

3:44

for the DPC coalition. So I think

3:46

that it is so important, and Garrison

3:48

has shared this before, that this movement

3:51

be physician led because we do not

3:53

want to get ourselves into the same fee for

3:55

service situation that we are currently trying to escape

3:57

left and right from. And so, Phil, it is so important

3:59

that you are a physician. You are still a practicing

4:02

physician with so many different

4:04

places you've practiced, and so it is

4:06

wonderful to have both of you continuously

4:09

involved in this movement. Now, Jay, I'll

4:11

turn the mic over to you.

4:13

it's a pleasure to be here with you all. I'm

4:15

Jay Keese and I I'm the executive

4:17

director of the Direct Primary Care Coalition Garrison

4:20

Bliss came to me in 2009,

4:23

I believe it was, and, and

4:25

and, and his with his protege

4:27

Norm Wu and, and, and a few other people

4:29

and, and asked for some help

4:31

in the lobbying and policy world after

4:33

they had actually already passed a bill in Washington

4:36

State to sort of navigate. What,

4:38

what would become known as the Affordable Care

4:40

Act. And so we started the Direct Primary

4:42

Care Coalition, which Garrison still chairs

4:45

back in 2009 to help pass

4:47

the provision that first defined

4:49

direct primary care in federal law.

4:52

And we have been active ever

4:54

since in passing not

4:56

only the provision that was in the act that first

4:58

defined DPC as

5:00

a part of the essential health benefits. Plan

5:03

part of the Affordable Care Act, but

5:06

then passed state laws in 33

5:08

different states that define

5:11

direct primary care as a medical practice

5:13

outside of state insurance

5:15

regulation. Phil, since

5:17

you know, almost the very beginning has been our

5:19

general counsel. Not only a doctor,

5:22

but an MBA and a lawyer, so we're,

5:24

we're really happy to have these two folks

5:26

as, as the physician leaders of the coalition

5:29

that have really helped us put together the policy

5:31

agenda, which has really been quite

5:33

unique over the course of the last 10 plus

5:36

years it's not it,

5:38

it's not easy to say you've passed

5:40

all these provisions in a bi

5:43

pa bi partisan manner in today's

5:45

environment, but these are things that we've

5:47

gotten the Obama administration, the

5:49

Trump administration, and the Biden administration

5:52

to agree on, that people ought to have better access

5:54

to primary care, it ought to be paid

5:56

for at a flat fee, without

5:59

insurance company involvement in terms of

6:01

Billing and coding and all the other things that

6:03

go into, you know, really

6:05

making primary care more burdensome and more

6:07

expensive and just let the doctor

6:10

and the patient make the decisions for primary

6:12

care as they should. And, and and here we are

6:15

facing a number of policy hurdles

6:17

that we still have to fix and some

6:19

new challenges ahead. I'm

6:22

very excited to have seen the growth

6:24

over these years and super

6:26

excited to have. This cadre

6:28

of great physicians that are really helping

6:30

to bring better primary care to everybody in America

6:32

and in every, in every

6:34

setting, Medicare, Medicaid, private

6:37

pay, uninsured.

6:39

The entire gamut is, is really

6:41

all the boats are rising because DPC

6:43

docs are there to help people really

6:46

get in tune with, with their own

6:48

health in a relationship that otherwise

6:51

isn't available anywhere else in the American healthcare

6:53

system. So. Sorry to

6:55

ramble, but I'm passionate about this.

6:57

I'm a patient, Dr. Matt Hayden

7:00

here in Alexandria, Virginia is my doctor

7:02

and he takes good care of me. And

7:04

it's, it's, it's just wonderful to

7:06

be a part of this movement.

7:07

Wonderful. It is. And you we have

7:10

literally the gamut of people who have been involved

7:12

in this world for so long on so many levels,

7:15

taking care of the patients all the way to policy.

7:17

And I really feel that this talk

7:19

is so important for people to hear right after summit

7:21

right after they'll they've heard your lecture

7:24

on the legal updates to DPC

7:26

and you've said this but you know people

7:28

still come up to you and say Oh, there's legal hurdles

7:30

with DPC and we will be talking about that today,

7:33

not only through what is going on

7:35

in Capitol Hill, but also how you as a listener

7:37

can become involved. So with

7:39

that, I wanted to go back into

7:42

the days before DPC.

7:44

So Garrison, there was a time when we

7:47

did not have primary

7:49

care being the bottom of the barrel when

7:51

it came to number of physicians going

7:53

into primary care when it came to

7:55

the way that a primary care physician was valued

7:57

by patients as well as employers.

8:00

So can you give us a flavor for how

8:02

things were before Direct primary

8:05

care?

8:05

In the dark ages, is that what you're saying? Well,

8:08

yeah, well, I started being

8:11

a primary, I started being a primary care doctor

8:14

in a private practice in 1980. Finished

8:17

my residency at the

8:19

University of Washington and went out

8:21

to, to earn a living doing

8:23

primary care, which is something that I

8:25

love from the beginning. I would, I

8:27

thought I was pretty reasonably well trained.

8:30

I mean, I listened to all the same talks

8:32

that you folks have probably listened to about, about

8:34

spending time with patients about

8:37

about open ended questions

8:40

and when I got out into practice,

8:42

it really was like that. I love

8:44

to spend time with people and I really

8:47

enjoyed the work. I joined a practice

8:49

that grew pretty rapidly. But

8:52

About the early 1990s,

8:56

it was clear that we were going to go broke

8:59

probably doing that, although

9:01

not immediately, but we were easing

9:04

our way up and we were seeing enormous

9:06

pressure. To get better

9:09

at the business because the, the

9:11

insurance companies were not increasing our income

9:13

as, as the cost of healthcare was rising,

9:16

but they were increasing the amount of work we had to

9:18

do. And I had

9:21

some, had had some pretty stunning

9:23

learning pretty stunning learning curve.

9:26

several years before that when my three year

9:28

old son had a brain tumor and I

9:31

was able to experience what it's like

9:33

to be the father of a

9:35

patient rather than the doctor of

9:37

a patient and to watch how

9:39

the healthcare system managed him in

9:41

a very good hospital, probably the

9:43

best, probably the best children's hospital

9:45

in the state and with the

9:47

right kinds of medical care, but

9:49

with not very much attention to

9:51

the actual service part of the

9:53

work and also very limited

9:56

support for parents. And

9:58

then I started to look at my own practice and

10:00

began to realize that maybe we were

10:02

slipping into some of those problems

10:05

that we were trying to speed things up. And we

10:07

were trying to figure out a way to

10:09

stay cash flow positive.

10:12

And we were struggling. And also

10:14

we were the pressure was to see more and

10:16

more people. And I

10:19

decided that although

10:21

this had what most doctors had not

10:23

reached any kind of breaking point I

10:25

had, and that I really wanted

10:27

to break off and go do something different

10:30

and better and spent

10:33

a lot of effort trying to think about how

10:35

it could be better. And in

10:37

particular, how big a panel

10:40

was the right size of a panel. How

10:42

much? How much time should be spent per

10:44

visit or per patient? Should

10:46

we see everybody every year? What kind of,

10:49

you know, try to figure out

10:52

how to make it better. How to see

10:54

people for urgent care urgently

10:57

and without sending them to the emergency

10:59

room or the hospital to get that

11:02

work done so to maintain a relationship

11:04

with them in which they could trust you. So

11:07

all of this stuff seemed very important to

11:09

me at the time. And eventually

11:12

I started working out the design,

11:14

which also eventually included a

11:17

question of how much would it cost?

11:19

Because I had already realized that insurance

11:21

companies, as they existed then,

11:23

even though they were paying much better

11:25

than they are now, they

11:27

didn't care at all about the rest, about

11:30

how many minutes I spent with a patient or whether

11:32

I cured them or anything. They were paying

11:34

little attention to that, but they were increasingly

11:37

trying to control. The amount of money

11:39

that they paid to us to do this

11:42

work, and gradually we were asphyxiating.

11:45

So, after a few computations,

11:48

it became clear to me that

11:51

with a panel of 600 to 800

11:53

people, which I thought I could manage because

11:56

I was pretty young and many of my patients

11:58

were reasonably young. And

12:00

I knew that I could do that. And

12:02

with that panel, it would cost about 50

12:05

to 50 to 60

12:07

per member per month to do it. Two

12:10

of my partners had just left to go

12:12

for start the first concierge

12:14

practice in the United States, which was

12:17

which was MD square at

12:19

a thousand dollars per member per

12:21

month. That, that used to sound like

12:23

a lot, but it's apparently not anymore,

12:26

but that was the first really concierge

12:28

practice. And I thought I liked

12:30

the monthly fee, but I didn't like the rest of the

12:32

baggage. I wanted to take care of everybody.

12:35

And I wanted something that Could

12:37

scale to take care of everybody.

12:39

So that so Seattle Medical

12:42

Associates switched from being a fee for service

12:44

practice in 1997

12:46

to being a monthly fee practice.

12:49

And then as time went on,

12:51

we discovered that we had to figure

12:53

out a way to teach other people how to do

12:55

this because it really worked way better than we thought

12:57

it was going to work. We suddenly discovered

12:59

that as good as we thought we were, We were

13:01

like three times as good when we

13:04

had the right panel size and the right amount of time

13:06

with patients. And the patients loved

13:08

it and we loved it. And I didn't

13:10

see a reason why the rest of the country

13:12

couldn't do that too, because it wasn't

13:15

expensive. So anyway.

13:17

A after that we started forming

13:20

national organizations to start to understand

13:23

this. It, it was originally, it was called the American Society

13:25

of Concierge Physicians and then

13:27

morphed into si, society for Innovative

13:29

Medical Practice Design and several

13:32

other names along the way.

13:34

And then Direct Primary Care was,

13:37

was, was created as

13:39

a descriptor so that we could pass a law in

13:41

the state of Washington where the insurance commissioner

13:43

thought that we were illegal. Flat

13:46

illegal and that he was

13:48

going to start closing our practices and we didn't come

13:50

up with an argument. So

13:52

after that it's just kind of progressed

13:54

along. I'm not going to go through the whole history, but

13:56

I do want to just let you know that

13:59

that health care has

14:01

been getting gradually worse since then.

14:04

It's now kind

14:06

of almost a sordid affair to

14:08

watch it Going on as

14:10

doctors are running as fast as they can

14:13

to get their coding right and to see

14:15

more patients than they ever saw before.

14:17

And it's all of the middleman middlemen

14:20

have stepped in to help us out and

14:22

and suck up the money that's

14:24

going into health care. And the

14:26

insurance companies have just figured

14:28

out what makes money for them, but they haven't really

14:30

decided yet a way to get actual

14:33

first rate care to human beings. So

14:36

we're doing that. And it's

14:38

scaling remarkably well

14:41

across this country right now

14:43

we're no longer a secret, and

14:46

we're even beginning to encounter policy people

14:49

who think they invented the idea and

14:51

think maybe we should try this now. So,

14:54

so there's a lot of cool

14:56

stuff going on. And there's a possibility

14:59

that the vision that

15:01

I had prayed for and hoped for

15:04

but never thought would encounter

15:06

might actually come to place, which

15:08

is that the vast majority of people

15:10

in the United States could be getting this quality care

15:12

and the vast majority of primary

16:04

care doctors could be having this kind of

16:06

a life and it would be

16:08

affordable and it would

16:10

save the country 20 to 30 percent

16:12

of what we're spending right now, which would be a bloody

16:14

miracle.

16:15

And so Garrison, this is where I want ask

16:17

you to give people a

16:19

rundown of QLiants and the experience

16:21

there, because people are not familiar

16:24

with QLiants as much as they used to, just based

16:26

on time since QLiants is closed.

16:28

Let's see. Well, we opened in 2007,

16:31

I think, and the

16:34

first thing we ran into was that we

16:36

needed to find a way to get somebody to

16:38

invest in our company, and they didn't

16:40

like the fact that we were being threatened by

16:42

the insurance commissioner's office. And

16:45

so we had to pass a law in the state of Washington.

16:48

And then we heard that the Obama

16:50

administration was going to create

16:52

a vast health care system,

16:55

and that there was a distinct

16:57

possibility that they would do something that would

17:00

undermine what we were trying to do

17:02

because they were they were considering making primary

17:04

care free without making primary care

17:06

doctors solvent, which,

17:09

which is A pretty wild

17:11

concept, but that that

17:14

was really on the table. So we

17:16

had to, we had to get busy in Washington

17:18

DC and that's, that's

17:20

where we met Jay, which is was

17:22

a match made in heaven. I gotta say

17:25

this guy has stuck with us through

17:27

thick and thin. And we

17:29

we've given him plenty of challenges to

17:31

take on, including the 33

17:33

States that now have laws. And

17:35

so, so. It,

17:37

it, we are, we are making real progress.

17:40

The health care system is, is not,

17:43

but I think it could with

17:45

proper support from primary

17:47

care.

17:48

And clearly everybody on this call

17:50

agrees with you and the listeners are probably shaking

17:53

their head in agreement too. I want

17:55

to bring Phil in here because.

17:57

In 2016 you

17:59

responded to an article that this,

18:01

that the American Academy of Family Practice had put

18:03

out and the article was

18:05

entitled, Is Direct Primary Care the Solution

18:07

to Our Healthcare Crisis? And the physician

18:10

who is a CPE was

18:12

commenting many things that you responded

18:15

to in your article in defense of DPC.

18:19

The reason I bring up and Garrison,

18:21

thank you so much for that little You

18:23

know the, the little crumb of what

18:25

QLiants was and how it helped

18:27

people. Because, Phil, I want,

18:30

I want to just go

18:32

into the things that, Garrison,

18:35

you can talk to in terms of what Phil

18:37

is speaking to in rebuttal of this original

18:39

article was true even

18:41

before this article was written. So, this

18:43

doctor is stating DPCs exacerbate

18:46

the growing physician shortage. And

18:48

so I will, I'm going to read you the things that

18:50

are very commonly heard in terms of criticism

18:52

of direct primary care. So number one,

18:55

DPCs exacerbate the growing physician shortage.

18:57

DPCs are essentially unregulated insurance,

19:00

capitating physicians and removing vital

19:02

patient protections. DPC relies

19:05

on an erosion of medical benefits. DPC

19:07

exacerbate disparities in care.

19:10

The, so the conclusion to this article

19:12

was the wrong solution to a real

19:15

problem. So Dr. Eskew.

19:17

Brilliantly in defense of direct primary

19:19

care wrote that None

19:21

of that is true. So Dr.

19:23

Eskew, can you please talk to those

19:26

points? Because your

19:28

perspective and this doctor's

19:30

perspective, again, we're even coming out after

19:32

QLiants had already been in operation

19:35

for almost 10 years. So,

19:37

that is where I wanted to go next.

19:39

So, Phil, I'll turn the mic over to you.

19:41

in terms of shortage, there's,

19:43

there's, there's probably a physician shortage

19:45

broadly, number one, but there's disagreements

19:48

on that. The biggest problem is the maldistribution,

19:52

and if you want to get physicians to do primary

19:54

care, it needs to be appealing again, and

19:57

this makes primary care appealing. This

19:59

lets you become the, you know, the

20:01

Dr. House, if that's who you choose to be.

20:03

When you, when you watch, you know, whatever your favorite

20:05

or, or, you know, Marcus Welby

20:08

pick, pick your one side or the other. But

20:10

the point is they had interesting cases.

20:12

They had hard problems that they got to solve. They

20:15

didn't have a list of 10 urgent care things

20:17

that that's all they saw. And they referred if they couldn't

20:19

answer your question in five minutes, which

20:21

is what the insurance companies want to turn family medicine

20:24

into some narrow scope, waste of

20:26

time. And we're pushing

20:28

back against that. And the reality is, if everybody

20:30

actually pursued broad scope primary care,

20:32

we wouldn't need as many specialists. So

20:35

a lot of specialists would be motivated to come

20:37

back into this and we would do it better. Other

20:39

countries do it better. You know, in the United

20:41

States, I think it's what, 30, 70. And

20:43

right now, in terms of primary care to specialty

20:46

representation in other countries are closer to

20:48

50, 50, which is where it should be. If

20:50

you want to look at what makes somebody live longer, well,

20:53

stopping smoking makes you live longer. Not

20:55

having an alcohol problem makes you live longer.

20:57

Does having a cardiologist or a nephrologist

20:59

or a pulmonologist or ophthalmologist

21:02

make you live longer? Statistically, no.

21:04

Having a family doc does. And

21:06

that's across the world. That's not unique to the United

21:09

States. So this draws people

21:11

back into family medicine, and it draws

21:13

specialists who wanted to silo into

21:16

an area that maybe we don't need that many people siloing

21:18

to broaden their own scope and move back into

21:20

their, especially for internists, back to

21:22

their primary care roots. Calling it

21:24

unregulated um, you know, has a, has

21:26

a healthcare regulation saved somebody's life?

21:29

It's the

21:31

first thing I think of, you know, it's

21:33

the person doing the regulating here is the patient.

21:36

You know, if the patient's actually dictating their

21:38

own care and involved

21:41

in spending their own money for their own care,

21:43

then they're making sure it's quality or they wouldn't

21:45

waste their money on it. The only time

21:47

we need a bunch of regulators is when a 3rd party's

21:49

doing it, and now you have some, you

21:51

know, Veblen good problem where you've got a patient

21:53

wanting to pay as much as possible for something

21:55

because it's really not their money. So

21:57

we bypass all that, and

22:00

I think. The, the attack,

22:02

there is an older 1 and I, what I would

22:04

say a better attack would have been that.

22:06

I think we're getting better at as well as how

22:09

do we know they're doing a good job? And

22:12

the, and the answer is downstream data.

22:14

And there's more and more of that out that that tells

22:16

people how good of a job we're doing. But

22:18

the, the, the temptation,

22:20

if you will, for a lot of new DPC practices,

22:23

especially when they're working with employers or groups

22:25

that want data is how do you communicate

22:27

that in a way that's. Realistic

22:30

because if you, if you use the,

22:32

the wrong codes

22:34

that are out there that are designed for fee

22:36

for service, they, they're going to ultimately

22:39

be used against you or, or create so many

22:41

inefficiencies in your own, in your own

22:43

model that you're trying to prove how efficient

22:45

it is and ruining it in the process. Erosion

22:49

of benefits. Should third parties

22:51

be involved in paying for primary

22:53

care? I'm not so sure they should not

22:56

if it's affordable. You know,

22:58

there's some people that can't afford gasoline and

23:00

some people that can't afford food and we have ways

23:02

for them to to get around on public

23:04

transportation and we have ways for them to get

23:06

food even when they can't buy it.

23:08

And we should look at those models when it comes

23:10

to paying for primary care. But the biggest

23:13

secret of all is it's affordable

23:15

for the vast majority of people. If you let

23:17

it exist. It's affordable.

23:20

And then exacerbating disparities.

23:22

No, that's absurd. Hang out and hang

23:24

out in the D. P. C. Office and

23:26

you'll see everybody. If you come to the

23:29

office I work at in Malden, South Carolina, you'll

23:31

see it looks like the village people because

23:33

you'll have, you'll have police officers

23:35

pull up. Firefighters book people.

23:38

They're delivering the, you know, picking up the garbage

23:40

pull up. We have all kinds of city employees. We have,

23:42

we have people that have no insurance that

23:45

were all they've got and they signed up on their

23:47

own or their employer just covered that. We've

23:49

got people that are through some churches in the area

23:51

that have the most creme de la creme plans you've ever seen.

23:53

You really don't care what the price of anything is. So

23:56

we do see everybody and

23:59

the, you know, the reality

24:01

is DPC patients are for

24:04

the most part, the ones doing the selecting

24:06

here. So if

24:08

anything I think our our patient

24:11

populations across

24:13

the country probably tend to skew toward at least

24:15

the activated patient, if not also

24:17

the sicker patient. So

24:19

we're not cherry picking patients. They're cherry picking

24:21

us.

24:22

And

24:22

amen. I want to say the amen

24:25

to that. I think that

24:27

my experience was that the people in my

24:29

practice who wanted to join me were either

24:31

the ones who were my biggest fans or

24:34

the ones who needed the most care, who

24:36

needed, who couldn't get what they needed

24:38

anywhere else because no one else had time for

24:40

them. And that's,

24:42

that's the draw of this practice. This

24:44

is not cherry picking. This

24:47

is the real stuff. And

24:49

and it can be purposed for that, and has been,

24:52

if you could ask Rishika about that, I mean,

24:55

that, that, you know, with Boeing, his

24:57

Boeing, with the sickest people at

24:59

Boeing, they had a special practice just

25:01

for them so, you can

25:04

design this for, for all levels

25:06

of people from the youngest to the oldest,

25:08

the most wealthy to the, to the most

25:11

impoverished it, it can work

25:13

in all of those districts.

25:15

And especially if you're new to the podcast, I

25:17

definitely would encourage you to check out the

25:19

other episodes that are on this podcast, because

25:22

we have physicians sharing exactly

25:24

what you guys are speaking to in practices

25:26

of today, right? You know, we can use

25:29

telemedicine because we can, we can use,

25:31

you know, in person visits because we can, we can

25:33

use telemedicine. Clinics that are on site, near

25:35

site, just like you're at right now, Phil,

25:37

you know, there's so many options and this is

25:39

how DPC can be personalized with

25:42

still, you know, practicing evidence based medicine

25:44

and still, you know, serving all

25:46

populations. There's people like Dr.

25:49

Angela Bymaster, who, Has a non

25:51

profit as well as a for profit branch of her DPC.

25:53

And so she's able to take care of some of the poorest

25:56

people in terms of fiscally poor

25:58

in San Jose in a 10, 10 by 10 block

26:00

radius. There's people who in

26:03

Dr. Kiesel who talked at the DPC

26:05

Summit, one of my former attendings in

26:07

residency. She is at a practice where

26:09

her people who do pay, pay

26:12

a little bit more so that anybody who shows

26:14

up on the doorstep can get care. Without

26:16

any questions. They get the exact same doctor.

26:19

There's people who service communities

26:21

at a higher price because

26:23

they can take care of the the other people in

26:26

San Francisco, so there's so

26:28

many options for people to know and I mentioned

26:30

those three in particular, because when I talked to

26:32

residents, especially a lot of people are

26:34

saying. Well, but DPC is concierge

26:36

medicine. One of the things that I wanted to ask

26:39

is, were you restricted at QLiants

26:41

because of coding? Like in the

26:43

fee for service world.

26:44

So Q Alliances was, Q

26:47

Alliance was a lab. So

26:50

when I left Seattle Medical Associates

26:52

to go, I moved my practice

26:55

over to a new startup. I

26:57

had some ideas about what I wanted

26:59

to do. But what I really wanted

27:01

to do was to make it a center of innovation

27:03

in, in, in what we're, we're

27:05

calling direct primary care,

27:08

but we weren't calling it then that, that at

27:10

the moment. And so

27:12

what we were, what we were

27:14

trying to do was to find a group of

27:16

people who would be willing to

27:18

come join us in our experiment. We

27:20

were trying to figure out who was interested,

27:22

who would our customers be. We

27:24

were trying to figure out what kind of

27:26

services could we provide. We

27:29

were trying to figure out what kind of price

27:31

would would keep us stable,

27:33

floating and growing without

27:35

being unaffordable. To the to

27:37

the populations that wanted to use us.

27:40

And we we had we've

27:43

developed some some serious

27:45

investors who wanted just as

27:47

much as we did. The first investor

27:49

was a guy named Nick Hanauer, who was who

27:52

was also the first investor in Amazon.

27:55

And, and he was a guy

27:57

who Who who said that

27:59

he was interested in disruptive

28:01

startups and that he considered

28:03

health care, the Mount Everest of

28:06

of the need for disruption,

28:09

there's no other business in this country

28:11

that needs disruption more than this. They

28:13

need to be refocused on on

28:15

taking care of patients. They need to be. refocused

28:19

on taking care of all the patients

28:21

have needs, including their financial needs.

28:25

And so, so

28:27

we, we we started the,

28:29

we invented some ideas. I mean,

28:31

a lot of you now have incorporated some of

28:33

those ideas. One of them was to give

28:35

away medicine. Originally,

28:38

we decided to set incentives as

28:41

a to look at incentive design,

28:43

for instance, so we wanted to make sure

28:45

our physicians were not incented to

28:47

either do more things or

28:49

do fewer things based upon how much

28:51

money they could make. That

28:53

was really important. We also

28:56

wanted a contract between us

28:58

and our patients in which we made

29:00

promises and they just agreed to

29:02

pay for them. So that we,

29:05

so that we were, we weren't just saying

29:07

we would try to provide the best care

29:09

that could be provided, which is kind of vague

29:12

and generally means that you're not working

29:14

very hard at anything to do, but

29:16

to say, to say We want to provide the

29:19

affordable care and with superb

29:22

service with with rapid

29:24

access, we wanted people to be able to

29:26

reach us day and night. We wanted

29:28

people to be able to to reach

29:31

their own doctor whenever possible.

29:33

And we wanted doctors to have longevity

29:35

with patients so that we knew them so

29:38

that we could be of use to them when they did call

29:40

us. And we

29:42

wanted to reconsider all of the services

29:44

that we provided. So, so,

29:47

that eventually turned out to be things

29:49

like finding discounted cash

29:51

colonoscopy and, you

29:54

know, providing the lab work you got with your,

29:56

for your annual exam in most

29:58

places, which was, they were charging 150

30:01

for, we could get it for 10 bucks cash.

30:04

And we could find, we could

30:07

do an x ray in the office and it would cost the

30:09

patient 10 because that's what

30:11

it cost us. to get a radiologist

30:13

to read it. So we were tried to be we

30:15

tried to live, live on our monthly

30:18

fee and not have any other cash flow

30:20

that would encourage us to do more

30:22

than we should. And

30:26

that turned out to be a great thing. Doctors

30:29

loved it. Patients loved it, but

30:31

then we had to find a market for it. And

30:33

that was the hardest part because the, because

30:36

employers are responsible for

30:38

most of the, of the market

30:40

in healthcare government is the

30:42

other big chunk of that. The government

30:45

from the state government to the national government

30:48

pretty much looked at us like they like

30:50

they were looking at Satan because

30:53

we weren't going to be doing things the way they do him.

30:56

It we were offering to have

30:58

we were offering to have them. They

31:00

wouldn't. Nobody would pay the monthly fee. And I think

31:03

that's largely still true in the United States.

31:05

But we said the patient will pay

31:07

the 50 bucks. All we want

31:09

you to do is allow us to be preferred providers

31:12

so that we'll be able to order all the other things

31:14

and handle their care without disruption.

31:18

So we so we worked through a lot

31:20

of those issues and we

31:22

got along a long way. I don't

31:24

think we have time to talk about our

31:27

interface with Medicaid, which actually

31:29

brought us to the ground, but that

31:31

was mostly because we didn't, we weren't

31:33

aware that Medicaid did not pay for all the

31:35

things I just mentioned. Medicare.

31:38

Even they wouldn't would not even pay.

31:40

You know, they were paying like 10 to 15

31:42

to 20 per member per month, Max,

31:45

which wouldn't you couldn't run the office on

31:47

that. And you certainly couldn't run a good office

31:49

and you couldn't provide enough time with patients.

31:52

And then when we showed that we were able to

31:54

do this. For 50 bucks,

31:56

if they would pay us 50 bucks,

31:58

they decided that we were so good at

32:00

taking care of people that they weren't sick anymore,

32:03

which meant that they should pay us yet less. And

32:06

that that pretty much brought us

32:08

to a halt, given that we had 30, 000

32:11

Medicaid patients by that time and no way

32:14

to go back. So it's,

32:17

it, it, it, it, you know, this, we

32:20

were, we were, were both evidence of the

32:22

possibilities of direct primary care.

32:24

But we were also evidence of the potential

32:27

dangers of

32:29

playing with, with some, some very

32:32

tough financial forces without

32:34

being fully ready to handle that

32:36

or knowing how to handle it. So, so

32:38

we, we definitely took a few punches

32:41

for the movement, but I think that

32:43

what we learned have really helped. Open

32:46

up up the the possibility

32:49

of serious growth across this country

32:52

because we've learned so much about what we can

32:54

do and can't do what we should do and shouldn't do.

32:57

And I think we are we are still

32:59

ready to engage with some of these

33:01

huge problems, but

33:04

on our terms, not their terms.

33:06

And this is why, again, it's so important

33:09

that you guys are sharing and

33:11

speaking today, because

33:14

we are at a point where, you know,

33:16

you may have heard about this a little bit in Dr.

33:18

Aiken's podcast that just recently

33:20

aired the last couple of weeks. But.

33:23

Dr. Aiken, myself, Garrison, Jay,

33:25

we were all doing some lobbying for

33:27

the direct primary care movement, sharing

33:29

our stories as individual physicians

33:32

on Capitol Hill, and it matters. And

33:35

Garrison, what you mentioned, this

33:38

this, what happened with Qliance and that

33:40

Medicaid, you know, cut the legs

33:42

out from under you guys really at Qliance

33:45

because of not valuing what amazing

33:47

care you guys were delivering. If you want to hear more

33:49

details, definitely listen to Dr. Erica

33:51

Bliss, your cousin, who was also with you at Qliance.

33:54

She shared about it in the 2018

33:57

DPC Summit that if you go to her episode

33:59

on the podcast there's a link to

34:01

that video there and definitely watch it for

34:03

more on QLiants. But the reason

34:05

I, I also appreciate the scarcity is

34:07

because we're at a time when, you know, on Capitol

34:10

Hill, we are,

34:13

We are still filled with optimism

34:15

and optimism in a way to,

34:18

to guide direct primary care into the future

34:21

with physicians at the forefront, so

34:23

that we do not build a fee for service

34:25

system going forward. So now,

34:28

Phil, I'm just pulling up what you have on the DPC

34:30

Frontiers. So this is the website that Dr. Eskew

34:33

created from nothing, and

34:35

it's an amazing resource that anybody can

34:37

use. so much. In the

34:39

resources tab under DPC defined

34:42

for a practice to qualify as a direct primary

34:45

care practice, the practice must, and

34:47

I'll just read this for people if they

34:49

have not looked at it or haven't looked at it in a while charge

34:51

a periodic fee, not bill any third

34:54

parties on a fee for service basis, and

34:56

any per visit charge must be less than the monthly

34:58

equivalent of the periodic fee. So

35:01

when you spoke at DPC summit

35:03

about, you know, the legal. the

35:06

legal status right now of direct primary care.

35:09

Can you speak to how you

35:12

hear Garrison's words, you know,

35:14

the history of QLiants and how you

35:16

are still able to be optimistic

35:18

about DPC, even given the current

35:21

state where not all states have legal

35:23

protections for direct primary care.

35:25

we've followed a little bit in the footsteps

35:27

of some other entities that have not

35:30

been insurance over the years, namely health

35:32

shares. And they

35:34

actually didn't pass laws in all 50 states

35:37

either. They passed it in enough that even

35:39

the states that didn't have those laws on the books,

35:41

the insurance commissioners kind of looked next door

35:43

and they said, Oh, okay. And

35:45

then the aggressiveness

35:48

faded over time. And I think

35:50

we've experienced the same thing. I,

35:52

I get emails from all across the country

35:55

from various, various physicians, you

35:57

know, investigating doing drip primary care

35:59

or, or early in the process, or even

36:01

those that have been added a while. And they

36:03

do ask

37:01

me sometimes some insurance

37:03

commissioner related questions. The

37:06

only two that have had any aggression

37:09

that I've caught wind of lately

37:11

were in Washington, which

37:13

actually has law on the books, but the office

37:15

didn't necessarily like the law that they had

37:17

on the books. And then there were

37:19

some whispers in Pennsylvania,

37:21

but not so much You

37:24

know, direct impact in any meaningful

37:26

way, and I always have

37:28

to remind people that the three

37:30

part definition you see on the website there.

37:32

It's not. It didn't just come from me.

37:35

That's that's early conversations

37:37

with others at the DPC coalition when

37:39

we've tried to clarify what this was really

37:41

simply. And I think the time we put

37:43

that together, there were only 4 or 5 states

37:46

with laws on the books and several

37:48

of those laws Work really

37:50

that good and they've

37:52

subsequently been improved. And

37:54

the third piece always gets the most questions

37:57

around it. Why does any per visit

37:59

fee have to be lower than the monthly fee? It

38:01

doesn't have to be. You can

38:03

go ahead and make that per visit fee much higher.

38:06

But if you do that, you're not going to get any

38:08

attention from the insurance commissioner. Ergo,

38:10

you don't need to be defined

38:12

as DPC. Do

38:14

whatever you want to do. But if you want

38:16

to, you know, focus on the

38:18

incentives that the DPC model creates

38:20

for ongoing care with patients, and

38:22

also not get that wrong attention.

38:25

That's the reason for the definition.

38:27

And we see this with the movement

38:29

growing like crazy that when

38:31

we invest in our patients and our patients

38:34

and our patients invest in us. Garrison,

38:36

you, you spoke to this so well that you guys

38:38

were invested in your patients and

38:40

you manifested a practice that was

38:42

carrying 30, 000 Medicaid beneficiaries

38:45

that to me, it just speaks

38:47

to how A lot of the

38:50

myths about direct primary care or the misconceptions

38:52

are really proven false

38:55

by each and every one of the practices

38:57

that that are open today and it will be

38:59

opening especially after an event like the

39:01

DPC summit. Phil, as you, as you speak

39:03

to how we can

39:05

still be effective, even if we don't have DPC

39:08

laws, there are two bills on

39:10

Capitol Hill that are hot

39:12

and going crazy in terms of one

39:14

that we were speaking to in February

39:17

has already passed the House unanimously

39:19

and the other one is hopefully going to be

39:21

in the September package. And so, Jay,

39:23

can you please tell us about

39:26

what are these two bills and

39:28

how can we help using our voices

39:31

to protect this physician led movement

39:33

going into the future?

39:35

So, I feel inclined to go back a

39:37

little farther than this

39:40

month since I'm, been involved

39:42

since 2009. But let me

39:44

go way back and and go

39:47

predate Garrison in the 1950s when

39:50

we had two non profit insurance

39:52

companies spring up. One was called

39:54

Blue Cross and Blue Cross

39:56

was designed to

39:59

make sure you were covered anytime you go in the hospital

40:01

because it went There you go, in any country in the

40:03

world, you see a cross, and you know, that's

40:05

the sign for a hospital. Blue

40:07

Shield was designed to shield you

40:09

from, you know, problems

40:12

that might arise, financial problems that might arise

40:14

from your healthcare, and it was designed to shield

40:16

you from your doctor. The whole idea

40:18

behind Blue Shield was it was gonna be, it

40:20

was gonna be insurance coverage in

40:22

case your doctor charged you too much.

40:26

Insurance companies were going to regulate that

40:29

through the practice of insurance.

40:31

And in some ways, you know, it,

40:34

it had, it had a little bit of there

40:36

was a little bit of a rationale to do that back

40:38

in the day, since the practice of

40:41

medicine was largely, you know, sort of unregulated.

40:44

Today, I would counter the

40:46

arguments that were made earlier. About

40:48

the practice of medicine not being regulated

40:51

by saying that

40:53

every single state in

40:55

America has a board of medicine

40:57

and that anyone who's licensed

40:59

as a physician practice primary

41:01

care is licensed by

41:03

that board of medicine and

41:06

what the provision in the Affordable Care

41:08

Act originally said was

41:10

that the practice of

41:12

DPC In the term of

41:14

art was used in the A. C. A. Of

41:17

the direct primary care medical home,

41:19

which was a D. P. C. Practice was

41:22

defined by the law that Garrison mentioned. It was

41:24

passed in Washington state and

41:26

that, you know, it's not the business

41:28

of insurance. It is a medical

41:30

practice regulated by the existing

41:33

laws and the boards of medicine in those states.

41:36

You are, in fact, regulated it. By

41:39

the board of medicine, in the scope of

41:42

your practice, which is primary care

41:44

there are rules about what you can and

41:46

you cannot do they've been on the books for

41:48

a lot of years. So we've never

41:50

really sought to change any of that.

41:53

What we did run into when we

41:55

passed the affordable care act, of course is States

41:58

that needed to update their their rules

42:00

their regulations and one of the reasons we don't have

42:03

Rules in and regulations in every

42:05

single state is that Some states

42:07

didn't really need to update them. They, they synced

42:09

fine with the Affordable Care Act. Some

42:11

decided they didn't want to, and have sort of

42:14

just said, you know, go, go and send

42:16

no more. And, and

42:19

but, for the, for the most part what

42:21

we've found is that in, in

42:23

almost every state we need it the

42:25

regular, the regulatory status

42:27

is there in the, in the Board of Medicine. So

42:30

what we've done is we've removed the insurance

42:32

commissioner and all of that administrative

42:35

burden that's put on to the practice

42:38

by taking DPC out of that in

42:40

both, you know, a practical sense

42:42

by removing the fee from fee for

42:44

service insurance reimbursement,

42:47

paying it up front like you would buy any

42:49

other product or good or service and

42:52

having a relationship with the people you're

42:54

getting the service from through DPC.

42:56

So fundamentally, we've changed the equation.

42:59

From buying

43:01

widgets, you know, buying, you know,

43:04

episodes of care to

43:07

creating a payment structure

43:09

to build a relationship with a professional

43:12

who is Garrison Bliss or Phil Eskew

43:14

or Mary Ellen Conception. And

43:16

and, and fast forward, we've

43:19

done a pretty good job. And I think I would argue that COVID

43:22

was a major validator of

43:24

DPC. Because while

43:26

the rest of the country was

43:28

trying to figure out a way to get care, and

43:31

the federal government was busy handing out checks to

43:33

bailout fee for service doctors who

43:35

couldn't see patients for a visit,

43:37

and therefore couldn't get paid their 115

43:40

bucks for a uh, 99124

43:44

DPC doctors answered the phone every

43:46

time a patient called, or did a Zoom

43:48

call like we're doing tonight. To figure

43:50

out how to take care of people because candidly,

43:52

you know, the most of the things you guys do, you

43:54

don't need to lay hands on the patient to really to

43:57

really do your stuff. You need

43:59

a conversation with your patient. You need time

44:02

and DPC has has allowed

44:04

you all to do that. And I'm, you

44:06

know, I would now say there's

44:08

really only two regulators

44:11

in the world that

44:14

still define DPC

44:16

as either some form

44:19

of insurance Or something

44:21

that, you know, is above and beyond

44:23

your means, right? And so

44:25

the first would be the IRS.

44:28

So when it comes to the almost

44:30

50 percent of people in America who

44:33

have or are eligible for a high deductible health

44:35

plan that's paired with a health savings

44:37

account due to anachronisms

44:39

in the tax code that haven't been changed since, you

44:42

know, 1974 the IRS still defines

44:44

what, what you all do as

44:47

some sort of other coverage

44:49

or insurance that makes an individual

44:51

ineligible to fund an HSA. So,

44:54

so if you have an HSA

44:56

and it's funded, fundamentally

44:58

you're not allowed to have a relationship with a DPC

45:00

doctor. Probably the most

45:02

wildly not complied with law

45:05

in tax code history. But

45:07

it's a problem. It's a particular problem when it comes

45:09

to trying to, you know,

45:11

stitch together a network of DPC docs

45:14

that will take care of patients

45:16

that an employer offers, and that employer

45:18

happens to offer, you know, a

45:20

high deductible health plan. That

45:23

people have an HSA that's paired with. So, we

45:25

have a bill the Primary Care Enhancement Act, it's

45:27

H. R. 3029, it is passed

45:30

out of the Ways and Means Committee in

45:32

a bipartisan vote awaiting

45:34

consideration hopefully in a

45:36

package that, that will come together

45:39

at the end of this year and, and,

45:41

and so we're excited about it. We we think we

45:43

can change the law. The law simply

45:45

creates an exception, so Or direct

45:47

primary care practices that charge less

45:50

than $150 a month

45:52

which is 98.9%

45:55

of direct primary care practices. We

45:57

realize it might cut some, some, some

46:00

high dollar practices out, but it basically says

46:02

if you are practice fits within these

46:04

guidelines, then then, then, then

46:07

the tax preferred dollars that are going into the HSA

46:09

are gonna be fine for the patient to contribute to

46:12

the HSA and the H and the patient will be able to

46:14

contribute. dollars out of that HSA

46:16

to, to you. And so nobody's

46:18

a stranger to this bill. It's been, it's been up for a couple of

46:20

sessions in a row. We've never had more

46:22

momentum than we do now. Thanks in part to

46:25

the group that was up on on Capitol Hill this spring

46:27

lobbying really hard for that.

46:30

And we have another bill that would allow CMS

46:32

to create a rubric for

46:34

primary care direct primary care

46:37

in Medicaid. And as, you know, Garrison

46:39

mentioned, we had a lot of learnings

46:41

to share with CMS and the Medicare agency

46:44

about how you know, we

46:46

could interact with with,

46:49

with DPC. One of them was

46:51

that there would need to be an immediate upfront

46:53

three legged stool where the

46:55

managed care provider that manages the Medicaid

46:57

contract in the state and the state.

47:00

And the DPC practice would all have

47:02

to agree on what is primary

47:05

care and, and, and what is going to be

47:07

paid for in a monthly fee and what's the value

47:09

of that monthly fee. Then finally,

47:11

there would have to be a, a

47:14

three way agreement between all of these

47:16

people and the Medicaid beneficiary that

47:18

says, Garrison and Phil

47:21

These are your doctors, and you're going to go see

47:23

them before you check into the urgent care or

47:25

the hospital or seek some other level

47:27

of care. So we're excited about

47:29

that. That has not only passed the Energy and Commerce

47:31

Committee in the House, but it passed the full

47:33

House of Representatives a couple of months ago

47:36

in a unanimous vote, very rare for

47:38

a health care issue these days, and

47:40

is moving along. So we're pushing really, two

47:43

really great bills down the pathway.

47:45

And then, In the midst of all this what's

47:47

the other big agency that we've left out? We've got,

47:50

we've got the IRS for, for

47:52

HSAs. We've got Medicaid. Well,

47:55

Medicare the Senate Finance Committee has

47:57

recently put out a request for

47:59

information about ways to

48:01

move to a flat monthly fee payment

48:04

for primary care services. Well,

48:07

lo and behold, we've got an idea for you. I don't

48:09

think any of that is a coincidence. I think they've seen

48:12

They've seen what happened with DPC

48:14

during the COVID period. They've read

48:16

the Milliman study and, you know, if you don't

48:18

believe us that we save, you know, 20 percent

48:20

of the total cost of care, believe the Society

48:22

of Actuaries that actually says if employers

48:25

front load a employer

48:27

sponsored benefit with direct primary care.

48:30

They save, you know, up to 20 percent

48:32

of the total cost of care versus

48:35

the patient that's just in the regular

48:37

old PPO. So,

48:39

we've spent a lot of years pounding

48:42

the pavement on Capitol Hill, Phil and

48:44

Garrison and I together and Mary all and,

48:46

and others and people that are new, new to it,

48:49

to really bring people to this level of education

48:51

where. Candidly, we used to spend,

48:53

you know, you have a half an hour in a meeting, you spend,

48:56

you spend 20 minutes describing

48:58

what direct primary care is.

49:43

And then you don't have any time at all to

49:45

ask what you want to ask, which is make it

49:47

legal for HSAs or put it into Medicare

49:50

or put it into Medicaid and don't screw

49:52

it up. You know, like whatever they ask is

49:55

now we walk in and they're like, Oh, direct primary

49:57

care. That's great. We all love it. How do we get that?

49:59

And and, and, and what can we do for you

50:01

today? And so, you know,

50:03

the, what is for all of you physicians

50:06

out there, they're, they're, they're listening is.

50:08

You know, we want you to join us at the Direct Primary Care

50:10

Coalition and come and lobby with

50:12

us. We have our next fly in coming up September

50:15

10th and 11th in conjunction with the Health

50:17

Rosetta Fest. And by the way, the employers

50:19

love this. It saves them money.

50:22

So, the employers, the brokers,

50:24

they're all gonna be in town lobbying to

50:26

pass these bills that we've worked really hard

50:28

to push these rocks up the hill. And

50:30

we're getting a lot of traction now. So,

50:33

you know, we're, we're in a very good place where people

50:36

understand the value equation of DPC.

50:38

I think they want it. And now

50:41

it's really up to the physicians

50:43

of America to come to the table

50:45

and, you know, really push it across the

50:47

finish line with these couple of policy provisions.

50:49

So, you know, what it is we're doing this

50:51

fall. We're looking at Improving

50:54

the ability for people with HSAs

50:56

to get DPC. Improving the ability

50:58

for people in Medicaid to get DPC.

51:01

Improving the ability for people in Medicare

51:03

to get DPC. We think everybody

51:06

ought to have it. I actually long

51:08

for the day when DPC isn't

51:10

DPC, it's just primary care. We

51:12

can drop the D because this is the way we deliver

51:14

it. Because it's the best way.

51:16

There's a lot of head nodding there. And,

51:18

you know, it's, it's very interesting because

51:22

just reflecting on the time in February

51:24

in D. C., you know,

51:26

it was very interesting to see

51:28

that, you know, Two of the top employers

51:31

in the nation, Amazon as well as Boeing.

51:33

We're sitting across the table while they're lobbyists

51:36

were sitting across the table from what

51:38

10 11 independent doctors. And,

51:41

you know, I think about how Garrison

51:44

you made you made the point earlier about how

51:46

so many people in this country are relying on their

51:48

employer to provide health care. And

51:50

something that I heard yesterday at the Chamber

51:52

of Commerce event that I went to was that

51:55

employees, excuse me, employers

51:57

pay for employment engagement. And

51:59

when a person is engaged

52:01

because they're healthy, that's, that's

52:04

a lot of overhead not

52:06

lost because of a patient being

52:08

sick or a patient, raising

52:10

the cost of healthcare for the entire company because

52:12

of their needs not being met. there's so

52:14

many ways that employers find this movement.

52:17

Very, very appealing.

52:20

And that's why Rosetta Fest has,

52:22

had over 750 people attending last

52:24

year, DPC doctors, as well as

52:26

people who are wanting to build plans

52:29

around DPC doctors, because people

52:31

are recognizing that this movement is

52:33

so important. So one of

52:35

the things that is a big concern going

52:38

forward in this movement is, not

52:40

taking is not losing

52:42

our autonomous practices and being

52:45

able to spend the quality

52:47

time we need to, and for us as physicians

52:49

to determine that time that's needed to take

52:51

quality care of patients. I would love

52:53

to hear Phil and Garrison, especially

52:56

your take on. These two

52:58

bills in particular and how to

53:00

continue going forward such that a physician

53:03

if they wish to can still be successful

53:06

and not have to code and

53:08

still be able to serve a person

53:10

who has Medicaid insurance or Medi Cal

53:12

insurance.

53:14

Yeah, I think I can answer your question to some extent.

53:17

First of all, there's nothing

53:19

we're advocating that insists

53:22

that everyone has to do it. So

53:25

this is voluntary stuff

53:28

and that the

53:30

early adopters for direct primary

53:32

care have largely been very

53:34

independent people with very strong

53:37

beliefs about how it needs to be

53:39

done. And. That's

53:41

fine. That's perfect. This is

53:43

that. That's the vanguard. And that's

53:46

also a model we think can go forever,

53:48

particularly in places where

53:51

you don't need scale. You know,

53:55

one person can only take care of so many patients.

53:58

Once your practice is full, you don't

54:00

have to change it. And you probably

54:02

shouldn't, but I think that, that

54:04

as this movement grows, and

54:07

we start to take care of more and more people,

54:09

I think we need to, to, to

54:12

look at ways to maintain the culture,

54:14

because the way I define direct primary

54:17

care, which is different from all this monthly

54:19

fee and no fee for service,

54:21

I define it as a culture of care

54:25

focused on patients in

54:27

which patients have, have

54:29

control. And we know

54:31

who we work for, regardless

54:33

of where the money comes from and

54:36

that we get enough money so we don't have to be thinking

54:38

about money. We, and we

54:40

don't have a way to make more money

54:43

by doing stuff to you or not doing stuff

54:45

to you. That's, this is,

54:47

this is an extension of an ethical

54:49

concept about how healthcare should be

54:51

practiced. And

54:54

if we can find a way to do that

54:56

without Medicaid or Medicare messing

54:58

us up, then I think

55:00

we should, we should be looking at it because

55:03

they are, they have the patients, they're,

55:06

you know, employers have been, are

55:09

a great source, but we

55:11

have to, we have to break down the barriers there

55:14

which is, which is what one of our bills is

55:16

about. But the, the Medicaid

55:18

bill is about making this available

55:21

to Medicaid. I mean, the Medicaid

55:23

bill that we've got ready to go, and

55:26

Medicaid patients probably can't

55:29

pay the monthly fee. They

55:31

can't, they can't necessarily pay that, what

55:33

it would take as a group. So,

55:36

this is a place where the government can be helpful,

55:38

but it also needs to know that we're not

55:40

going to play the way we've been playing

55:42

with Medicaid. And Medicaid is not going

55:44

to play with us anymore either. So

55:47

we're going to tell them what it costs to do

55:49

this right. They're spending on average

55:51

about 800 per member per

55:53

month, nationwide, for Medicaid

55:56

patients. Well, if you could

55:58

pay us 150 or 100

56:01

even. And we can

56:03

make that that number come down

56:05

from 800 to 600 magically

56:07

after you after the money you've given us.

56:10

That's what we're offering you. So,

56:12

so it's a deal for you, but

56:14

it also allows us to say

56:18

you don't get to tell us how to practice.

56:21

And if you want to collect

56:23

numbers, feel free, collect your numbers as

56:25

you wish, but we are not necessarily

56:27

here for the purpose of spending our

56:29

time writing notes to satisfy

56:32

your need or collecting your data

56:34

for you, because that costs us time

56:36

and money. Both of which we can't afford

56:39

if we're going to do the, our first job right. So,

56:42

so I think, I think that this movement

56:44

is now tougher

56:47

and smarter than it was

56:49

when I started. So

56:51

we know, we know where, where

56:53

the bodies are buried. We also,

56:55

we also know where the weaknesses are in,

56:58

in the, in our relationships.

57:00

With governments and

57:02

with some employers,

57:05

and we're able to that they're

57:07

beginning to understand how important it is to

57:09

preserve this kind of

57:11

care, which is delicate

57:13

and has to be done right and has to be

57:15

adequately reimbursed. And then

57:17

you have to get out of her way and let us do it.

57:19

And Phil, can you speak to what she

57:22

mentioned earlier? The 150 spend

57:24

with a patient's HSA.

57:25

That's been in there. That's been

57:27

in several of the versions of

57:29

the Primary Care Enhancement Act for for years,

57:32

and it was mainly there to get a score. We

57:34

all sort of hold our nose with that. And

57:37

as Jay pointed out for 99 percent of

57:39

practices, it doesn't matter for the

57:41

ones that have a fee of higher than that amount.

57:44

Odds are if you ask their patients, they don't

57:46

give a darn because they were already

57:48

either not worried about their HSA

57:51

and just using it to, you know, save

57:53

money and didn't think that there was a tax risk

57:55

or, or, or some other reason. It's not,

57:57

that price point isn't one that's hitting

57:59

employers, which is where the,

58:02

the biggest pushback is right

58:04

now on HSAs. So,

58:07

to, to, to Garrison's point I

58:09

think Garrison, even more than most, knows,

58:12

knows exactly how problematic Medicaid

58:14

can be, especially when it's a Medicaid managed

58:16

care company. And are

58:19

you, are you dancing with the devil

58:21

by talking to them? Maybe a little bit,

58:23

but you don't walk away right away. You try

58:25

and get the details right. You try and show them

58:28

patiently, carefully. How

58:30

this needs to be done. And that

58:32

means you don't walk away from the table at the beginning.

58:34

You have the conversation just like we

58:37

have the conversation with Medicare and we've had

58:39

it repeatedly and they've tinkered with

58:41

various pilots in the past and sort of botched

58:43

him and we didn't participate. But one of

58:45

these days, they won't budge it and

58:47

then that'll be really neat. And

58:50

if you're not around to to help

58:52

them get it right, then that whole process is going to

58:54

take longer, or maybe, maybe

58:56

won't happen. So we're trying to get those

58:58

things to work. And that's,

59:01

that's maybe the hardest part of this. I think we're,

59:04

we're pretty close to having the tax

59:07

issues corrected and arguably

59:09

the HRA and FSA piece already

59:11

are corrected. And it's mainly just the HSA

59:13

that's still there, but then

59:15

the question is, what do you do with Medicare and Medicaid?

59:18

And You either watch them go

59:20

bankrupt or find some

59:22

much, much better solution. Kind

59:25

of what we're talking about here where suddenly

59:27

the patients care about price again.

59:29

Yeah, and I think we're at a pivot point in our

59:32

conversation with all

59:34

of these agencies where they've seen the data,

59:36

which is really important. They

59:38

understand the results both intuitively

59:41

And from a perspective of,

59:44

of, of, of the value

59:46

equation that's being lost actually hearing

59:49

tomorrow on the, on the in the house

59:51

on, on you know, how well

59:53

has the CMS center for innovation

59:56

done? And the reality is a lot

59:58

of the programs that they've put forth have

1:00:00

not. Saved a lot of money

1:00:02

for Medicare and improved care in the Medicare

1:00:04

program. So, and

1:00:06

in 2015, we put MACRA in place

1:00:09

to try to, you know, push

1:00:11

people to advance payment models. And

1:00:14

lo and behold, here we are almost

1:00:16

a decade later. And

1:00:18

the framers of MACRA, the very same people

1:00:21

who wrote the law on MACRA are looking

1:00:23

at looking to what, what might the

1:00:25

next idea be? And, and

1:00:27

those very people are saying, well,

1:00:29

we think we might want to try out just

1:00:31

a flat monthly fee and see how

1:00:33

that goes. That's

1:00:35

a great idea. I'm so glad you

1:00:37

came up with that idea. And

1:00:39

we're going to help you come up with that idea. So

1:00:42

we are actually, as we speak you

1:00:44

know, with, with consultation from

1:00:46

the key members of the direct primary

1:00:48

care coalition who have, who have been to

1:00:50

DC to do the lobbying and do the work,

1:00:53

putting together a set of responses that say,

1:00:55

Hey, Not this is the

1:00:57

way you have to do it, but these are

1:00:59

our experiences. If

1:01:02

you mess up the monthly

1:01:04

fee with a lot of per visit fees

1:01:06

and shared savings and

1:01:08

risk adjust this and that you're

1:01:11

still going to drive misaligned

1:01:13

incentives to see

1:01:15

or to not see patients. And

1:01:18

the whole idea here is pay

1:01:20

Garrison 150 bucks a month and

1:01:23

let him take care of you. And, and

1:01:25

watch the, the amount

1:01:28

drop from, you know, the

1:01:30

money CMS is spending in

1:01:32

Medicare. Look at the Medicare

1:01:34

claims data, Medicare,

1:01:36

downstream and compare it to the patient who's

1:01:38

got the DPC to the patient

1:01:41

who doesn't, the same way Milliman did

1:01:43

for the Society of Actuaries a couple of years

1:01:45

ago. And let's see what happens.

1:01:48

And I think that's really what's on the table

1:01:51

for Medicaid and Medicare. In

1:01:53

Medicaid, it's a little more complicated. So

1:01:56

the bill, just so people understand

1:01:58

it, the way the bill is drafted

1:02:00

is it brings stakeholders together

1:02:03

to to sit around a table and

1:02:05

by name, including direct primary care

1:02:08

physicians. To have a discussion

1:02:10

with the Medicaid managed care establishment

1:02:14

with CMS itself and with the states

1:02:17

on what might work best in each

1:02:19

state. Obviously, a Medicaid program

1:02:22

in Idaho is going to be different than a Medicaid program

1:02:24

in California is going to be different from

1:02:26

a Medicaid program in Maine and a Medicaid

1:02:28

program in Oklahoma. So, it's

1:02:31

the states that will drive these things.

1:02:33

And CMS has now been instructed by

1:02:36

Congress to say, Hey,

1:02:38

let's sit all these people down at the table and figure

1:02:40

out the right way to do it. But let's make sure the

1:02:42

DPC doctors have a seat at the table. That's

1:02:45

what's at stake. And

1:02:48

Phil mentioned the score because it doesn't

1:02:50

really mandate a program and say,

1:02:52

Hey, CMS, you got to pay for this. It

1:02:54

has a zero score. So

1:02:56

it's a really good idea, again,

1:02:58

to figure out a way to do this and,

1:03:01

and Yes, you're going to have to compromise a little

1:03:03

bit. Will you have to report on some measures? Maybe.

1:03:06

We like the person

1:03:09

centered primary care measures that have been developed

1:03:11

by the Larry Green Center. We've proffered

1:03:13

to CMS that they use

1:03:15

those as, as a way to measure whether or

1:03:17

not you're satisfied with your primary care.

1:03:20

Lo and behold, CMS really loves that and

1:03:24

wants to use them. So, because

1:03:26

they're good and they measure things that are

1:03:28

of value to the patient. And

1:03:30

a relationship with a primary care doctor is

1:03:32

of value to almost anyone.

1:03:34

I would ask you what would

1:03:37

you rather have? A health benefit

1:03:40

that allows you an engagement that's going to make

1:03:42

you pay money to an insurance company

1:03:44

to potentially cover 80 percent of your care,

1:03:46

and you're going to have to cover 20 percent of your care, or

1:03:48

would you like a free membership

1:03:51

with a primary care doctor who's been

1:03:53

through umpteen years of med school and

1:03:56

had umpteen years of practice behind

1:03:58

his or her belt? To guide

1:04:00

you as a Sherpa through

1:04:02

the complicated web that is our health care system

1:04:04

today. That's what you're getting when you, when

1:04:06

you, when you sign up for direct primary care,

1:04:09

beyond just great care from a doctor.

1:04:11

So, people get that. And

1:04:13

I think we're at a major pivot point where

1:04:16

policymakers, both at the state

1:04:18

and the federal level, say,

1:04:20

hey, how can we take the gloves

1:04:22

off and let this thing flourish? And

1:04:24

that, and that's what we're trying to do. It's

1:04:27

not going to be perfect. It never is.

1:04:29

But we do promise we will never support

1:04:32

anything that will mandate that you have to do whatever

1:04:34

the man says

1:04:36

Now, any last minute words for the audience that you

1:04:38

guys have to share,

1:04:40

Where we've been at this for a long

1:04:42

time. We are, we

1:04:44

want to make sure that you all know that you are welcome

1:04:47

to help us and to, to

1:04:49

get to, because somebody's going to keep pushing

1:04:51

this rock up the hill for a long time, long

1:04:54

after I'm gone. But,

1:04:56

but one of the things we'd like you to think about

1:04:58

is participating with direct primary

1:05:00

care coalition in whatever

1:05:03

way you can, but mostly we would

1:05:05

love to have you come and help dP care.

1:05:07

org. Is one place

1:05:09

you can go to to

1:05:11

volunteer to come join us

1:05:13

for the, for the battles that are coming up.

1:05:16

And in particular, the ones over these bills that we've

1:05:18

been talking about.

1:05:19

Yeah. Thanks, Garrison. And, and our next fly

1:05:21

in will be coming up in conjunction with the

1:05:23

Health Rosetta Fest in September. We

1:05:26

will have a steering committee meeting

1:05:28

that'll be open to anybody, whether you're a member

1:05:30

of the DBC coalition or not

1:05:33

September 10th. And a

1:05:35

fly in to visit Capitol Hill

1:05:37

the afternoon of September 10th and September

1:05:39

11th. And then the Rosetta Fest starts

1:05:42

on the 11th. And we're

1:05:44

working with Dave Chase and his

1:05:46

group at Health Rosetta to bring

1:05:49

a couple of speakers uh, from the Hill

1:05:51

to talk about these bills and what's

1:05:53

going on in Congress. So,

1:05:55

again dpcare. org is where you can go to

1:05:57

find out information and sign up. And

1:05:59

we look forward to having you September

1:06:02

10th and 11th in Washington to as

1:06:04

Garrison put us, continue to push, push

1:06:06

these rocks up the hill and

1:06:08

literally push yourself up the hill

1:06:10

and join us to leave some shoe leather

1:06:12

and, and, and lobby our legislators

1:06:14

on Capitol Hill to make, make sure we pass. the

1:06:17

Primary Care Enhancement Act and the Medicaid

1:06:19

Primary Care Improvement Act this year.

1:06:22

And then, Phil, can you mention any

1:06:24

last words on the DPC Frontier?

1:06:26

So, yep. Thanks for the hat tip towards

1:06:28

DPC Frontier earlier. I that's

1:06:30

been a labor of love for me for about 10 years now.

1:06:32

The most recent blog post on there talks about

1:06:35

a discussion I gave earlier this

1:06:37

year with Lee Gross conference at Docs

1:06:39

for Patient Care focusing on conflicts

1:06:41

of interest. And I

1:06:43

think Family physicians

1:06:45

especially understand all the conflicts of interest

1:06:47

that come apart in the regular or come about in the

1:06:49

regular system and lead to compassion

1:06:52

fatigue. And and we

1:06:54

need to keep that in mind and tell our stories in

1:06:56

D. C. And elsewhere and

1:06:58

make sure this becomes less of a problem

1:07:00

going forward, not only for

1:07:02

ourselves, but for the rest of the country.

1:07:05

And just so that you

1:07:07

are aware, there is a blog that's

1:07:09

going to be accompanying this podcast episode at

1:07:11

mydpcstory. com, where

1:07:13

I'm going to also have attached to this

1:07:15

episode what is the Larry Green

1:07:17

study? You can actually read the questions that

1:07:19

are the patient centered, basically feedback

1:07:22

on a primary care doctor office's

1:07:24

experience. It is a survey

1:07:26

that is patient centered and is

1:07:28

so important. You can also find

1:07:30

the links to both of the bills that

1:07:32

Jay has mentioned, as well

1:07:34

as the link to the Milliman study and

1:07:37

episodes where Dr. Bliss,

1:07:39

Dr. Eskew, and Jay have all shared on this podcast

1:07:42

previously. I'm also going to link

1:07:44

Dr. Bliss's article that he wrote

1:07:46

for DPCnews. com, where he

1:07:48

spoke about his experience in February, and

1:07:51

the actual steering committee meeting recording,

1:07:54

so you can take a listen to that. to see

1:07:56

what is a steering committee all about and

1:07:58

how important it was for independent DPC

1:08:01

doctors to be at the table. So with

1:08:03

that, thank you so much everybody

1:08:05

for joining us today and sharing

1:08:07

your takes on the current status of direct primary

1:08:09

care, especially when it comes to Capitol Hill.

1:08:12

Thanks, Mariel.

1:08:13

Thank you.

1:08:16

If you have any questions or comments on the episode

1:08:19

or for Dr. Bliss, Dr. Eskew, or Jay,

1:08:21

head on over to the my DPC story SpeakPipe, our

1:08:24

podcast voicemail line. You can find

1:08:26

our voicemail anytime by going to the contact

1:08:28

page@mydpcstory.com. For

1:08:31

even more DP DPC stories, practice updates,

1:08:33

and exclusive recordings on DPC, become

1:08:35

a community member at the My DPC story Patreon.

1:08:38

You can find the link on the homepage@mydpcstory.com.

1:08:42

Look forward to hearing from Dr. Jeffrey Shukman

1:08:44

of White Olive DPC in Woodland Hills, California

1:08:47

next week. In the meantime,

1:08:49

stay informed, stay healthy, and keep

1:08:51

telling others about DPC. For

1:08:53

more about DPC on the daily, check out dpcnews.

1:08:56

com. Until next week, this is Maryal

1:09:00

Concepcion.