Direct primary care will continue to grow because it empowers price transparency, quality, and patient satisfaction.
Philip Eskew, DO, JD, MBA
Fam Pract Manag. 2016 Sep-Oct;23(5):12-14.
Author disclosure: Dr. Eskew discloses that he has an ownership stake in DPC Frontier, a free DPC online resource; is an employee and officer of ProactiveMD, which offers DPC services to employers; and is on the speakers’ bureau for Access Healthcare, where he occasionally speaks at CME events.
Direct primary care (DPC) is a growing movement across the United States involving at least 429 practices in 47 states.1 Family medicine physicians operating DPC practices share several characteristics:2
They charge a periodic (monthly or annual) fee for a defined set of primary care services,
They do not bill any third parties on a fee-for-service basis for the services covered by the periodic fee,
Their per-visit charges are less than the monthly equivalent of the periodic fee.
DPC practices differ considerably from concierge practices in both legal design and practice operation.2 Pure DPC practices do not bill any forms of traditional insurance, and this lowers practice overhead and allows these physicians to spend more time with the patient rather than wasting time on busy work requested by insurance companies. In contrast, concierge practices “double dip” by continuing to bill in a traditional fee-for-service fashion and by charging a membership fee. Overhead in a concierge practice is not reduced, and these physicians must be willing to spend less time with patients who decide not to pay their monthly fees, which are usually much higher than DPC monthly fees. Ignorance of the distinction between DPC and concierge models is often a source of attack against DPC,3 which I have addressed elsewhere.4
This article will address three common misconceptions about and criticisms of the DPC model.
1. Is direct primary care legal?
Yes, DPC is “not insurance” (since there is no risk transfer), and legal DPC contracts can be drafted in every state. As of Aug. 16, 2016, 17 states have passed laws related to direct primary care. (See “Direct primary care laws by state.”) Most of the state legislation is motivated by a desire to define DPC as “not insurance” so that the state insurance commissioner does not feel obligated to prohibit or regulate the practice model. DPC is arguably legal in every state without this legislation, but legislation is often helpful because it clears up legal gray areas and thus removes barriers to physician adoption of the model.
Each of the 17 state laws include a variety of patient protections. They generally require practices to state that the DPC agreement is “not insurance,” to permit patients to end the agreement at any time without owing additional fees, and to describe the scope of services offered so patients understand what is being purchased.
At the national level, the Affordable Care Act defines and encourages DPC as well. It allows insurance companies to develop “wrap around” insurance plans designed to be coupled with DPC and sold in a bundled fashion in state insurance exchanges so that they may be compared to traditional insurance plans in an “apples to apples” fashion.
The DPC model is easily understood and enjoyed by patients, and my research has not discovered a single malpractice claim from a DPC patient. For example, although the Washington State Insurance Commissioner was skeptical of the DPC model when it was established in the state in 2007, his office’s “Direct Practice Annual Report to the Legislature” found no formal or informal patient complaints filed against the 33 practices serving 11,504 patients.5 Unlike traditional insurance, which can feel like an arranged marriage between the patient and physician, the DPC model involves mutual selection by the patient and physician, and the physician is not incentivized to limit care. If the patient perceives a lack of value, he or she may end the relationship at any time.
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