Q&A WITH PHILIP HIXON
Direct primary care expected to rise
Q: What is direct primary care?
A: Direct primary care is an alternative “membership” health care model. Similar to
“concierge” health care for the wealthy, direct primary care allows physicians to spend more time with patients while providing better quality care. Services may include primary care, urgent care, chronic disease management, and wellness support, provided in exchange for a low monthly fee under a DPC agreement. At many direct primary care practices, the cost of office visits, routine tests, and procedures are included in the monthly fee.
Q: Is direct primary care common?
A: An estimated 700 plus direct primary care practices exist nationwide. This number is expected to rise as physicians and patients are looking to escape the “red tape” associated with traditional practices and third-party payer models. Although each practice differs, at the heart of any direct primary care practice is a physician or group practice dedicated to providing affordable, routine care essential for the well-being and ongoing maintenance of a patient’s health. Over half of the states, including Oklahoma, have passed direct primary care legislation to encourage growth of this affordable, alternative model. The Centers for Medicare & Medicaid Services is exploring development of a direct primary care model for patients on Medicare or Medicaid, who might not otherwise be eligible to participate.
Q: How does direct primary care work?
A: Direct primary care arrangements are founded on agreements between direct primary care physicians and their patients. Legal counsel should be involved in developing the patient agreement. Under most agreements, providers charge patients an affordable monthly fee for all primary care services provided in the office, regardless of the number of visits. Some direct primary care providers even include email, text and house calls in the services available as part of the agreement. By charging patients a set monthly fee, the health insurance “middle man” is removed from the equation and, thus, the overhead associated with claims, coding, claim refiling, write-offs, billing staff and claimscentric electronic medical records systems is significantly reduced. Direct primary care physicians see an average of one-quarter to one-third the number of patients per year compared to physicians in a traditional insurance model.
Q: What does the Oklahoma direct primary care Legislation do?
A: It seeks to accomplish two simple goals: define direct primary care as a medical service outside the scope of state insurance regulation and provide basic consumer protections.
Q: How is direct primary care different from health insurance?
A: It is important for health care providers and consumers alike to understand that, although direct primary care removes the insurance middle man from primary care, direct primary care does not eliminate the need for health insurance. Patients who elect to participate in direct primary care agreements often maintain separate insurance coverage for “catastrophic” medical services. Also, while most direct primary care providers opt out of all health insurance, including Medicare or Medicaid, it’s possible for direct primary care plans to receive “qualified health plan” treatment under the Affordable Care Act, provided that such plans comply with applicable rules and regulations. Direct primary care providers, who continue to accept payment from health insurance or a public health care program, should have qualified legal counsel evaluate the impact federal fraud and abuse laws may have on their practices.