Lecture: Direct Primary Care ‐Direct Primary Care Terminology, Legal, and Legisla ve Issues ‐DPC: In the Trenches‐ Pu ng the Joy Back into Family Medicine Philip Eskew, DO, JD, MBA Brian Forrest, MD ACOFP FULL DISCLOSURE FOR CME ACTIVITIES
Please check where applicable and sign below. Provide additional pages as necessary.
Name of CME Activity: ACOFP 52nd Annual Convention and Scientific Seminars
Dates and Location of CME Activity: March 12-15, 2015, The Cosmopolitan Las Vegas, Nevada
Lecture: Direct Primary Care
-Direct Primary Care Terminology, Legal, and Legislative Issues (Eskew)
-DPC: In the Trenches- Putting the Joy Back into Family Medicine (Forrest)
Saturday, March 14, 2015 3:00-4:00pm
Name of Faculty/Moderator: Brian Forrest, MD
DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM
x
A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing
health care goods or services.
B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care
goods or services. Please check the relationship(s) that applies.
x
Research Grants
Stock/Bond Holdings (excluding mutual funds)
x
Speakers’ Bureaus*
Employment
x
Ownership
Partnership
x
Consultant for Fee
Others, please list:
Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s)
that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper:
Organization With Which Relationship Exists
Clinical Area Involved
1. Access Healthcare Direct Network-CEO
1. Practice Transformation to DPC Model
2. DPCMH.org /DPCMH Association-President
2. Not For Profit providing information and resources on DPC
3. Access Healthcare, P.A.-Practicing Physician
4. Get Healthy Inc-Chief Practice innovation Officer
5. Twin Oaks Software Development-Consultant
6. NCAFP/AAFP/multiple state chapters
3. Owner and Employee at Practice
4. DPC Health Care and Wellness Portal and Software
5. DPC Membership Management software
6. Expert Faculty/Speaker on DPC
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DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS
____x__A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or
investigational uses of products or devices.
______B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational
uses of products or devices as indicated below:
I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this
information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional
information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require
the ACOFP to identify a replacement.
Signature:
Date:
Brian Forrest, MD
1/6/15
2/27/2015
Direct Primary Care:
Terminology, Legal, and Legislative Issues
Philip Eskew, DO, JD, MBA
Family Medicine Resident PGY-3
Heart of Lancaster Regional Medical Center
ACOFP Annual Convention - March 14, 2015
DPC Terminology, Legal & Legislative Issues
• Learning Objectives:
•
•
•
•
•
A) Obtain an understanding of common DPC Terminology
B) Appreciate the diversity of DPC offices and locations across the US
C) Medicare considerations – “opt out” vs “fee for non-covered service”
D) Awareness of the “Business of Insurance” hurdles
E) Review state and federal DPC regulatory & policy considerations
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Questions We Will Answer
• How may we define Direct Primary Care (DPC)?
• What about “Concierge” medicine?
• How many physician groups are really doing this?
• How does DPC interact with Medicare? (and Medicaid?)
• What are the legal hurdles?
• Which states have DPC legislation?
• Does the Affordable Care Act impact DPC practices?
Direct Primary Care Defined
• For a practice to be defined as DPC, it must be a:
• primary care practice that
• 1) charges a periodic fee for services,
• 2) not bill any third parties on a fee for service basis, and
• 3) any per visit charge must be less than the monthly equivalent of
the periodic fee.
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Defining Direct Primary Care
Retainer Medicine / Membership Medicine
Direct
Primary Care
Split /
Hydbrid
Concierge /
Boutique
• DPC = a periodic fee with no “double dipping”
• Concierge is synonymous with the fee for non-covered services model
Concierge Care Defined
• A primary care practice that
• 1) charges a periodic fee for “non-covered” services, and
• 2) continues to also bill third parties on a fee for service basis
• Concierge practices, such as MDVIP or MD2, continue to bill third
parties in the traditional fee for service fashion in addition to the
periodic fee
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DPC vs Concierge – Cost Differences
• Price is not a component of the definition
• Concierge fees are often much higher
• MD2 initially charged $20,000 per year for “non-covered” services
• DPC groups often charge around $1,000 per year for all services
• Overhead costs are unchanged in concierge practices
Many Groups Support DPC
• ACOFP – DPC Task Force
• Direct Primary Care Coalition
• American Academy of Family Physicians
• DPC Interest Groups, Workshops, public policy endorsement
• American Academy of Private Physicians
• Family Medicine Education Consortium
• Organized multiple DPC National Summits
• American Association of Physicians & Surgeons
• DPC United
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DPC Folks Think Differently
DPC Research Methods
• Located as many DPC practices as possible (100), recorded publicly
available data from the practice website:
• Practice Fee Structure
• Membership ranges (avg of high and low charges for pts > 29 years old)
• Any per visit fee (average of four visits per year)
• Any enrollment fee (divided by twelve for a monthly comparison)
• Practice Design (pure DPC or split)
• Medicare status (opt out vs accepting)
• Practice self description (DPC, “Direct,” Concierge, other)
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Results
• All Practice average monthly cost = $100.55 (range $35.67 to $562.50)
• All Practice Median monthly cost = $79.00
•
•
•
•
Self Described DPC average monthly cost=
Self Described Concierge average monthly cost=
Split practice average monthly cost=
Opted Out practice average monthly cost=
$80.68
$199.59
$89.57
$100.47
• Enrollment Fee = $82.63 (only 24 of 81) (range $29 to $300)
• Per Visit Fee =
$16.85 (only 17 of 81) (range $5 to $35)
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What’s in the Name?
• Only 44 of 100 practices located in the study referred to themselves
using the term “Direct Primary Care”
• 17 did (inaccurately) self describe using the term “concierge,” which
can lead to confusion for both patients and policy makers, although it
did correlate with a higher membership price
• Many other adjectives were used to describe each DPC practice
• “If you have seen one DPC practice, you have seen one DPC practice”
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Charging a Per Visit Fee
• Approach used by only 17 out of 81 practices with price info
• Average of $16.85, Median of $20 with range of $5 to $35
• The fee does not appear to affect the number of in-office visits
• Qliance and Access Healthcare data suggests an avg of slightly under four inoffice visits per year
• Other DPC docs report an avg of 1% of patient panel requires services daily,
supporting an avg of slightly under four (3.65) office visits per year as well
Charging an Enrollment Fee
• Only used by 24 of 81 practices with price info
• Average of $82.63, Median $77.50
• Range of $29 to $300
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Limitations
• Complicated pricing structures
• Lack of price transparency among all websites
• Scope of practice variance
Summary Findings
• DPC is Affordable
• Median $80 per month, Average $100 per month
• Over 90% of practices are small and independent
• Per visit fees are used by less than 1/4 of DPC practices
• Enrollment fees are used by less than 1/3 of DPC practices
• Public price perception is accurate
• DPC – affordable
• Concierge - expensive
• Flexible geographic location – 36 states, rural or urban
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Medicare
• “Opting Out”
• Must be actively renewed every two years
• Legally safer option (False Claims Act, Stark, etc.)
• Ideal for a “Pure” DPC practice
• “Non-covered Services”
• Terminology game – must stay one step ahead of the government
• Moonlighting is less complicated
• More common in “Hybrid” practices
Medicaid and Traditional Insurance
• Do not sign any traditional third party contracts!
• This would give insurance companies leverage to block your DPC efforts
• You can “go public” with denials of coverage (Brian Forrest has an example)
• Always have each patient sign an individual contract with your
practice (even when brought to you by an employer or other group)
• The ONLY appropriate role of a third party in DPC is payment
•
•
•
•
These agreements should not have any effect on your documentation or price
Medicaid managed care pilot (Qliance)
Medicare Advantage (Iora)
Eventually more patients via state run insurance exchanges
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The “Business of Insurance”
• State Insurance Commissioners argue that DPC is too much risk
• Membership contract amounts to the “unlawful sale of insurance”
• No case law directly on point
• Huff v St. Joseph’s Mercy Hospital of Dubuque Corporation
• IRS definition anticipated related to Health Savings Accounts
• Would be additional persuasive evidence that DPC is not a “health plan”
• Each state may approach this issue independently
• Six states have passed laws designed to address this concern
• Wise contract terminology will be your defense – minimize “risk”
States with DPC Laws
• The Good
•
•
•
•
Washington
Utah
Louisiana
Michigan
• The Bad
• Oregon
• The Ugly
• West Virginia
• The Irrelevant
• Arizona
• Pending
•
•
•
•
•
•
•
•
Georgia
Idaho
Mississippi (SB 2687)
Missouri (HB 769)
New Hampshire (SB 176)
Oklahoma (SB 560)
Texas (HJR 109)
Florida
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State
Date Passed
Title
Phrases Defined
"Not Insurance"
Washington
2007
West Virginia
2006
Oregon
Utah
Arizona
Louisiana
2011
2012
2014
2014
Requirements for
Certification as
Direct Patient-Provider Preventive Care Pilot
Retainer Medical
Medical Retainer
Direct Primary Care
Direct Primary Care
Primary Health Care
Program
Practice
Agreements
Provider
Practice
Requires that a "direct
"primary care" =
fee" be charged on a
outpatient,
Poor definition of "DPC
failed to define
Provider Plan", Poor
periodic fee, vague
monthly basis, no
"primary care" poorly nonspecialist, "retainer
definition or use of
defined using terms
medical fee" poorly "Routine" health care definition of "Primary definition of "direct
services
Care Provider"
fee"
term periodic fee
basic and simple,
defined
Unclear - the only time
the phrase "not
insurance" is used is in
the mandatory
Yes (& HMO)
Yes
disclosures section
Yes
Yes
Yes
Reporting Obligations
Yes
Yes - Severe
Mandatory Disclosure
Discontinue Care
Provision
"Double Dipping"
Prohibition
Yes
No
Yes
No
No
None
No
No
Marketing Restrictions
Inadvertent
Pilot/Exchange Ban
Promotion of DPCMH
in exchange
No
Severe
No
No, only via disclosure
requirements
Potentially
No
No
Mild restrict, primary
care is broadly defined
No
Scope
Policing Authority
Separate License
needed
Must submit annual
statements to the
insurance
commissioner
No
Yes
None
Yes (in both contracts
and marketing
materials)
Brief "not insurance"
Medical Retainer
Agreements
"Routine" health care
services
Yes
No
No
No
No
Yes
Brief "not insurance"
No
Yes
None
Yes
No
No
Yes
No
No
No
No
Likely
Potentially
No
Potentially
Potentially
No
No
No
No
Broadly defined
Broad
No
Mild restrict, primary
care is broadly defined
Broadly defined
None
None
LA St Med Bd
None
No
No
No
No
Narow
Narrow
Dept of Ins - may
investigate and
subpoena, broad
authority to adopt new
HCA & Ins Commish
rules
Yes
Michigan
2015
Yes
Discontinuing Care Provisions (WA, LA)
• Patient participates in fraudulent activity
• Patient fails to pay for services
• Patient is abusive and is an emotional/physical danger to DPC
• Patient “repeatedly fails to comply with the recommended txt plan”
• DPC discontinues operations as a DPC
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Required Disclaimer (Louisiana)
• “This agreement does not provide comprehensive health insurance
coverage. It Provides only the health care services specifically
described.” (WA, LA)
• Inform the patient of his financial rights & responsibilities to DPC
• Encourage patient to maintain insurance for non DPC services
• State that DPC will not bill a health insurance issues for DPC services
• Include contact information for the state medical board
West Virginia “Preventive Care Pilot Program”
•
•
•
•
•
•
•
•
•
Initially limited to six sites
Program expires (again) on June 30, 2016 (grandfathering available)
Health Care Authority – full control of provider selection (Cert of Need)
All fees, marketing materials, and forms are subject to prior approval
from the insurance commissioner
No marketing (except for known uninsured or known HDHP = $3,000)
Mandatory 6 month wait for employer to purchase DPC conversion
Must submit income tax returns to HCA
http://www.hcawv.org/Pilot/AttchA.htm
“Primary Care” defined using terms “basic” and “simple”
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State by State Summary
• Terminology problems continue
• Only 3 of the 6 states with legislation even use the term DPC
• Any DPC definition (if provided) is poor
• Only Washington, Louisiana, and Arizona offer some type of definition
• A broad definition is contained in the Affordable Care Act
• States where DPC could be more difficult
• Vermont
• West Virginia
• Oregon
State Model Legislation Recommendations
• Define DPC using 3 part definition
• Should contain a clear “NOT Insurance” provision
• This is consistent with the “not a health plan” language in the ACA
• Mandatory contract and advertisement “not insurance” disclaimers
• No separate state registration should be necessary
• Require an individual contract with each patient
• List recommended discontinuation of care contract language
• Broadly define primary care scope of practice
• Promote formation of “wrap around” insurance policies
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Affordable Care Act
• Sec 10104 HHS “shall permit a qualified health plan to provide
coverage through a qualified direct primary care medical home plan
that meets criteria established by the Secretary…”
Qualified Health Plan
• Essential Health Benefits
•
•
•
•
•
•
•
•
•
•
Ambulatory patient services
Emergency services (reduced)
Hospitalization (reduced)
Maternity and newborn care
Mental health / substance abuse / behavioral health
Prescription drugs (reduced)
Rehabilitative and habilitative services and devices
Laboratory services (reduced)
Preventive and wellness services and chronic disease management
Pediatric services including oral and vision care
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Federal Register HHS Rules
• “Direct primary care medical home plan” = an arrangement where a
fee is paid by an individual, or on behalf of an individual, directly to a
medical home for primary care services, consistent with the program
in Washington
• “Primary care services” = routine health care services, including
screening, assessment, diagnosis, and treatment for the purpose of
promotion of health, and detection and management of disease or
injury
Federal Register HHS Rules
• “We considered allowing an individual to purchase a direct primary
care medical home plan and separately acquire wrap-around
coverage. However DPCMHs are providers, not insurance
companies… allowing a separate offering would require consumers to
make two payments for full medical coverage, adding complexity…”
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Federal Register HHS Rules
• “While we recognize the importance of accreditation and quality
assurance, we are not establishing that direct PCMHs be accredited in
order to participate in QHP networks. We encourage QHP issuers to
consider the accreditation, licensure, or performance of all network
providers.”
• “We do not interpret that phrase as including providers of nonprimary care services, such as specialists.”
• “We are not directing exchanges to create incentives for contracting
with direct PCMHs. We encourage exchanges to promote, and QHP
issues to explore, innovative models of delivery along the care
spectrum.”
Top 3 Legal Advisements
• If you decide to start a DPC practice:
• Consider the “Business of Insurance”
• Opt out of Medicare
• (and avoid signing standard Private Insurance and Medicaid contracts)
• Go “all in”
• Hybrid practices are legally riskier
• Hybrid practices have higher overhead
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Broad Predictions
• DPC will grow exponentially over the next five to ten years
• IRS will change Health Savings Account interpretation
• Wrap-around “catastrophic” insurance plans will be offered
• Will likely represent over half of the primary care market in 10 years
• Increased interest in primary care, physician ratio will improve
• Litigated victories against initial insurance commissioner challenges
• Second series of suits will later be filed based upon scope
• Triple aim actually achieved!
Any Questions?
Email: [email protected]
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Direct Primary Care in the Trenches:
Meeting the Quadruple Aim
Brian R. Forrest, MD
Copyright 2014 Access Healthcare Direct all rights reserved
What Keeps Family Physicians up at
Night?
•
•
•
•
•
•
Concern about Medicare RAC Audits
Confusion about ACO implications
Wondering if they will be able to be independent
Uncertainty about viability of their practice
ICD-10 and other bureaucratic changes ? costs ?
SGR, RUC not working, workforce problems
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Physician Trends and Attitudes
• Survey of 1311 physicians nationwide by Physicians Practice
9/14
• 53% considering or already in Direct Primary Care
• 35% considering or already working in Concierge Model
• Only 20% in process or have achieved PCMH recognition
• 4.4% plan on entering ACO
• 3.9% plan to become PCMH
• 4% plan to become hospital employed
• Pro
DPC-Direct Primary Care
– Significantly lower out of pocket costs for most
– Quality improved due to more time (value- based instead
of volume-based care)
– Complete price transparency
– Lowers overhead/helps practices financially
– Improved access for underinsured and poor
• Con
– Major transition/disruptive
– Recruiting patient panel (copay culture)
Adapted from Forrest, B.R. Physician’s Practice
Pearl 12/7/11 New Primary Care Models Can
Change the Way You Practice Medicine
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Concierge and DPC-Similar and
Different
•
•
•
•
Both improve quality of care for patients
Both improve physician experience/pay
Concierge severely shrinks panel size
DPC improves access for low
income/uninsured whereas concierge worsens
• Workforce improved instead of compromised
with DPC
What is the Difference Between
Concierge and DPC?
• DPC generally affordable for the average
person (Honda vs. Ferrari)
• DPC can be successful in rural and poor
communities
• DPC can lower out of pocket costs and
downstream costs
• DPC panel size is optimal
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Vision Realized-My Favorite Moment
How Access Healthcare Model Created:
The Hypothesis: 1999My
Study Different Models(15 years ago)
-Data on 42 providers
• If You:
Decrease Overhead (micropractice) and
Have patients pay in full at time of service, monthly, or
yearly (direct payment)
• Then you can:
Reduce Fees,
Increase Collections,
And Focus on patient care-Improve Quality
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What People Said About This Idea
“You’re Crazy!”
“That will never work.”
“You won’t be able to afford to stay in practice.”
Primary Care Math
Traditional
Our Model
$1.00
$1.00
x.65 collected (avg in US)
x.99
--------.65
.99
-60% overhead (avg in US)
- 18%
--------.26 left
.81 left
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Overhead Dramatically Reduced
65%
18%
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Genius of the GYM
$5
$3
Access Healthcare: a D-PCMH
Micropractice Model
• Charge low per member per month directly to
patient or their employer or their insurer*
– nominal per visit fee to cover overhead costs
– Net profit double to triple per patient per year
• A La Carte Non-Member transparent pricing at
80% off typical rates for service
• 4 FTE equivalents in overhead costs saved per
physician-mostly due to no “insurance related
staffing”
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Affordable Care
Medical Home Member “subscription/membership
model”: patients charged affordable fee per month
and a nominal fee per office contact- no extra charge
for common labs, EKGs, U/As, etc.
Patients who come in rarely only for acute complaints
are not forced to be “members” and can have
services from an “a la carte” menu posted in waiting
room- typically 80% off most services
A La Carte Model: patients who opt not to be members (usually young patients with occasional acute problems
like UTIs) add up bill on a discounted price transparent menu with 80% discount
◦This makes out of pocket costs average less than a
the least expensive individual cell phone plan per
year (even the chronically ill multisystem patientincluding labs, in office procedures, the entire basket of
services in our office )
Summary of DPC Model for AH
•
•
•
•
•
•
Lower patient charges-80% less (improves access for
underinsured)
Higher collections (99% for 12+ years) with overhead 15-22%
More time with patients/less patient volume(even with similar
panel)
Not bound to insurance contracts - no insurance filed
Less stress/Lower risk exposure/Decreases medical mistakes 1
Allows better familiarity and firmer patient relationships thus
decreasing risk
Allows time to coordinate all aspects of patient’s medical care to
truly be the patient’s medical home
1,2
•
1-O’Hare, Dennis C. et al. FPM.2/2004 Vol 11. No.2” The Outcomes of Open Access
Scheduling.”
2-Linzer, Mark et al. Advances in Patient Safety Vol 1.”Organizational Climate, Stress, and
Error in Primary Care: The MEMO Study.”
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Kick the Payer out of the Exam Room Make the Physician-Patient Relationship a 2 Party affair
The 5/50 Paradox
?
Medicaid patients
Insured Patients (52%)
?
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QCAP-The Quadruple AIM
Increased
Improved
Quality
Cost
Access
Patient/Physician
80
70
60
50
SBP
40
LDL
HDL
30
20
10
0
Traditional/PCMH
Hybrid
DPC Practice
COSEHC DATA 2014
www.cosehc.org
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2/27/2015
Patients attaining target goals who were not at control at
baseline
70
60
50
40
30
20
10
All Practices
0
SBP
LDL ≤ 100
LDL≤ 130
A1c
DPC Practice
COSEHC DATA 2014
www.cosehc.org
Physician Income Expectations
For a family physician with patient panel capacity of
1200 and a visit volume of 16 patients maximum per
day incomes can be similar to specialists like
cardiology or GI and better than general surgery and
most of the other internal medicine subspecialties
If you want to do packages for the extremely
economically challenged and create a lower fee
schedule or sliding scale that is reduced by another
50%(as compared to average DPC practice fee), this
can still net 50% more in salary for a family physician
even if their entire panel was in this
demographic.(works for rural communities or low
median income areas)
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2/27/2015
ACCESS HEALTHCARE, PA
Chronic Disease Management and Valuing Trust
Does Trust Matter?
• How much trust is built in a 35-minute visit versus an 8-minute visit?
• Research shows the cost of litigations when the patient and doctor spend more
time together and have more trust is significantly lower 1,3
• The average primary care doctor pays $11,000/yr. in malpractice premiums.
• Two physicians at Access Healthcare together pay less than $4000 per year 2.
• Also the decreased volume of 30 patients vs. 12 patients, means that you are
2.5 times less likely to be sued just based on volume.
1A
study of sued and non-sued obstetricians found that patients who saw obstetricians with the most
frequent number of prior lawsuits were significantly more likely to report spending less than 10 minutes
with their physician during each visit;
2 Dr. Brian Forrest, Access Healthcare
3Kristin E. Schleiter, JD; Difficult Patient-Physician Relationships and the Risk of Medical Malpractice
Litigation
AMA Journal of Ethics. March 2009, Volume 11, Number 3: 242-246.
ACCESS HEALTHCARE, PA
Management of Chronic Disease in a DPC Model
• Only 50% of patients nationally with high BP who are
seeing a doctor and are being treated for high BP
have their BP under control1
• 80% of patients at goal in a review of 3 DPC
physicians2
1
NHANES 2007-2010 data
2
Access Healthcare Direct patient data 2011-2013
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Access Healthcare Direct
Diastolic Blood Pressure
300
Number of patients
250
200
82% ATGOAL
8%
90% ATGOAL
25
45
150
100
220
200
50
0
Baseline
ATGOAL
Follow-up
NOT ATGOAL
JNC 7 Goal Attainment: < 90 mm Hg; < 80 mm Hg diabetic
www.cosehc.org
ACCESS HEALTHCARE, PA
US vs. World vs. Access Healthcare Direct Practices
All Patient Out-of-Pocket costs per
year including insurance premiums
in DPC Model with High Deductible
Plan
http://www.oecd.org/els/health-systems/oecdhealthdata2013-frequentlyrequesteddata.htm
The Organization for Economic Co-operation and Development (OECD)
© OECD. All rights reserved
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ACCESS HEALTHCARE, PA
Two DPC physicians, One Quarter – 2Q2013
Results reflect a traditional profile…
Access Healthcare1:
•
In a full quarter, doctors
provide about 600
diagnoses.
•
This equates to about 200 a
month or 50 a week.
•
Most patients have more
than one ailment.
•
Patient population is
demographically and
diagnosis code c/w NC
averages-except higher
portion of uninsured
1Access
Healthcare Review of patient visit data 2011-2013
Access Healthcare LLC, All rights reserved
ACCESS HEALTHCARE, PA
Doctor and Patient Experience Compared:
Total Doctor-Patient Minutes/Year
Doctor minutes for patient
160
140
140
40
30
100
25
20
80
15
60
40
35
35
120
10
20
8
5
0
20
Traditional Care
Access Healthcare
0
Traditional Care
•
Access Healthcare
In the AHC model, patients get more minutes, and are charged less leading to more favorable
outcomes.
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ACCESS HEALTHCARE, PA
Patient Experience Compared:
Observation
Traditional
Patients per day
30
DPCMH
12
Doctor minutes available
15
45
40
Doctor minutes for non-patientfacing work
7.5
10
35
Doctor min. average for patient
interface
8
35
Typical Per Patient Insurance out
of pocket costs for premiums
$2500 Employee Plan1
Doctor minutes for patient
30
25
20
$ 33% less
2
15
8
10
Typical Visits per Year
2.5
4
5
Total Doctor time
20
140
0
Hospitalizations per 1000 pt/yr
11
4
•
35
Traditional Care
Access Healthcare
In the DPC model, patients get more minutes, and are charged less leading to more
favorable outcomes.
1 Various
leading plans were reviewed including BCBS and UHC, this figure represents the approximate employee-based outof-pocket from those plans, per person covered.
2
Review of a 2013 BCBS plan with high deductible and catastrophic health coverage
Interesting Tid Bits
• Primary-care physicians with rising overhead, more
paperwork, and packed waiting rooms are propelling
ever-greater numbers to shed insurance and charge a
retainer- up to 33% by 2016 according to Accenture
Survey
• In 2011 the average American medical practice spent
$82,975 per doctor just dealing with insurers,
according to the Commonwealth Fund.
• In 2010, patients in this model visited emergency
rooms 65 percent less than similar patients. Thirtyfive percent fewer of them needed to be hospitalized.
They required 66 percent fewer specialist visits.
• In 2012 the average premium for an employer-provided
insurance policy for a family of four climbed to a record
high of $20,728, according to Milliman, a health-care
consultancy.
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2/27/2015
Key Problems the Model Solves:
•
•
•
•
•
•
•
•
•
Financial viability of independent practices (overhead can be
<20%)
Physician burnout- med students often say it seems like we
are on vacation
Work force recruitment-med students see hope in this modelbeing able to make as much as other specialists helps
GME bottleneck-private residency programs can be self
funding
Access to primary care for most
Practice determines reimbursement/payment rates
Malpractice risk decreased
Non-clinical bureaucracy/paperwork decreased
Quality metrics and value based care are built in with
measured practices exhibiting top tier chronic disease
management
One Medical Student’s ThoughtsWhy Medical Students Should Be Excited About Direct Primary Care(excerpt from blog published on DPCMH.org, KevinMD and Primary Care Progress)-By Brian
Lanier
Direct primary care makes me incredibly optimistic about the
future. I will avoid the hamster wheel and provide the kind of
care I envisioned, while building deep, rich connections with
my patients. I will be offering a level of care previously only
available to the rich that almost anyone can afford. I will be
taking meaningful steps towards true, primary-care driven
and patient-centered health reform, and I won’t have to wait
for the “system” to figure it out. I will be able to provide the
majority of care my patients require instead of having time
only for refills and referrals. In short, I will be part of the
solution, both for my patients and for the system as a whole.
Brian Lanier is a fourth-year medical student at the University of North Carolina and a future family physician. Follow him on Twitter at @lanierbrian.
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2/27/2015
AAFP Response:DPC
The AAFP recently created a document with frequently asked questions(4 page
PDF) to accompany the Academy's newly created policy on direct primary care
(DPC), a model in which practices charge patients a flat monthly or annual fee in
exchange for access to a broad range of primary care services.
"The AAFP supports the physician and patient choice to, respectively, provide and
receive health care in any ethical health care delivery system mode, including the
DPC practice setting," says the policy. It notes that the model is structured to
"emphasize and prioritize" the physician/patient relationship to improve health
outcomes and lower costs and is consistent with the AAFP's advocacy of both
the patient-centered medical home and a blended payment model.
According Glen Stream, M.D., M.B.I., of Spokane, Wash., "There is more than one
way to build a patient-centered medical home (PCMH)." He noted that the number of
AAFP members developing DPC practices was increasing.
"The model eliminates the insurance middleman and provides revenue directly
to the practice to innovate in both customer service and quality of care for the
patients they serve," said Stream.
Significance of Direct Primary Care in 2013-2014
-Employers-low cost option for employers, ACA has a section discussing that this
qualifies as insurance with HBE qualified plan as approved by HHS-section 1301 A 3
-Patients-higher satisfaction and better outcomes at lower out of pocket costs with
complete price transparency
-Medscape article reports explosive growth of this model and in conjunction with
Concierge practices represents currently 12% of primary care- expected to be 30-40%
of market by 2016
-Summit in St. Louis last October –Washington D.C., New Orleans, Miami, AZ- AAFP to
hold 3 regional workshops at the end of the year and Annual Assembly
-Insurers-products launching now to integrate into HBE eligible plans-including
Medicaid and Medicare Advantage
-Large Companies like Expedia.com, Freelancers Union, Whole Foods, Grove Park
Inn, Huntington Bank, McDonalds, and Taco Bell/Long John Silver’s already looking
to or currently contracting with DPC practices.
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2/27/2015
Medicaid and DPC looks promising
-In Washington State, Coordinated Care has partnered with 5 DPC practices to
provide primary care for Medicaid Patients
-With the initial 40,000+ enrollees: ER visits are down 60%, hospitalization and readmission down 65%, and overall costs for this Medicaid population is 30% less for
2013 than the non-DPC pilot practices
-Opportunity exists to do this in any state (like NC). It would make Medicaid a
preferred payer by many family physicians- double the net revenue per patient of fee
for service is possible (and payment is upfront every month-no waiting on delayed
reimbursements)
-In Washington State, participating physicians getting $50+ per member per month
-This can really make practicing in rural and low income communities sustainable and
recruit needed workforce into those areas
Last updated 6/14
Access Healthcare Direct Network Practice
Practices Using our model/software including hybrid practices
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2/27/2015
Where to Learn More
Sprey, E. Physicians Practice “New Practice Models are Gaining Acceptance” 9/14
Forrest, B.R. Physicians Practice Pearl “New Primary Care Models Can Change the Way You Practice
Medicine” 12/11
Forrest, B.R. Medical Economics Cover Story “Cutting Edge” 5/25/11
Mescia, Tony. Weekly Standard “Cash for Doctors Revisited” 4/11
Mescia, Tony. Weekly Standard Cover Story “Cash for Doctors” 5/23/10
Morgan, Lewis. Medical Economics Cover Story “Keeping it Simple” 1/22/10
Forrest, B.R. Physicians Practice. July 2008. “Cash and Carry Healthcare Still Works.”
Forrest, B.R. Family Practice Management. June 2007. “Breaking Even on 4 Patients per Day.”
Forrest, B.R. Physicians Practice. June 2007. “Cash and Carry Health Care.”
Forrest, BR. NC Medical Journal May 2005. Innovations in Primary Care. “The Access Healthcare
Model”
Backer, Leigh Ann. Family Practice Management. February 2006. “2500 Cash Paying Patients and
Growing”
Twitter @innovadoc
(just starting to use this but giving regular DPC updates now)
http://www.physicianspractice.com/pearls/new-primary-care-models-can-change-way-you-practice-medicine (link to first article above)
http://newsle.com/BrianForrest source of compilation of 20+ articles on the DPC model
www.accesshealthcaredirect.com website for DPC network practices. Undergoing renovation and updates
www.DPCMH.org free membership for students and residents- website for members only
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