Lessons from Qliance closing its doors

The news that Qliance is closing its doors gives us an opportunity to reflect on the lessons learned from the enterprise.  The direct primary care (DPC) model espoused by Qliance struck some folks as an important innovation in care delivery, one focused on bringing more primary care services to the patient.

In watching the organization over the years, and in conversations with former investors, employees, and collaborators with the organization, I’ve culled together a few lessons from the Qliance endeavor.

  1. “Cash is king,” particularly in health care.  Dr. Erika Bliss, CEO at Qliance, told Geekwire that the abrupt closure of the firm was a result of a lender making an unauthorized withdrawal of funds from Qliance’s bank account.  This is painful for a business when it happens, but it is also not terribly exceptional. It’s the thing banks can do when they think their client is not likely to pay back existing debts.  This action exacerbated an already existing financial strain on the company.  They had a gofundme page up earlier this year, which wasn’t a great sign.  The lesson for any organization, but particularly the highly capitalized organizations in health care, is to protect your cash position.  Without it, your business is lost.
  2. Having the right leadership at the right time matters.  Being a good visionary leader does not necessarily make one a good operator or strategist.  Through conversations with folks close to the company, Dr. Bliss was a visionary leader, was adept at raising investment funds, and was committed to patient care.  However, Qliance had problems keeping other senior leaders on the team.  The organization wasn’t able to build a deep bench of committed, senior administrative talent that would be empowered to build the organization where Bliss wasn’t as strong.  Challenging the traditional model of health care financing (which is really what Qliance was doing) requires a strong leadership team, something that never seemed to gel at Qliance.
  3. Even with perfect leadership and funding, DPC is a round peg in the square hole of health care.  This is true for three reasons.  First, the primary DPC financing model comes from a direct relationship with the patient, outside of the traditional insurance financing model.  Second, the regulatory framework in Medicaid, exchange and Medicare doesn’t support the DPC model very well.  Third, primary care is still centrally important to managing care, but an MD or DO is not necessarily the right license level to do that on an enterprise scale at an effective price point for the consumer.  ARNPs and other mid-levels are often better suited for a range of primary care issues.
  4. More on the changing nature of primary care.  Building on the point above, the general trend in care management is to push care to the lowest part of the license range as possible where the individual care giver is working at the highest part of his or her license as possible.  That means that long term care workers, MSWs, PAs and ARNPs are doing a great deal of good primary care work.  They can’t handle the full load of primary care demands, but they are taking on an increasing share of the actual care delivery.  This shift increasingly means that the primary care physician (PCP, MD or DO) has lots of competition for throat swabs and sutures.  Where the PCP has highest value is as the care coordinator among specialists, Rx, behavioral health integration, and inpatient/outpatient transitions.  That’s becoming the highest and best use of the PCP – and that kind of care coordination was not really what Qliance was about.  Generally speaking, Qliance providers were PCP docs and ARNPs working at the mid-range of their license rather than the top, who operated as independent actors rather than as care coordinators for complex medical issues.  That’s just not the direction primary care is doing these days.

So, in the end, I think Qliance was challenged for both internal and external reasons.  That said, looking at DPC as a whole – if it’s a medically-based, doc-led and non-coordinated, non-integrated model – is going to be problematic for financing, delivery and cultural reasons.

I think direct care models that support wellness, integrated health management, and do so at a cost level that is sustainable (ie: providers at appropriate licensure levels) makes sense.  I like Arivale, for example, but that’s a game changer in a number of ways and reasons that Qliance could never be.