Healthcare Rebel Alliance: Q&A with Garrison Bliss

Your interest in philosophy and ethics led you to medicine, and you are often called the father or godfather of Direct Primary Care. When did you decide or realize you were building a movement and not just a practice?

Garrison Bliss: When I left the world of Fee-For-Service medicine (FFS) in 1997, I did so because I felt driven to fend off a kind of medical care that I regarded as both unethical and unrewarding. Like many primary care doctors, I viewed my job as a mission, not a business. That mission included understanding the bedrock principles required for healthcare to be ethical and effective. Healthcare should never be driven by money, fame, or ego. We should never DO anything, or NOT DO anything because it would bring in more money. Our care should be tailored exclusively to the needs of our patients, and they should have the ultimate power to take or refuse our advice. Our duties to them should be in writing, not just on a list of intentions. Patients should have the right to leave our practice and join another doctor's practice at any time if we have not met their needs. We must have enough time and enough resources to keep our promises. I wanted a workplace that rewarded great care and punished poor performance, whether technical or interpersonal. I also wanted as much feedback as possible from our patients to confirm that we were on the right track.

When I switched my practice to what is now known as Direct Primary Care (DPC), I had no idea whether this would work for me or my patients, but I could not tolerate the status quo. It took about a week after opening my new practice before I knew that it was destined to exceed my expectations. A substantial portion of my patients had enough interest in this idea to join, getting to financial break-even on day one of my new practice. The culture of my office adjusted quickly and easily to a patient-driven enterprise from our prior life of overwhelm and frustration from the insurance game we had rejected. Our income became adequate, stable, and unwavering throughout the year, supporting our office and staff regardless of season, medical demand, or outside economic forces. On the first day, we stopped thinking about how to get paid and started to think about how we could make more and better promises, and about what we needed to do as an office to live up to those promises. It didn't take long to realize that we were on to something transformational.

The national DPC movement began with a phone call from John Blanchard MD in Michigan, who had read an article about us on the front page of the Wall Street Journal in 1998. By the time he called, he had already created his own practice and was in the process of starting a national organization. He wanted me on the Board. I agreed.

By 2005, my awareness of the attractiveness of this care model was confirmed by both doctors and patients in multiple states, and I began to entertain creating a scaling version for the rest of the United States. By 2010, we had successfully passed legislation in Washington State, fighting off a major challenge by the Insurance Commissioner (who initially claimed that, under state law, we were not medical care, but an insurance company). That bill coined the term Direct Primary Care, which rebranded this movement and differentiated us from "concierge" medicine. By March 2010, we were included in the Affordable Care Act, reinforcing our claim that we were being paid for care and absolutely NOT being paid as an insurance entity. Since then, we have passed a total of 33 State bills to clarify that DPC is not insurance.

From that day forward, this movement has been grassroots and formidable. We have evolved as a live culture, not simply as a business model or scheme. There are now multiple successful scaling DPC enterprises and many thousands of Physicians, Nurse Practitioners, Physician Assistants, and even Specialists who are trying on this culture.

Nick Soman, Decent: You have advised doctors interested in offering Direct Primary Care to make sure they want it. What does that mean to you? What aren't they seeing from the outside?

Garrison Bliss: Primary Care is not for every doctor. You have to understand that people come to medicine for many reasons. Some find their way here because they are good at studying, passing tests, and getting grades that make them eligible. Some want to be researchers and academics. Some are drawn to the enormous potential financial payoff that many specialties provide. Many are hoping for personal fame or recognition. Primary care is a haven for those of us who crave the honest and continuing relationships we have with multiple generations of people, the joy of partnering with patients to create opportunities for them to become healthier and to realize their goals, not ours. Primary care doctors are rarely seekers of personal fame, impressive wealth, or limelight. They love being in rooms with people who have problems we can help them solve. The best Primary Care doctors are also active teachers and supporters of projects that our patients undertake. We are here to help them plan their approach, and we are there to applaud their successes or to soften the pain of their defeats. We like the long game, helping the anxious and depressed to become less burdened; working with smokers, narcotic abusers, and alcoholics to understand and manage their addictions. We are at home with patients afflicted by chronic diseases. We think that it is our job to help our patients find the best specialists for them, to minimize patient costs and inconvenience, to mitigate the communication errors that undermine patient safety, to reconcile medications from multiple specialists that are dangerous or incompatible when taken together. When the specialists have finished their evaluations, we are here to work with our patients to help them manage their meds and to understand the details of their diagnoses and the reasons for complying with treatment. Primary Care can do 80-90% of all care required for our patients over a lifetime. Most Primary Care docs I know welcome this challenge and have little interest in caring solely for the wealthy and entitled.

Nick Soman, Decent: What excites you most about the evolution of DPC so far? What frustrates you?

Garrison Bliss: Quite honestly, I have been amazed to see how well this practice model works to improve the lives of both patients and doctors consistently year after year. I am floored by the ability of Direct Primary Care to reduce the cost of healthcare by 15% to 50% (after including our periodic fee in the costs). This sounds impossible to most observers of medical care. It is not a result of hiring physicians who are geniuses (although some are). In DPC, we have stopped taking money from insurers for doing stuff that we shouldn't be doing. Instead, we have been rewarded for the extra time we spend with patients and the trusting relationship that reinforces and empowers our work and their well-being.

In the frustration department, DPC has had to fight with insurance companies and insurance commissioners for two decades to establish that we charge a monthly fee for access to high-functioning healthcare instead of engaging in a fee-for-service universe that is making healthcare far too expensive and less effective or safe than it should be. We have slogged through an era in national politics that has allowed ideologic combatants to bring a halt to even the most benign and bipartisan innovations. We are hopeful that this year will be different, finally allowing us to pass legislation that will give us more access to employees with HSAs and Medicaid patients—all without compromising our model. If achieved, this will eliminate the most onerous barriers to adoption of DPC by patients and employers. It also could create enormous demand for DPC nationwide. This in turn could FINALLY make Primary Care a popular option for Medical students and residents. Right now, only 5-10% of the graduating medical school students select Primary Care as their path forward. For American healthcare to become high functioning, we need to establish a medical workforce that is 50% Primary Care and 50% Specialty Care (currently about 20%/80%). I hope that I will be around when we hit this target.

Nick Soman, Decent: DPC is clearly having a moment right now, and as often happens, business and government interests are angling for control. What needs to happen next at the industry level to realize your vision of the best version of DPC?

Garrison Bliss: DPC is an experiment in playing field design and in culture creation. As initially envisioned, the point of creating DPC was to manufacture a kind of model of medical care that would show this country and the world that it was not only possible but highly preferable to rebuild our national and international healthcare systems with this model in mind. Thanks to Dave Chase and Health Rosetta, this battle has been joined by self-insured employers who are increasingly willing to innovate to reduce their healthcare costs while improving the lives and health of their employees. Dave has spent decades finding out who in this country has been successful at creating solutions for our dysfunctional healthcare system. When you package these together and attach them to a foundation of Direct Primary Care, miracles happen.

Of course, there are many in our $4 trillion medical economy who wish to either criticize or "control" our efforts. There are also potential investors who think of this movement as a 10x opportunity for THEM. My recommendation to all such interested parties is: We are doing this for our patients, not for you. Many of us in this movement have established a culture that works extremely well without you. If you want to help us, don't mess with our culture and don't try to sell us a business model that damages doctor-patient relationships, innovation, and autonomy. If you wish to help this movement, use your power to get support for DPC in Congress (we have two active bills right now). Engage with medical schools and residencies to encourage the creation of the thousands of well-trained primary care docs that this country needs. Donate money to funds that help the poor, the underserved, and the chronically ill to obtain high-quality primary care, ideally from DPC doctors. A number of our DPC practices have already established donor-funded resources that can pay the fees for any financially strapped patients. If you own a business and you value your employees, look for DPC docs near you and make it easy for your employees to use them.

Nick Soman, Decent: Who else in healthcare inspires you, and why?

Garrison Bliss: American healthcare has not shown me much in terms of transformative design. I like, in principle, some of the free market ideas I have seen, particularly the Surgery Center of Oklahoma with its emphasis on transparency, access, and affordable pricing. I was also elated to see a raft of vendors in the DPC space at the recent DPC conventions, who are aiming to provide the software and medical tools DPC docs can use to further improve their accessibility, quality, and wow factor of our care. At an AAFP DPC Summit last month, there were roughly 50 vendors who wanted to serve our movement. I encountered advanced home sleep monitoring tools with low pricing, rapid reporting, and Primary Care interpretable results. There were multiple companies selling hand-held ultrasound systems that would allow DPC docs to do bedside evaluations of a wide variety of organs at the time of visit, thus bypassing the wait and costs associated with urgent care, ERs, and hospitals. I continue to be amazed by Hint Health, which many years ago wrote the first DPC-friendly monthly billing systems and now has built a technical infrastructure designed to connect our movement seamlessly with software and hardware companies who operate consistently with our culture and support our medical practices. In the near future, we expect to see more and more AI-assisted Primary Care software specifically designed to improve the patient experience, outcomes, and doctor-patient relationship. DPC is also very involved with finding easy and inexpensive ways for our patients to get their medications in pre-packed format at our offices, either free or at our own wholesale cost. The final ray of sunshine is the recent emergence of the Direct Specialty Care Alliance. I had the pleasure of meeting Diana Ginita MD PhD, who is a Rheumatologist and a leader in this movement. There is also increasing interest in Pediatrics and other specialties which have similar problems with the status quo that Primary Care doctors have.