So for a small practice going forward - best path is some sort of subscription model? This avoids insurance companies and VBC funding . But it then presents many issues with demographics of your population , viz, you will self select for better paying patients in order to remain afloat . We primary docs CAN retain lower income patients and do our own work supporting those who cannot pay enough . This takes me right back to when I began in 1985 in a rural county in the mid Atlantic region.When we started , we did not even participate with Medicare ( patients could of course submit on their own for reimbursement ) . And we knew there were just some patients who would not / could not pay much or at all. So we collected more from those who could . Dr B you are bursting my bubble - I saw the ACO/PHO ideas as ways small practices COULD participate in a more socialized set of costs ( dealing those who had less to pay ) without having to go the full concierge / subscription route. For all their bad points and possible corruptions , the ACOs do have a population based approach.
I wish it were true that ACOs could help those who cannot afford. However, in real life, financial engineering and incentives completely change the picture.
ACO LEAD will try to pay more for dual eligibles, as a proxy for seniors with lower incomes. However, this will also end up being gamified, and benefits will go to large organizations with scale.
Also, ACOs have become a backdoor to push SDOH into primary care, allowing policymakers to wash their hands of the problem.
The older model, where local docs with community ties would take care of people, was, on average, better. The new way to do this is a subscription model—which, given high-deductible plans, may still end up being cheaper for people.
Thanks for the reply . I remain concerned the subscription model is at best a partial solution . And SDOH was always in primary care , not sure how ACOs are backdooring . You can no doubt tell my training is FP ( even though by nature and now by practice I am IM ) . Again , thanks for the conversation . Best.
High-deductible health plans have created a whole class of underinsured people. Subscriptions offer a solution for this group while allowing small practices to avoid some of the insurance shenanigans and, hopefully, not only survive but also provide better care.
SDOH were always in primary care, but current VBC models explicitly penalize primary care for outcomes explained by SDOH. E.g., if people cannot afford medications, PCPs fail the Medication Adherence quality measure - leading to financial penalties in VBC contracts.
Thank you for your thoughtful comments and conversation.
Hey — I came across your writing and really liked how you think.
I’m exploring something similar from a different angle — writing about human behavior through a system design lens (like debugging internal patterns).
Just started publishing on Substack. If you ever get a moment to read, I’d genuinely value your perspective.
Also happy to support your work — feels like there’s an interesting overlap here.
So for a small practice going forward - best path is some sort of subscription model? This avoids insurance companies and VBC funding . But it then presents many issues with demographics of your population , viz, you will self select for better paying patients in order to remain afloat . We primary docs CAN retain lower income patients and do our own work supporting those who cannot pay enough . This takes me right back to when I began in 1985 in a rural county in the mid Atlantic region.When we started , we did not even participate with Medicare ( patients could of course submit on their own for reimbursement ) . And we knew there were just some patients who would not / could not pay much or at all. So we collected more from those who could . Dr B you are bursting my bubble - I saw the ACO/PHO ideas as ways small practices COULD participate in a more socialized set of costs ( dealing those who had less to pay ) without having to go the full concierge / subscription route. For all their bad points and possible corruptions , the ACOs do have a population based approach.
I wish it were true that ACOs could help those who cannot afford. However, in real life, financial engineering and incentives completely change the picture.
ACO LEAD will try to pay more for dual eligibles, as a proxy for seniors with lower incomes. However, this will also end up being gamified, and benefits will go to large organizations with scale.
Also, ACOs have become a backdoor to push SDOH into primary care, allowing policymakers to wash their hands of the problem.
The older model, where local docs with community ties would take care of people, was, on average, better. The new way to do this is a subscription model—which, given high-deductible plans, may still end up being cheaper for people.
Thanks for the reply . I remain concerned the subscription model is at best a partial solution . And SDOH was always in primary care , not sure how ACOs are backdooring . You can no doubt tell my training is FP ( even though by nature and now by practice I am IM ) . Again , thanks for the conversation . Best.
Agree that subscription is a partial solution.
High-deductible health plans have created a whole class of underinsured people. Subscriptions offer a solution for this group while allowing small practices to avoid some of the insurance shenanigans and, hopefully, not only survive but also provide better care.
SDOH were always in primary care, but current VBC models explicitly penalize primary care for outcomes explained by SDOH. E.g., if people cannot afford medications, PCPs fail the Medication Adherence quality measure - leading to financial penalties in VBC contracts.
Thank you for your thoughtful comments and conversation.
But the PURPOSE of VBC is to destroy independent practices, or rather, to destroy physician independence altogether.
Why be surprised when it does what it is supposed to do?
I am trying to raise awareness about this issue. Appreciate your feedback.