Tag Archive: DPC

Direct primary care finding potential market among employers, Medicaid managed care plans

Direct primary care is much less pricey. Patients pay $100 a month or less directly to the physician for comprehensive primary care, including basic medication, lab tests and follow-up visits in person, over email and by phone. The idea is that doctors can focus on treating patients, since they no longer have to wade through heaps of insurance paperwork. They spend less on overhead, driving costs down. And physicians say they can give care that’s more personal and convenient than in traditional practices.It’s legal under the Affordable Care Act, which identifies direct primary care as an acceptable option. But since it doesn’t cover specialists or emergencies, consumers still need a high-deductible health plan. Still, the combined cost of the monthly fee and that plan is often still cheaper than traditional insurance.

Source: Concierge Medical Care Comes To the Middle Class : Shots – Health News : NPR

This is an interesting trend that could at least in theory coincide with the shift back to the “major medical” model common in the 1950s and 1960s where people paid out of pocket for primary care, using health insurance for high cost, major medical care events.

But whether pre-paid primary care bundled with a high deductible plan ends up costing less than, say, a gold or platinum rated Obamacare individual plan designed for the frequent user of primary care (such as families with young children) looking to minimize out of pocket costs is an open question. Unless perhaps monthly cost of pre-paid medical care falls to $40 as discussed in this analysis, which sees that as unlikely to pencil out for direct primary care practices. And as a practical matter as suggested in the analysis, not many people visit primary care docs frequently enough to make the arrangement worthwhile.

Where direct primary care makes better sense financially and where it has gained traction is among employers who offer it as part of their health benefit package. These employer groups can bring more belly buttons to the table in negotiating rates with direct primary care providers. Even larger economies of scale can be had with Medicaid managed care plans, where direct primary care practices offer Medicaid beneficiaries who typically bounce among various providers and emergency rooms much needed medical homes. From the NPR article:

In Seattle, a company called Qliance, which operates a network of primary care doctors, has been testing how to blend direct primary care with the state’s Medicaid program. They started taking Medicaid patients in 2014. So far, about 15,000 have signed up. They get a Qliance doctor and the unlimited visits and virtual access that are hallmarks of the model.

“Medicaid patients are made to feel like they’re a burden on the system,” said Dr. Erika Bliss, Qliance’s CEO. “For them, it was a breath of fresh air to be able to get such personalized care – to be able to talk to doctors over phone and email.”

The article goes on to report that Qliance contracts with Medicaid managed care provider Centene. Other states including North Carolina, Idaho and Texas are keeping an eye on the Washington arrangement and considering similar programs, according to the article.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Absence of rules means Direct Primary Care Medical Home QHPs unlikely to be offered on exchange marketplace in 2014

An innovative type of health plan that bundles pre-paid primary and preventative care with catastrophic insurance coverage isn’t likely to be sold on state health benefit exchange marketplaces in 2014.

The reason is the federal Department of Health and Human Services (HHS) has not yet developed rules governing Direct Primary Care Medical Home Plans, recognized at Section 1301(a)(3) of the Affordable Care Act as qualified health plans (QHPs) eligible to be sold through the exchanges. However, Section 1301(a)(3) requires such plans meet HHS criteria. HHS has not yet issued regulations defining those standards nor any guidance indicating when the rules will be forthcoming.

In April of this year, the California HealthCare Foundation issued an issue brief on Direct Primary Care Medical Home Plans authored by Dave Chase noting these plans offer significant potential health care cost savings over all inclusive plans such as HMOs while providing economic incentive for primary care physicians – many of whom will be needed to care for new patients obtaining health coverage under the Affordable Care Act.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Little noticed ACA provision may hold key to restoring primacy to primary care to bend cost curve

Witnesses at a recent California legislative committee hearing bemoaned what is well known among health care policy wonks: poor access to primary care and its relationship to complex, chronic conditions that drive the 80-20 rule on health care spending: that 20 percent of patients account for 80 percent of the health care spend.

An excerpt from the California HealthCare Foundation’s California Healthline report on the hearing:

“We need to look at better management of chronic conditions,” said Assembly member Richard Pan (D-Sacramento), chair of the Committee on Health. “It’s one of the greatest cost factors in our health care system.”

How much cost?

The numbers are “astounding,” according to Sophia Chang, director of the Better Chronic Disease Care Program at the California HealthCare Foundation and one of the panelists at yesterday’s hearing. CHCF publishes California Healthline.

“We’re dealing with an epidemic,” Chang said. “Growing numbers, growing costs.”

The article goes on to quote testimony by Kevin Grumbach, chair of family and community medicine at UC-San Francisco:

“All this talk about chronic care and the patient-centered medical home is fundamentally about the primary care foundation of a well-functioning health care [system],” Grumbach said. “Systems that are built on a solid foundation of primary care are much better able to deliver the triple aim of better care, better outcomes and lower cost, and in an equitable way.”

Unfortunately, he said, California’s primary care system “is completely topsy turvy,” he said.

A little noticed provision of the Patient Protection and Affordable Care Act could contain the means of restoring the primacy of primary care and putting health insurance into the more logical and sensible role of covering large, unexpected medical costs.  It allows state health benefit exchanges to offer qualified health plans (QHPs) that are bundled with primary care directly paid by the insured, not the QHP. These “Direct Primary Care Medical Home Plan” QHPs would logically be those offering lower actuarial value (such as the “bronze” and “silver” metal tier plans that cover 60 and 70 percent, respectively, of expected claims costs).

Such a product could offer real benefits for both individuals and small businesses purchasing coverage in the exchanges starting this fall as well as for health plan issuers.  The former would benefit from lower premiums since they would be purchasing a lower cost plan. Health plans would benefit because insureds that pay for their own primary care – likely through pre-paid primary care contracts with primary care doctors and clinics – would have access to primary care and lifestyle coaching to ward off the development or progression of chronic conditions.  And primary care providers would also benefit by pre-paid direct primary care plans since they would provide a degree of predictability to their business models and potentially attract the large number of new primary care physicians that will be needed by the many newly insured under the ACA. That sounds like a promising means to achieve Grumbach’s triple aim.

Plan issuers, however, might initially resist offering such Section 1301(a)(3) plans since they would require them to retool their plans to be more like the “major medical” plans that predominated in the United States until all inclusive managed care plan models covering primary care proliferated beginning in the 1970s. But amid relentlessly rising medical costs that threaten their current business models and the opportunity presented by the new exchange marketplaces to devise new plans, now may be the right time for them to adopt DPC-based plans. Such plans might be marketed as “DPC (Direct Primary Care) compatible” just as high deductible plans are termed “HSA compatible.”

To spur their adoption, the Internal Revenue Code should be amended to allow individuals to take an income tax deduction for pre-paid direct primary care, just as they now can for contributions to health savings accounts.


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

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