Direct Primary Care: Improving Care and Cutting Costs in Maryland
The direct primary care (DPC) model is an innovative framework for health care purchasing that gives family physicians and their patients a meaningful alternative to the conventional fee-for-service (FFS) payment paradigm for primary care services. The defining characteristic of a DPC practice is that it offers patients the full range of comprehensive primary care services—including acute and urgent care, regular checkups, preventive care, chronic disease management, and care coordination— in exchange for a flat, recurring membership fee that typically is billed to patients monthly.
Direct primary care benefits patients by providing a greater degree of access to—and time with—their physician. The DPC model promotes the development of more meaningful physician-patient relationships. It also rewards family physicians for providing comprehensive, longitudinal care for the whole person, while reducing the overhead costs and negative incentives associated with FFS billing of a third-party payer. An FFS system rewards physicians more for visit volume and rapid throughput of patients than for quality, service, and outcomes. In contrast, DPC rewards physicians for providing high- quality primary care services and giving patients the time and attention they want—and deserve—so they can better manage their health. The membership fee is a recurring charge billed directly to patients in exchange for comprehensive primary care services provided by the physicians and staff in a DPC practice under the terms of a membership contract.
The practice membership fee most commonly is based on the breadth of primary care services specified in the membership contract, typically ranging from $25 to $125 per month. Typically, the membership fee also includes several sets of ancillary services, such as labs, referred tests, healthy lifestyle activities (e.g., yoga, massage, nutrition coaching), as well as negotiated discounts for health care services from other providers.
The opportunity to spend more time interacting with patients and providing ongoing follow-up services is at the heart of the patient-centered care provided in DPC practice settings. The regular and recurring revenue generated by the practice retainer fees allows physicians participating in DPC practices to overcome some of the pressures associated with the traditional FFS payment system. Because DPC physicians are no longer generating revenue solely on the basis of how many patients they see per day, many report that they have significantly more time to spend with patients in face-to- face visits. Additionally, many DPC physicians provide a larger array of non-face-to-face services, such as tele- visits or e-visits, for their patients, to ensure primary care services can be accessed in a manner most convenient for patients and their families.
Additionally, many family physicians practicing in DPC settings report that the opportunity to spend more time with patients has resulted in improved professional satisfaction. This anecdotal evidence is bolstered by the evaluations and assessments that draw a connection between physicians’ satisfaction and the duration of patient visits. Further, DPC practices report significantly reduced operating rates when compared with traditional primary care practices. This is primarily because DPC practices do not need to maintain staff dedicated to organizing, reviewing, filing, and managing payment claims to third-party payers.
Lastly, because many DPC practices do not participate in contracts with private insurance carriers, they avoid the economic pressures of diminishing contract service rates. DPC practices that choose to continue participating in insurance carrier contracts can act in a far more proactive manner and participate in insurance contracts that are economically beneficial for the practice and its patients.
MDAFP: YOUR VOICE ON THE DIRECT PRIMARY CARE INITIATIVE (SB 531/HB 718 IN 2018 SESSION)
During this year’s Maryland General Assembly Session, MDAFP focused heavily on passing a Direct Primary Care bill that would provide certainty for physicians who choose that form of practice. Finance Committee Chairman Thomas “Mac” Middleton served as the primary sponsor in the Senate and Delegate Arianna Kelly championed the bill in the House.
CareFirst and other health insurers in the state quickly objected to the legislation arguing that it would cost them customers by allowing some physicians to be outside their systems. After a spirited hearing that included several MDAFP members, Chair Middleton convened a workgroup to try and work out the differences but was unable to iron out a solution before session ended in April. MDAFP has been conducting some discussions with the insurers out of session and will come back hard in the 2019 session to push this important initiative.