EDITOR: ‘What is the point where DPC and concierge medicine ends and insured care begins?’

Working With Employer Plans.

concierge doctor directoryBy Michael Tetreault, Editor

JUNE 3, 2015 – According to Concierge Medicine Today, 85% of Concierge Medicine clinics still accept or participate in insurance (i.e. HMO, PPO, Medicare, Etc.) on behalf of their quarterly and annual subscribing patients.

And according to a DPC Journal physician poll, 45% of Direct Primary Care (DPC) Clinics still participate and/or accept insurance on behalf of their direct-pay, monthly subscription patients.

The Difference Between Concierge Medicine and Direct Primary Care (DPC)

NOTE: The DPC Journal and their research and data collection arm, The Concierge Medicine Research Collective (, we have found that there are four (4) distinguishing factors that differentiate Concierge Care from its demographically diverse and often misunderstood companion, DPC … and it is NOT price …

  1. Insurance participation of the doctor/practice;
  2. DPC, most commonly, attracts a Gen. X and Millenial demographic under the age of 45.
  3. Monthly billing (seen at most DPC clinics), compared to annual and quarterly retainers offered at most concierge clinics, and;
  4. The amount of services offered.

One hundred percent of both DPC and concierge medical care provided by a clinic or physician does not include specialty or hospital care. These types of practices often recommend that their members obtain a high-deductible wraparound policy to cover emergencies and catastrophic events.

Efforts are underway to combine changes in plan design with the DPC purchasing methodology. To date, two insurance carriers have tailored offerings to DPC-based patients — Cigna and Associated Mutual. Cigna has paired its “Level Pay” program targeting self-insured employers with 50 to 250 employees and is offering this only to Qliance employer clients so far.

Erika Bliss, M.D., of Seattle, has been immersed in the DPC model since 2006. She is one of the founders of Qliance Medical Management. As president and CEO, she oversees a network of DPC clinics in the state that benefited from millions of dollars in capital investment from private business.

Bliss, a family physician who carves out 25 percent of her time for direct patient care, said that the Qliance clinics had grabbed the attention of payers, purchasers and the government. “Large purchasers of health care (corporations) are saying ‘This makes sense — you work hard on things that matter, not cranking out a bunch of visits and billing for them.'”

hsa concierge medicine direct primary careInsurers recognize the potential for this model as well. Some are looking at insurance plans that work with DPC clinics to keep costs and premiums down, said Bliss.

Expedia, Inc., one of the world’s leading online travel companies recently partnered with Qliance, a leading healthcare organization operating a network of clinics that provide comprehensive primary care services, to open an onsite clinic at its Bellevue, Washington headquarters. Now, Expedia, Inc. employees and their dependents have easy access to primary health care services, including Saturday hours. The company hopes this effort will help prevent treatable symptoms from becoming chronic issues and encourage employees to use their sick time and medical benefits when needed. In just the first month of operation, employees and their dependents utilized nearly 300 office visits at the clinic.

“We are really pleased at how much use the clinic has received so far,” said Connie Symes, Executive Vice President of Human Resources at Expedia, Inc. “It’s great to see that the tools being provided are making health and well-being more convenient and accessible. As an employer, we spend a great deal of time attracting the best and brightest talent and we are equally focused on helping them be active and engaged employees of Expedia, Inc. We have a vested stake in the vitality of our workforce, and so we really can’t afford not to make preventative care a top priority for our employees.”

direct primary care journal2Sharon, an Office Administrator at a DPC Clinic in Maryland tells The Direct Primary Care Journal that she’s finding many of her patients are receiving their open enrollment information right now. “Can DPC fees be paid from an HSA?” asks Sharon.

Roy Ramthun of HSA Consulting Services based in Washington, DC, “No this has never been clarified. Advise patients they cannot deduct or pay their annual fees with HSA dollars or other similar accounts. They should be able to reimburse fees for individual services if the doctor can produce a fee-for-service bill.”

Associated Mutual has stated it is offering a wraparound policy but hasn’t announced details yet. Physician Care Direct is working with DPC practices and networks, as well as multiple carriers, to facilitate wider adoption of the DPC model. They expect the combined cost of the DPC wraparound policy and DPC fees to be less than a standard health insurance plan.

assembly 2015

Industry sources also tell The Direct Primary Care Journal that a DPC clause was written into the Affordable Care Act (ACA) allowing retainer practices to be included in the proposed insurance exchanges, with the caveat that these practices be paired with a wraparound insurance policy covering services outside of primary care. According to a 2013 report by the California HealthCare Foundation, It is the only non-insurance offering to be authorized in the insurance exchanges slated to begin in 2014; however, there is no requirement that DPCs be included.

By charging a membership fee, the doctors can then sell their various services to members at a deep discount.

WE-AA563_CONCIE_G_20131106124211DPC doctors and concierge medicine physicians both help keep costs for patients by avoiding unnecessary referrals and through referring to ancillary and imaging services willing to offer significant discounts.

How deep?

Dr. Robert Nelson of MyDoc in the Atlanta metro area, a DPC doctor, states “If you walk into a Quest or Lab Corp facility the cash price for a routine blood chemistry panel (CMP) will be $62.58 and $46, respectively. I can offer the same exact lab test to my patients for $15, which covers my costs and the time related to clinical follow up as well. This shows the power of free-market leverage when you get out from under the third-party payment model. The good news is that these direct fees paid to direct-pay physicians or discount labs can still be applied towards a deductibles and always go towards total out-of-pocket expenses for the year.”

CNNMoney reports “By cutting out the middleman, [one doctor] said he can get a cholesterol test done for $3, versus the $90 the lab company he works with once billed to insurance carriers. An MRI can be had for $400, compared to a typical billed rate of $2,000 or more.”

Interestingly, this is all happening at a time when the rise of health care costs has gone into pause.

“I have noticed that any patient that comes in as a “cash pay” will always pay less than what a hospital or imaging center is billing the insurance for the same test. Also, remember, that some tests ordered are not typically covered by insurance (like a coronary CT) so, cash prices are extraordinarily important for these scenarios,” says Dr. Tiffany Sizemore-Ruiz, a concierge doctor in the Miami/Fort Lauderdale Area.

The actual cost of medical care fell for first time since Gerald R. Ford was president of the United States.

the marketing md book“I can get much cheaper prices for my patients. My PSA’s are $30.00 and Lipids $15.00 … and that is with a mark-up. General Health Screens (CBC, Thyroid, Liver Kidney and glucose tests) are $35 at my office. Next door at the lab, GHS SOT is greater than $200 and Lipids are higher than $100,” says Dr. Sizemore-Ruiz.

So what’s behind the slowdown in health care spending?

Clark Howard writes, ‘First, employers are switching to high deductible health plans where you are responsible for so many thousands of dollars upfront before the company picks up the tab. When that happens, you start to treat health care like a consumer and become more cost conscious. Second, generic drugs are on the rise, which keeps the cost of health care down.’

Bob Adelmann wrote in The New American, ‘Naturally the insurance industry isn’t too happy about it, but at present there’s little they can do. For the moment, “concierge” medicine and its more modest iteration, “direct pay” medicine, is increasingly being seen by patients and doctors alike as a way out of the maze of medical practice requirements caused by government intervention in what used to be a simple transaction: a private matter between a doctor and his patient.’

doctors guide to concierge medicine

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