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Direct primary care
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Direct primary care is a healthcare model that has emerged as an alternative to the third-party insurance system. It is a retainer-based model, meaning that patients pay a flat fee—called a retainer—to their physician, covering all their primary care visits and services. Most direct primary care practices do not accept insurance.
Because direct primary care is a new model that has grown very quickly, in some states there is a lack of clarity on how they should be regulated. In many cases, direct primary care practices have been regulated under insurance laws as risk-bearing entities. To protect direct primary care practices from future liability, 17 states had enacted legislation clarifying that direct primary care is not subject to state insurance regulation as of April 22, 2016.
Overview
Direct primary care is a healthcare model that has emerged as an alternative to the third-party insurance system. Direct primary care is a retainer-based model, meaning that patients pay a flat fee—called a retainer—to their physician, covering all their primary care visits and services. In this kind of arrangement, patients contract directly with their family physician, and most direct primary care practices do not accept insurance.[1]
The direct primary care model is different from that of concierge medicine, another type of retainer-based care. Concierge primary care practices typically accept insurance but—for thousands of dollars per year—will also offer patients perks like direct access to their physician, shorter or no waiting times, and sometimes home visits. In direct primary care, the monthly fee is typically $100 or less for all services. Direct primary care practices often see fewer patients than traditional practices, and their physicians tend to spend more time with their patients in appointments.[1][2][3]
Direct primary care has proliferated over the past decade, primarily due to concerns about "doctor shortages, narrow networks, and ... third-party reimbursement," according to the Heritage Foundation. In 2004, the U.S. Government Accountability Office identified 146 retainer-based practices, which included other types of this model such as concierge medicine. In 2014, about 4,400 physicians were working at retainer-based practices, according to the American Academy of Private Physicians (a practice is a medical business in which one physician or a group of physicians treat patients). Counting direct primary care practices specifically, the organization DPC Frontier identified 345 practices in 2016, some of which include more than one physician.[1][4][5][6]
Insurance regulations
Under the Affordable Care Act, individuals were required to purchase a supplementary health insurance plan that covers specialist and catastrophic care in addition to their direct primary care arrangement. Additionally, direct primary care providers were allowed to sell their arrangements on the health insurance exchanges, as long as they were coupled with a supplementary plan. This is because direct primary care on its own did not constitute insurance.[4]
However, because direct primary care is a new model that has grown very quickly, in some states there is a lack of clarity on how they should be regulated. In many cases, direct primary care practices have been regulated under insurance laws as risk-bearing entities. For instance, in 2005, the West Virginia Insurance Commission investigated a concierge medicine practice to determine whether it was illegally selling insurance without a license.[7][8]
To protect direct primary care practices from future liability, 17 states have enacted legislation clarifying that direct primary care is not subject to state insurance regulation. Below is a map showing which states have enacted direct primary care legislation as of April 22, 2016.[9]
Support
Proponents of direct primary care say the model allows physicians to provide better care to their patients than traditional insurance. They say that the traditional third-party reimbursement system forces doctors to spend too much time filling out paperwork, leading them to see more patients and spend less time with each in order to maintain their income. In direct primary care, with a smaller administrative burden and fewer patients to see, doctors can spend more time with patients and develop a better relationships with them. Patients also typically have near-immediate access to their physician and can even call or email them with questions. Advocates say that this model puts greater focus on the patient, delivering higher-quality care and better health outcomes.[4]
Supporters of direct primary care say that the model can also lower healthcare costs. Qliance and MDVIP, two direct primary care practices, conducted internal studies of their practices; Qliance determined they saved 20 percent on healthcare costs compared to traditional insurance, while MDVIP found a "72% decrease for those with commercial insurance in MDVIP-affiliated practices" compared to traditional practices. Additionally, because patients receive greater attention from their physicians under direct primary care and develop closer relationships with them, they may receive more preventive care, which could cut down on high costs associated with complex conditions in the future. Some advocates also assert that the direct primary care fee and monthly premium for catastrophic insurance together are cheaper than a comprehensive insurance plan.[4][10][11][12]
Supporters also say the model could relieve the shortage of primary care physicians by making primary care a more attractive option and thus drawing in more physicians. They say that in the current dominant model of fee-for-service and third-party reimbursement, doctors spend too much time filling out paperwork and see too many patients, causing them to burnout and retire early. They also argue that medical students choose other specialties when they hear about this environment and the lower pay primary care physicians receive. The direct primary care model eliminates the coding and billing paperwork associated with third-party insurance and allows physicians to spend more time with their patients. Physicians may also earn more under the model. Advocates say this reduces physician burnout and will attract more physicians to the field.[4][12]
Criticism
Critics of direct primary care say that widespread adoption of the model would reduce access to healthcare for low-income and uninsured populations. Some have voiced concerns that those who could not afford the monthly fee would not have access to primary care services. Claire McAndrew, a private insurance program director for Families USA, has said that without comprehensive insurance, specialty healthcare services could be too costly and out of reach as well.[10][11][12]
Additionally, because a direct primary care arrangement on its own does not count as insurance, patients at these practices often carry an additional catastrophic health plan. These are plans with very high deductibles, some as high as $6,000, and are meant to protect against major health emergencies such as auto accidents. They also have much lower monthly premiums. Critics say that many people, especially those who are low-income, may be attracted to the lower monthly costs without weighing the financial risk of a major health event. The costs of such an emergency would be especially devastating for a low-income individual, they say.[10][11][12]
Opponents of direct primary care also say the model could worsen the shortage of primary care physicians. Direct primary care physicians typically see far fewer patients than those at traditional practices. Seeing fewer patients means more patients have to go elsewhere, exacerbating wait times at traditional practices.[13]
Recent legislation
The following is a list of recent direct primary care bills that have been introduced in or passed by state legislatures around the country. To learn more about each of these bills, click the bill title. This information is provided by BillTrack50 and LegiScan.
Note: Due to the nature of the sorting process used to generate this list, some results may not be relevant to the topic. If no bills are displayed below, then no legislation pertaining to this topic has been introduced in the legislature recently.
Recent news
The link below is to the most recent stories in a Google news search for the terms direct primary care. These results are automatically generated from Google. Ballotpedia does not curate or endorse these articles.
See also
External links
- DPC Frontier
- Direct Primary Care Coalition
- American Academy of Private Physicians
- The Heritage Foundation, "Direct Primary Care: An Innovative Alternative to Conventional Health Insurance"
- Kansas Health Institute, "Doctor running for lieutenant governor swears by 'direct primary care' model"
Footnotes
- ↑ 1.0 1.1 1.2 American Academy of Private Physicians, "Direct Primary Care Offers Affordability in Private Medicine," December 22, 2014
- ↑ California HealthCare Foundation, "On Retainer: Direct Primary Care Practices Bypass Insurance," April 2013
- ↑ TIME, "Medicine Is About to Get Personal," December 22, 2014
- ↑ 4.0 4.1 4.2 4.3 4.4 The Heritage Foundation, "Direct Primary Care: An Innovative Alternative to Conventional Health Insurance," August 6, 2014
- ↑ U.S. Government Accountability Office, "Concierge Care Characteristics and Considerations for Medicare," August 12, 2005
- ↑ DPC Frontier, "DPC Mapper," accessed April 21, 2016
- ↑ Kansas Health Institute, "Direct primary care not subject to state insurance regulation under new law," May 14, 2015
- ↑ American Medical News, "West Virginia looks at retainer model," January 2, 2006
- ↑ DPC Frontier, "States with Direct Primary Care Laws," accessed April 22, 2016
- ↑ 10.0 10.1 10.2 MarketWatch, "Why concierge medicine will get bigger," January 17, 2013
- ↑ 11.0 11.1 11.2 State of Reform, "Qliance study shows monthly-fee primary care model saves 20 percent on claims," January 15, 2015
- ↑ 12.0 12.1 12.2 12.3 Kansas Health Institute, "Doctor running for lieutenant governor swears by ‘direct primary care’ model," September 8, 2014
- ↑ The Hill, "Is direct primary care part of the solution or part of the problem?" October 13, 2014
