What is Direct Primary Care?

Direct Primary Care Explained

Direct Primary Care (DPC for short) is primary care offered directly by primary care physicians (pediatricians, internists, family physicians) to consumers without the need of insurance. The model completely eliminates financial burdens physicians deal with when interacting with insurance carriers. Insurance co-pays, deductibles, co-insurance, billing and coding fees, collection fees, accounts receivable, and low reimbursement are just some of the financial burdens that are eliminated as a result of implementing the model. The model is overall very beneficial to both patients and physicians.

Direct Primary Care Benefits

Physician Benefits

Today’s primary care physician (pediatrician, internist, family practitioner) is facing multiple challenges. Decreasing reimbursement from insurance companies and Medicare, increasing regulations, excessive paperwork, and rising overhead expenses (malpractice insurance, billing, coding, collections, EMR/EHR systems) are challenges that are threatening the doctor-patient relationship. Direct primary care physician benefits include:

• Paid on a per-member, per-month basis
• Removes all the expenses for coding and billing
• Eliminates accounts receivable (AR) and collections, and speeds up the revenue cycle
• Reduced paperwork
• No interference from insurance companies
• Continuous cash flow (revenue stream)

Patient Benefits

In today’s society, more than 30 million Americans are considered to be uninsured or underinsured. High cost and largely discriminatory policies of health insurance companies have prevented these individuals from getting access to medical care. Direct primary care takes away the need for high-cost, discriminatory health plans and gives patients direct access to the medical care that they need. Specific patient benefits are:

• Full access to medical care for all Americans and residents
• Protects the doctor-patient relationship
• No barriers to care — no being told by a third party (insurance company) that you cannot have certain treatments or procedures
• More time spent with your physician — unhurried appointments
• 24/7 phone, fax, and e-mail access
• No co-pays, no deductibles, no co-insurance
• No limit on visits
• No prior authorizations required

Financial Benefits

Physicians and medical groups today are facing many financial burdens. These include low reimbursement from insurance companies, Medicare, and Medicaid; denial of claims; downcoding of claims; high amounts of accounts receivable (AR); and high billing and coding fees. These financial woes are common throughout the current Fee-For-Service (FFS) system and are causing severe harm to physicians’ and medical groups’ bottom lines. These woes will only continue to get worse as insurance companies try to protect their shareholder and corporate profits.

The direct primary care model is the best antidote for these financial woes. Direct primary care models specifically pay physicians on a per-patient, per-month basis (providing higher revenue per month); 100% of patient payment goes directly to the physician (0% goes to the pockets of insurance company executives); eliminate contracts with insurance companies; eliminate billing and coding (eliminating all associated expenses); and eliminate accounts receivable (no more debt produced by patients and slow-paying insurance companies). If you like what you hear, consider switching, and make sure to check out Medical Access USA’s direct primary care model.

Legal Issues

Is direct primary care, in general, legal under the Affordable Care Act (aka ObamaCare)? The answer… is yes! Section 10104 of P.L. 111-148 (Patient Protection and Affordable Care Act) states that the Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified DPC medical home plan meeting the Secretary’s criteria, so long as the qualified health plan meets all otherwise-applicable requirements and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.

As most people know, the success of direct primary care practices is thanks to not having to deal with insurance companies. Under Section 1555 of the Affordable Care Act, you can legally drop insurance and you will not be penalized for it. Section 1555 provides that no individual, company, business, or nonprofit shall be required to participate in any health insurance program created or expanded under the Act, and that no penalty or fine shall be imposed on any issuer for choosing not to participate. Stay tuned for more information from BHM Healthcare Solutions.

Photo credit: commons.wikimedia.org

Matthew D. Taber, M.S. is Chief Operating Officer of Medical Access USA, a company which offers full access to medical care to patients and 100 percent reimbursement to primary care physicians through direct primary care models.