In Qliance’s Wake: Lessons for DPC
Last month, DJ Wilson reflected on the announced closure of Qliance with general conclusions about the healthcare industry. However, some of his comments about primary care were inaccurate as they relate to the current market.
One of the major issues regarding the Qliance experience is that the reasons for their failure are specific to Qliance and both their capital partners and insurance partners. The failure of Qliance should not be generalized to either direct primary care, or to the general world of primary care. Primary care is fairly unchanging and untouched by medical technology, almost by definition.
The nature of primary care is focused on the patient-physician relationship, perhaps more than any other specialty. The failure of primary care is the failure of the system to properly emphasize its role as the engine of efficiency in healthcare. The effort to provide the right care to the right patient at the right time is not an issue of better defining the diagnostic or therapeutic technology. It is, at it has always been, the effect of knowing your patient and having both the time and opportunity to fully flesh out a patient’s priorities.
A good primary care physician directs one patient to the orthopedist who is least likely to recommend a major intervention once and then sends the very next patient to the fastest surgeon in the group. A good primary care physician knows which orthopedist will adjust and adapt treatments for the benefit of the entire family’s wishes, including the reluctant patient, who prefers to go straight to hospice.
The trouble with primary care is that resource planning assumes coughs and colds is all we treat. But we cannot miss the pneumonias interspersed unbeknownst to the clerk recording the complaint. Chest pain may be a strained muscle or it may be a heart attack. Blood in the stool may be anything from hemorrhoid to colon cancer or more complicated problems like vascular malformations. The lower the skill level at the front line, the more likely there will be a huge and probably unnecessary work-up. Primary care is the setting where the clinical skill combines with the art of medicine, competent communication and intuition to keep a lid on healthcare costs.
Most cardiologists already know what they are dealing with before the patient walks in, or should know, if primary care is effectively fulfilling its role. Primary care is a world where between 1/3 and 2/3 of primary care visits are undifferentiated, which means, they may not be strictly speaking organic or deadly. We are a filter for the worried well and an advocate for the seriously ill. Additional efficiencies are driving the fact that primary care’s scope of practice includes everything from glaucoma screening, dermatology, minor surgical procedures, asthma monitoring and treatment, diabetes and other chronic disease management. Even specialist opinions in the information age can be done with the support of remotely located specialists.
From a health system perspective, of course hospitals and multi-specialty clinics want to push front-line patients to providers with the lowest possible degree of training for care. It makes sense when they hold the key to all the unnecessary investigation and procedures that will result. But from the patients’ perspective, people want low-hassle, accurate direction from a competent front-line physician.
We will always need the tertiary specialists at universities around the country, but the community-based specialties become progressively more redundant once primary care fulfills its proper systemic role. This is where health tech can play a role disrupting the overwrought costs and administration of the health system we have developed. Tech can improve and enhance the communication between patients and their health advisors, who should have the best skills and diagnostic discernment that medical education can produce.
It is ironic that by all appearances insurance companies and capital partners sank Qliance. After all, as incumbents, it was their business models on the line if Qliance succeeded. The rest of us won’t make the same mistake. And primary care will emerge stronger than ever; the tonic to America’s health costs and the cure for the ills of its healthcare system.