Look, I’ll be honest with you. Most origin stories in medicine are boring as hell. Policy papers. Someone’s dissertation gathering dust.
Not this one.
Dr. Garrison Bliss didn’t stumble into direct primary care because he read some white paper or attended the right conference. His three-year-old son got a brain tumor, and suddenly this idealistic young doc fresh out of residency found himself on the other side of the stethoscope, watching the healthcare machine chew up his family and spit them out with a bill.
The doctors treating his kid? They were winging it, basically. Whole-brain and spinal radiation. A Hail Mary pass with side effects that would haunt his son for decades. Growth hormone issues. Spinal problems. And good luck actually reaching these specialists when you needed them. They were always “making rounds” somewhere else.
“I began to learn the weaknesses of my sport,” Bliss said later, which might be the most understated way anyone’s ever described watching their toddler get nuked by radiation.
His son made it. He’s got grandkids now, works in software. But those scars (literal and otherwise) didn’t fade for Dr. Bliss.
When Your Practice Makes You Sick
So he goes back to his Seattle primary care office, right? And he can’t shake this one question: Am I actually doing what my patients need, or am I just doing what works for me?
The answer sucked.
He started small. Kicked the pharma reps out. You know, those well-dressed folks who show up with free lunch and pens and suddenly everyone’s prescribing their new wonder drug. Stopped ordering chest X-rays for every single annual exam because honestly, how much radiation are we comfortable blasting people with? Let his staff actually advocate for patients even when it meant messing up the sacred physician schedule.
Nothing crazy. Just ethical stuff, you’d think.
But here’s the thing about small changes. They compound. They snowball. Pretty soon you’re looking at your entire practice model and going, “Wait, why are we doing any of this the way we’re doing it?”
The Concierge Wake-Up Call
1995 hits, and two of Bliss’s partners bail to start a concierge practice. They take all their richest patients with them (nice, right?). Meanwhile, the hospital system that bought Bliss’s practice flips it to some company that treats “cost-cutting” like an Olympic sport. Employee retention? Patient experience? Physician wellbeing?
Cute ideas, but have you seen our margins?
The practice went from something meaningful to just another medical mill.
But here’s where it gets interesting. Those ex-partners who bailed? They accidentally showed Bliss something. A glimpse of what medicine could be when insurance companies aren’t running the show.
So he starts noodling on the math. What would it actually cost to run a practice on direct fees instead of playing the reimbursement game? He’s hunched over spreadsheets (sexy, I know), running scenarios, and eventually lands on this: 400 to 800 patients per doc, $50 a month each.
That’s it. That’s the formula.
“We could be available seamlessly to people all the time,” Bliss figured. “We could even take care of our own patients independently, so that they always got their doc.”
Revolutionary concept, apparently. Actually seeing your own doctor.
They sent out invites to 10,000 existing patients.
600 said yes.
What Those 600 Patients Got
Here’s what happened to that core group of early believers.
Their doctors actually called them when it was time for a flu shot. Same-day or next-day appointments for urgent stuff. Not “we can squeeze you in three weeks from Thursday.” Hour-long annual exams where the doc wasn’t eyeing the clock and already mentally drafting the next chart note.
Was it perfect? Of course not. But it was built on something the rest of healthcare had apparently forgotten about: trust, communication, and giving a damn.
The “Godfather of Direct Primary Care” was born. He didn’t pick the nickname, but it stuck.
Why This Model Actually Works (And Why That Scares People)
For patients, it’s pretty straightforward. You pay your monthly fee. No surprise bills, no fighting with insurance over whether your sinus infection was “medically necessary.” You get actual time with your doctor. Wild concept.
For us physicians? We get to remember why we went to med school in the first place.
“People who do direct primary care are ecstatic,” Bliss said, and honestly, when was the last time you heard a primary care doc use that word about their job?
But here’s where it gets uncomfortable for the establishment. DPC patients are healthy. Like, demonstrably healthier. Fewer ER visits. Better chronic disease management. Lower overall costs.
Which means less money flowing through the traditional system.
And that makes you a threat.
The Empire Strikes Back
Success attracts attention. Not all of it good.
Enter Nick Hanauer, early Amazon investor (yeah, that Amazon), who literally walks into Bliss’s office one day while he’s dictating a chart. They grab coffee, and Hanauer’s pitching this idea for concierge medicine for wealthy folks. Bliss counters: what if we made this scalable? What if we built something that could actually disrupt the whole damn system?
Hanauer writes a check for $1 million. Jeff Bezos invests. The press goes bananas.
Qliance Health is born, and suddenly everyone’s watching.
Including the people who really, really don’t want this model to succeed.
Washington State’s insurance commissioner (tipped off by a payer, naturally) claimed Bliss was operating an unlicensed insurance company and threatened to shut the whole thing down. Classic regulatory stranglehold disguised as consumer protection.
Bliss mobilized 2,400 patients to write letters. The commissioner backed off.
Then the state legislature tried to tax DPC practices like insurance companies, which would’ve essentially killed the model through paperwork and fees. The governor literally took his pen and crossed out that section of the bill.
You don’t see that kind of intervention often. Direct primary care got lucky.
When Good Medicine Meets Bad Business
Qliance ran for about a decade. Tech companies loved them. Sports teams signed on. Even some traditional healthcare orgs (the irony) partnered up. Patients raved. Early data showed they were improving care and cutting costs.
Should’ve been a home run, right?
Then they struck a deal with a Medicaid managed care organization. Patient load explodes from 10,000 to 40,000 in a matter of months. Sounds great until you realize the infrastructure wasn’t quite ready for that kind of growth.
But here’s the kicker. Qliance delivered. They reduced overall healthcare utilization, provided eight times the primary care, saved millions of dollars.
The managed care company refused to pay.
Their argument? Qliance must’ve cherry-picked healthy patients. (They hadn’t.) When Medicaid wouldn’t cover the bill, the managed care org just shrugged and walked away from the contract.
Complexity and dysfunction won. Qliance eventually closed. Dr. Bliss went back to solo practice, partly because of the contract disaster, partly because he was approaching retirement and frankly tired of fighting.
Sometimes the good guys don’t win. Or at least, not in the way we expect.
What We’re Supposed to Learn From All This
If you’re a DPC clinician reading this (or thinking about becoming one), Bliss’s journey offers some hard-earned wisdom.
Make sure you actually want this life. Starting a DPC practice isn’t some romantic escape from the insurance grind. It’s hard. The ramp-up is slow and nerve-wracking. You’ll field weird questions from family members who think you’ve joined a cult. Take the AAFP courses. Read everything Bliss and folks like Dr. Philip Eskew have written about the common pitfalls. Go in with your eyes open.
Get yourself a mentor. Find someone who’s already doing this and buy them coffee (or beer, depending on how their week went). Ask if they need a partner. Pick their brain. The DPC community tends to be generous with advice because we all want the model to grow. There’s no proprietary secret sauce here, just people trying to practice good medicine.
Your partners matter. A lot. And I don’t just mean your physician partners (though obviously them too). Your EHR vendor, your billing support, your professional network. These relationships can make or break you. Bliss specifically credits Elation Health with building software that actually works for DPC instead of fighting against it. Strong systems don’t just reduce hassle. They reduce existential risk.
And hey, while we’re talking about partners who matter, let me put on my DPCBookkeeper hat for a second. Your accounting partner falls into this category too. I’ve seen too many brilliant DPC docs get tripped up by the financial side because they’re using a bookkeeper who doesn’t understand the model. Your practice operates differently than fee-for-service. Your revenue recognition is different. Your tax strategy should be different. Getting this stuff right from the start saves you headaches (and money) down the road.
The Fight’s Not Over (It’s Really Not)
Dr. Bliss is almost retired now. Still seeing some of the same patients from 1997, still writing op-eds and testifying about healthcare policy, still showing up for the cause.
His reflection on all this: “For me, it’s a little bit like the end of the movie ‘The Godfather,’ when he’s wandering around in the garden with the grandchildren.”
Which is maybe the most perfect metaphor for where we are with DPC. We’ve got this elder statesman figure who built something from nothing, fought all the battles, took all the arrows. He’s earned his garden time.
The rest of us? We’re still in the trenches.
For Those of Us Still Fighting
Every patient you keep out of the ER. That’s a win. Every chronic condition you actually manage instead of just medicating. That’s a win. Every burned-out colleague you inspire to try something different. That’s a win.
Will the system push back? Absolutely. Payers will question whether you’re “real medicine.” Regulators will tie themselves in knots trying to figure out how to categorize you. Some of your med school classmates will dismiss DPC as boutique care for rich people, even while you’re proving otherwise with Medicaid patients and blue-collar families.
But we’ve got something the old system doesn’t have. Patients who genuinely love their healthcare experience. Physicians who don’t dread Monday mornings.
That’s not nothing.
Bliss proved you could build an ethical primary care practice that serves actual humans instead of billing codes and quality metrics and patient satisfaction scores that measure everything except actual satisfaction.
Now it’s on us to take that proof of concept and turn it into the norm.
Practice by practice. Patient by patient. Conversion story by conversion story.
The Godfather built the foundation. Whether we build the rest of the house? That’s on us.
To learn more about Dr. Bliss, check out his article here: https://healthrosetta.org/education/garrison-bliss-the-negaclaim/
Daniel from DPCBookkeeper.com here. If you’re thinking about making the jump to DPC or you’re already in practice and want to make sure your financial foundation is solid, reach out. We specialize in bookkeeping and tax strategy for direct primary care practices because honestly, your accountant who mostly works with restaurants and retail shops isn’t going to get the nuances of your model. Let’s talk.