If insurance plans are removed from the billing cycle for primary care, it’s not clear how clinical laboratories will be reimbursed for their services
Direct Primary Care (DPC) is gaining popularity in the United States. This emerging movement enables primary care providers to bill patients directly for services rendered, bypassing traditional health plans. On a large scale, employers can contract with primary care practices directly for their employees’ primary care coverage. The idea is to lower healthcare costs. But what exactly is DPC and how are clinical laboratories affected by it?
In operation, direct primary care is similar to concierge medicine, where a patient pays an annual retainer for direct access to a specific healthcare provider. DPC practices offer members unlimited, on-demand visits to primary care physicians for a flat, monthly fee.
The DPC movement has its own lobbying group—the Direct Primary Care Coalition—which supports physicians who opt to practice direct primary care. According to the group’s website, there are currently about 1,000 DPC practices in 48 states which serve over 300,000 patients.
DPC has gained Senatorial support. In December, Senators Bill Cassidy, MD (R-LA), Doug Jones (D-AL), Jerry Moran (R-KS) and Jeanne Shaheen (D-NH) introduced legislation to “lower the cost of healthcare and expand patients’ access to their primary care providers.”
Their bill (H.R. 3708), titled the “Primary Care Enhancement Act of 2019,” would amend the Internal Revenue Code of 1986 to “allow individuals with direct primary care service arrangements to remain eligible individuals for purposes of health savings accounts, and for other purposes.”
A press release announcing the Senate version of the bill (S. 2999), described DPC as a model that “encourages patients to develop personal relationships with their primary care physician, including extending access to care beyond office visits and business hours and through telemedicine. It focuses on prevention and primary care, relying less on specialist and hospital referrals. It is a growing model used by more than 1,000 practices across 48 states and the District of Columbia.”
The press release also states, “DPC models replace copays and deductibles with flat, affordable monthly fees. Current law makes DPC incompatible with health savings accounts (HSAs) paired with high-deductible health plans (HDHPs).”
Direct Primary Care in Practice
Physicians seem to like the DPC model. It frees them, they say, from the unnecessary interference of insurance providers, the burdens of excessive paperwork, and ever-increasing administration costs, while allowing them to have a better patient-doctor relationship.
“I know all my patients by name. I have time for them,” Matthew Abinante, DO, told The DO, a journal of the American Osteopathic Association (AOA). “I probably interact with about 20 patients a day when you factor in the electronic communication.”
Abinante is a board-certified family physician. He practices at Elevated Health, a direct primary care practice in Huntington Beach, CA. Patients pay an average of $75 per month for membership. This fee includes unlimited same day/next day appointments and the ability to talk to a doctor via telephone, e-mail, text, or video chat—24/7.
At Elevated Health, some minor clinical laboratory tests and procedures are included in the monthly fee. They include:
- Minor suturing,
- Cryotherapy, and
- Skin biopsies.
Other medical laboratory testing, imaging, and medications are available to patients at contracted wholesale prices, which are quoted up front. This is consistent with the trend for price transparency in healthcare.
“What everyone really needs to know is that patients do get better care when their doctor is more satisfied with what they’re doing. And that takes time. What the [fee-for-service] system cannot provide us is time with the patient,” Tiffanny Blythe, DO, told The DO. Blythe runs Blue Lotus Family Medicine, a DPC practice in Kansas City, MO.
When Direct Primary Care Does Not Work
The DPC model has been tried before. In 2010, a DPC provider called Qliance was formed primarily on investment capital from Jeff Bezos of Amazon. The goal was to free doctors and patients from the constraints of traditional health insurance.
Qliance opened several clinics in the Seattle area and by 2014 had nearly 50,000 DPC patients—including employees of Expedia and Comcast. It also had a contract to provide primary care services with a state Medicaid insurer. Nevertheless, Qliance closed in 2017.
“We would open up a clinic and add a bunch of docs before we had enough patients to pay for it,” Nick Hanauer, a Seattle venture capitalist and investor in Qliance, told STAT.
“It’s just hard to get the customers because you had to break the paradigm that was in everyone’s heads about how healthcare had to work, and you had to disrupt the relationships people had with their insurance companies,” Hanauer explained.
“Somebody with more economic power than we had could do this—and should,” he added.
Not All Physicians Support Direct Primary Care
Since the DPC model is so new, there is little research or statistics to confirm it will have a positive effect on healthcare outcomes or lower healthcare costs. Some healthcare professionals have reservations about direct primary care. Their concerns include the potential for less oversight of practitioners and the possibility that patients will slight themselves regarding insurance coverage.
“What we don’t hear about are the people who need more than can cover and what happens to them when they fall into that gap,” Carolyn Engelhard, a health policy analyst and Assistant Professor at the University of Virginia School of Medicine. “We don’t know if they just don’t get care or then enter the traditional healthcare system and start over.”
There are also concerns that DPC plans could draw a large percentage of healthier patients, which could raise costs for those in traditional insurance plans, and that it may be more difficult for DPC patients to gain access to needed specialists and other services.
“Healthcare is fragmented, and if we continue to have little carve-outs so some [doctors] can practice medicine the way they want, it is not helping to make the system more responsive and integrated,” Engelhard added.
Nonetheless, both Direct Primary Care and Concierge Medicine are growing in popularity in the US. And because it’s unclear how clinical laboratories would interact with or bill DPC practices, clinical laboratory leaders should keep a close eye on this trend.
As more patients opt for these models of care, healthcare organizations, pathology groups, and clinical laboratories will have to create ways to adapt. Since DPC practices are out of most networks, clinical labs may have to bill patients directly for their services. Not all clinical labs are prepared to do that, and those that are could experience a slowdown in the payment process. Labs may also have to contract with physicians to provide testing services on a pre-determined wholesale cost basis.
—JP Schlingman
Related Information:
Can Amazon Cut Insurers Out of Primary Care?
A Pioneer In ‘Flat-Fee Primary Care’ Had to Close Its Clinics. What Went Wrong?
5 Things to Know About Direct Primary Care
10 Differences Between Concierge Medicine and Direct Primary Care
I am a family physician who is leaving traditional fee for service insurance controlled primary care. The previous article discussing how terrible the DPC model of primary care is completely wrong. I have been giving primary care to my patients for over 20 years. During that time I have been in a group practice, a Medical Director of a community health clinic – federally qualified community health clinic and also practiced add a critical access hospital and finally was working for a for-profit organization. All of those ways of practicing medicine focused on money and not the patient I just left my for-profit/fee for service position where I was very successful financially. However, in that practice I maintained 3000 patients. It was difficult for patients to get an appointment with me as I was always booked and sometimes double booked. A 15 minute appointment meant that I could spend eight minutes with a patient. On most nights I was up till 11 o’clock completing notes and reviewing charts. It prevented me from practicing my art of medicine. I have chosen to start my own direct primary care practice. I charge $99 per month for an individual and $160 for a couple per month . There are no other hidden fees. Patient can make their own appointments online and my appointment now run from 30 minutes up to one hour. I have time now to treat patients as people instead of a number. I believe that I can provide better health care and keep people from needing to visit emergency rooms or even be hospitalized. This form of medicine is both accessible and affordable. For individuals that do not have insurance this is ideal because 90% of what most people need can be taken care of by primary care physician especially a seasoned family doctor of 20 years. The previous article was written by somebody that knows nothing about Medicine. I believe insurance companies are evil and I don’t see this as a joke. They are money driven and serve their stockholders. As an FYI I did part of my training in England under their NHS system. Every Brit that I came across hated their national system. Many went on to get private insurance. Individuals with private insurance always got better service and had more accessibility to medical care. As a geriatrician and a board-certified family doctor I can think of no better way to treat people in primary care than the old Marcus Welby MD way of treatment.
I am 67 years old, on medicare and lost my two Primary Physicians in two years.I wish to make you aware, if you are not already, that all across our state and country hundreds of thousands of patients are being abandoned by Primary Care Physicians who opt to practice under the DPC model . On average 190,000 former patients, per 100 primary practices switching to DPC, have to look for a new Doctor.This scheme also undermines the Obama ACA Act.Plus patients have no government recourse with bad Doctors because DPC practices do not have to adhere to the same rules and regulations as traditional Primary Care PracticesDumping or abandoning hundreds of thousands of former patients to practice the DPC model does not seem to be a sustainable method of practicing medicine.and the ethical questions are being ignored. This is especially hard for senior citizens on medicare to find a new doctor and ethically suspect. Health Savings Accounts should not be used to pay for this type of Medical Practice to do so would put further burden on our medical system and patients.Below is an excerpt from an American College of Physicians article:
Our paper in no way says that physicians have an ethical obligation to see a certain fixed number of patients, whether in traditional FFS practices, DPC, concierge, or any other type of practice. Rather, we recommend that when a physician “downsizes” his or her patient panel for any reason (not limited to concierge or DPC; physicians in traditional practices may choose to begin seeing fewer patients for any number reasons), there needs to consideration of what the impact will be on patients that no longer will have access to the practice and would have to get care elsewhere, the impact on the large community, and especially, the impact on access for poorer patients. (Does the downsizing, for instance, when combined in other changes in the practice, result in poorer patients being disproportionately being the ones who are left behind?, even if they would prefer to remain in the practice?) Downsizing also creates legal and ethical issues associated with patient abandonment that physicians need to be aware of. Here is the relevant statement from our policy paper:
“Physicians in practices that choose to downsize their patient panel for any reason should consider the effect these changes have on the local community, including patients’ access to care from other sources in the community, and help patients who do not stay in the practice find other physicians.”
Bob Doherty Senior Vice President, American College of Physicians Government Affairs and Public Policy
Sincerely
Mike Schiappa
Thank you for bringing more attention to direct primary care (DPC) for all Americans. It is a growing practice model for primary care with has been undervalued, abused, and burdened with excessive red tape and paper work to the point of burnout and depression. Many in primary care are leaving medicine for administrative jobs or leaving health care all together. Direct primary care has been a saving mission for many physicians.
Unfortunately, there are some confusing pints in your article that should be clarified. First, DPC is nothing like concierge medicine at all. DPC is way more affordable often 1/3 to 1/2 the cost of concierge “admission fees”. Concierge still continues to demand and accept insurance plans requiring co-pays and deductibles for visits as well as staff to handle insurance claims. DPC clinics do not deal with insurance at all and all our services in the office are included in the one monthly fee. Most DPC clinics have twice as many patients than concierge physicians as well.
The comments about the failures of Qliance are not even close as to why this large DPC organization failed. I suggest you listen to Dr Erika Bliss’ own story of Qliance since she was the founder of the clinic: https://video.hint.com/dr-erika-bliss-the-qliance-experience
The made a “deal with the devil” and got back into bed with Medicaid which failed to pay them after proving massive savings.
Finally, Dr. Engelhard’s comments are without any facts. It’s almost as if she would rather family physicians continue to see more and more patients for 5 minute visits under the pressure of hospital systems and insurance administrator, burnout and patient care be dammed?
Happy to chat more about this issue but DPC is the last hope for primary care at this time and for patients too.
Dr J Shane Purcell, MD