I grew up a New York Yankees baseball fan in the fifties and sixties. Among the many stars on the Yankees, none became more famous for one-liners and quips than #8, Yogi Berra. Yogi’s famous reminder, “It ain’t over til it’s over,” seems so fitting today as we await some sort of resolution to the COVID-19 pandemic. (For any Lenny Kravitz fans, out there, yes, he recorded a song by the same name, and it made the Billboard 100 charts. But history suggests the credit goes to Yogi. Besides, I am not sure if Lenny could handle a fastball.) Two months ago, I wrote about this novel coronavirus, and how unsure and worried I was about how we would fare, despite my basic optimism. I feared that traditional primary care practices would be greatly challenged. I was hopeful that direct primary care practices (DPC) like mine were well-positioned to care for patients and to weather the financial impact during the pandemic. One month ago, I followed up with what I hoped would be a “midstream” update, expressing my regret that so many of my concerns had been confirmed. The virus was more contagious than thought. We, as a country, were not ready. Proven treatments, much less efficacious vaccines, were not emerging. Our health care system, particularly primary care practices which already overly-dependent on third-party payors and a “heads thru the door” formula, was scrambling to meet the challenges of this virus and the consequences of “sheltering at home” telemedicine, previously criticized as less than “good medicine,” was being hurriedly embraced by systems, physicians, and even payors as a strategy to continue to provide care and salvage lost revenues, however inadequate the payments and however unprepared practices were. I also reported, hopefully with the proper tone, that my practice in North Carolina and the many DPC practices across the country with which I was familiar were faring well. Our patients were continuing to receive care and were very appreciative of the access and ease of communication afforded by the DPC model. Now we are in May, and Yogi was correct. It ain’t over. Despite understandable efforts to reopen businesses and get workers back to work, the virus itself has not gone away and shows no signs of going away soon, particularly this winter. We appear to be in for a difficult battle, of the human race against a virus, and the economy against a pandemic. This feels like a war. I am in awe of those on the front lines. The unselfishness of the many brave nurses, therapists, aides, physicians, cleaning staff, and other hospital workers is truly remarkable. They are indeed heroes. There has been much suffering and much loss. Lives. Retirements. Livelihoods. Businesses. Industries. And that clearly includes, as I feared, primary care. Practices have lost a lot of money. Practices are closing. Physicians are contemplating leaving medicine, perhaps never to return. Primary care is in deep trouble. That seems clear. Is there any reason for hope? I have looked at the so-called “primary care Marshall Plan.” On the surface, it has merit, and does offer some needed changes to primary care. But it does not solve all the ills of traditional primary care today: poor access, inadequate reimbursement, burdening overhead, cumbersome metrics, exhaustive “hoops to jump thru,” lack of independence, unpredictability, and financial insecurity. Nor is there any evidence of this Marshall Plan being embraced by payors or employers, certainly no time soon. So I remain uncertain about this virus, and about the future. But I do know this. I chose the right path six years ago when I decided to open a DPC practice. My practice was doing well prior to COVID-19, and I was a happier physician. I am confident this will continue. DPC works. During a pandemic, and during so-called normal times. Just as I am proud of the entire health care community during this pandemic, I am also touched by what I have seen in my own DPC community. Practices continuing to care for the uninsured and the less fortunate. (Note to reader: DPC is not “concierge medicine.”) Practices not charging their patients for a month. Patients being told their membership would not be canceled because of nonpayment, giving them time to get back to work and get a paycheck. Donations being made to good causes in the community. Volunteering in the community. Distributing and even sewing masks. Providing education and being beacons of truth and objectivity, in the midst of so much misinformation and unfounded claims. DPC works. And it is doable. We believe DPC offers hope and a path forward for primary care physicians who may be disenchanted or their careers threatened. We think there is an audience of fellow physicians ready to listen, physicians who have previously contemplated DPC and now, unfortunately, are more ready, and physicians who have never heard of DPC. We are eager to see them follow the path we took. We have the resources and energy to assist in many ways. Yet, we know scaling DPC up will be a challenge. There are many barriers and obstacles. The status quo has much to lose. But primary care is losing, and we think there is a solution. To close, I will share another “Yogi-ism”: “When you come to a fork in the road, take it.” Well, we are at that fork. Follow the status quo, and expect the same results, or take the path less taken, DPC, and return primary care to what it can be and should be. I know the choice I would make. Again. Thomas Rhyne White is a family physician. Source
