Considerations for opting out of Medicare as a direct care physician

The structure of a direct primary care (DPC) practice relies on patient membership fees rather than insurance reimbursement. Many DPC physicians set up categories of fees that are based on the patient’s age, including those patients over age 65. Some DPC physicians may opt to accept Medicare reimbursement for those patients, but some choose to opt out. There are a number of considerations to think about when deciding whether to opt out of Medicare as a DPC physician.

The first consideration is that the Medicare opt-out is for a two-year period. After the two years, the DPC physician has the option to opt back in. This means that once the DPC physician opts out of Medicare, “they cannot submit claims to Medicare for any of their patients for a two-year period.”

Additionally, for the patients’ consideration, any outside services referred to by the DPC physician would still be covered by Medicare for those patients who are eligible for that coverage. For example, if a patient needs laboratory services that are not part of the DPC membership fee, Medicare would cover those costs, “provided the physician is not paid, directly or indirectly, for such services (except for emergency and urgent care services).”

DPC physicians who opt out of Medicare should ensure their patients are aware of their status. There may be complications for patients who have also secured a Medicare Advantage plan, which are “generally written to cover things that Medicare does not cover.” Physicians and patients must sign an agreement stating that, given the physician’s opt out status, none of the DPC services can be submitted to Medicare.

A DPC physician who decides to opt out of Medicare, “must file an affidavit that meets the necessary criteria and is received by the MAC (Medicare administrative contractors) at least 30 days before the first day of the next calendar quarter. There is a 90-day period after the effective date of the first opt-out affidavit during which physicians may revoke the opt-out and return to Medicare as if they had never opted out.”

Krystle Thornton
September 21, 2018

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Does HIPAA apply to direct care practices?

The Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, is a complex law that most patients assume applies to all of their private information in a healthcare setting. There are different aspects of HIPAA that apply to the sharing of private data with other medical providers and to the transmission of patient data electronically. The basis of HIPAA is protected health information (PHI) which has its own specific definition and requirements.

The HIPAA Privacy Rule defines protected health information (PHI) as individually identifiable health information, including demographic information, information about the patient’s physical or mental condition, genetic information, and information about the patient’s healthcare plan or payment system. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology.

Direct primary care (DPC) practices may or may not be subject to HIPAA regulations, depending on how they operate. In fact, according to the American Academy of Family Physicians (AAFP), “pure DPCs operating completely outside of the insurance industry are not as constrained by parts of HIPAA, the Health Information Technology for Economic and Clinical Health (HITECH) act, and the Affordable Care Act that protect patients’ confidential medical information.”

DPC practices that do not transmit patient data to insurance companies are not bound by the rules of HIPAA, protecting that data. So, if a DPC physician maintains paper files and never communicates with anyone else regarding the patient, HIPAA would not apply to that practice. However, most DPC physicians maintain electronic health records (EHRs) and do communicate with other healthcare providers in the interest of providing quality care for their patients. In these cases, they are subject to the HIPAA regulations regarding PHI and ePHI.

Krystle Thornton
September 18, 2018

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Check out Elation’s Direct Care Interview series

As many direct care physicians know, there is never a bad time to learn more about and improve the way patients receive care. That’s why we strive to constantly give physicians resources, tips, and advice for how to provide innovative care.

At the same time, it’s important to spend time understanding how direct care physicians can grow their businesses – whether you are new to direct care or looking to scale your practice.

Recently, we started doing an interview series with some of the most successful direct care physicians that use Elation as their EHR. These physicians include Dr. Garrison Bliss (Bliss MD), Dr. Vivek Sinha (Belleview Medical Partners), and Dr. Jeremy Smith (MyMD Select).

By listening to these interviews, you can hear more about these physicians’ direct care journey, insights for other direct care practices, and how choosing an EHR system developed with the physician in mind has benefitted them.

In case you missed it, we also recently launched Elation for Direct Care, a new version of Elation that is focused on direct care physicians and their practices.

We’re committed to helping the direct care movement succeed and deliver on its promise to provide high-quality, personal care. With these resources and an EHR platform that allows physicians to focus on their patients, direct care practices can do what they do best – delight patients.

You can check out the videos here and learn more about Elation for Direct Care.

Krystle Thornton
September 10, 2018

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Most popular direct care marketing strategies

Independent physicians who launch or transition to direct primary care (DPC) practices may bring existing patients with them but may also need to market their practices to potential new patients so they can grow their businesses. With DPC, the physician needs to promote the practice and will probably also need to provide a little education and reassurance as to the DPC model itself in order to attract new patients.

The first step in marketing a DPC practice is to build a compelling and informative website. The website provides the online presence that can help the DPC practice build credibility and provide information in an accessible format. In particular, a well-designed and responsive website will help the practice stand out from the crowd.

In addition, there are a number of other marketing strategies that can benefit the DPC practice:

  • Patient referrals. Happy patients are the best marketing tool for a DPC. Word-of-mouth referrals made by current patients emphasize their satisfaction not only with the DPC model but with the specific DPC practice.
  • Blogging. Educational blogs posted on the practice website can provide information and answer questions potential patients may have about the way the DPC practice operates. Blogs may also cover, at a high level, health issues that may be of particular concern in the practice’s geographic area or for a particular demographic. For example, a blog post could discuss the general symptoms of Lyme disease if the practice is located in an area known for ticks.
  • Social media posts. Posting timely, relevant content is one way to bring exposure to the DPC practice. When initiating any sort of online communication where patient information may be at risk, physicians should, of course, carefully avoid any HIPAA violations.
  • Community involvement. The practice may sponsor a community event or a local youth sports team or volunteer for a non-profit organization, to gain exposure and to give back to the community. The key to this strategy is to be sincere about a desire to give, rather than overt about using it as a marketing strategy.
  • Reviews. Encourage satisfied patients to post reviews on sites that potential patients may visit for information about the practice and its “ratings.”

Gabby Marquez
August 29, 2018

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Revisiting the tax treatment of direct care

The discussion around taxes and direct primary care (DPC) practices primarily focuses on the Health Savings Account (HSA) and the Affordable Care Act (ACA). Given the structure of the DPC, it is not considered insurance, even though it does qualify for meeting the ACA individual mandate. Many DPC patients also opt to carry high-deductible insurance for catastrophic and major medical events not covered by their DPC membership fee.

To date, patients cannot use HSA funds to pay their DPC membership fees and, in fact, cannot join a DPC if they have an HSA. A bill that has passed in the House and is pending in the Senate may change the tax implications for a DPC. HR 6199, the Restoring Access to Medication and Modernizing Health Savings Accounts Act of 2018, would enable “millions of Americans with HSAs to have great access to affordable primary care from a DPC doctor of their choice. While not perfect this will allow almost all DPC practices to see patients with HSAs and allow their fees to be paid from the HSA.”

As to the use of Flexible Spending Accounts (FSA), given certain conditions patients may be able to use those funds with a DPC membership. The DPC must be “structured properly” to qualify. As Dr. Phil Eskew, licensed physician and attorney, states, “the practice would want to bill in arrears, focus on preventive nature, consider itemized statement of preventive services, etc.”

DPCs are eligible as employer plans, that is, the healthcare coverage provided for employees by a business. Even though the Internal Revenue Service (IRS) once determined that DPCs do not qualify to “satisfy market reforms,” and employers of a certain size would be subject to fines, with the passage of “H.R. 34: 21st Century Cures Act the potential for a $100 per day fine for the less than fifty employers desiring to pay for DPC services with pretax dollars has largely been eliminated.”

Gabby Marquez
August 24, 2018

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10 differences between DPC and concierge care

Healthcare delivery evolves with technology, demand, reimbursement plan structures, and many other factors. However, sometimes independent physicians have a desire to return to the days of a simple delivery structure with no insurance involved and with more time to spend with fewer patients. Those physicians often start or convert existing practices into either a direct primary care (DPC) or concierge care practice.

The premise of both models is essentially the same, that is a return to the days of the family physician who has time to spend with each patient in the office and before and after visits. Each model offers the independent physician the opportunity to focus on the patient’s specific healthcare needs, without worrying about insurance reimbursement or meeting tight daily appointment schedules. The DPC and concierge care models both run on patient membership fees that cover a range of basic services.

What are the differences between a DPC and a concierge care practice?

  1. Monthly fees are typically less for a DPC. Patients pay between $50 and $100 a month, depending on the DPC practice’s membership fee scale. Many practices offer special rates for children or seniors. Concierge care patients typically pay between $100 and $200 month for their membership fees.
  2. DPCs offer basic primary care services, although membership fees may also cover x-rays or labs. Concierge care encompasses a much broader range of services.
  3. All of a DPC’s services are covered by the patient membership fees. Independent physicians in DPC practices may encourage patients to carry catastrophic insurance but do not accept insurance payments for their basic services. Concierge care physicians will generally accept insurance or Medicare.
  4. Patient panel sizes differ somewhat. In a recent survey of 5,000 physicians in DPC and concierge practices, 69% of the DPC physicians indicated their patient panel was between 50 and 550. In that same survey, 76% of the concierge care physicians stated that their patient panel was between 250 and 550.
  5. Although DPC physicians make themselves available for communication with patients before and after the visit, concierge care physicians are typically available to treat patients before and after office hours.
  6. Since DPCs do not accept Medicare or any other type of insurance, they are not subject to the Medicare regulations to which concierge care practices must adhere.
  7. DPC is indicated in the Affordable Care Act (ACA) as an acceptable form of healthcare coverage, while concierge care is not.
  8. DPC practices are more attractive to younger patients while the majority of the concierge patients are over the age of 50.
  9. Concierge care may be more attractive for patients with chronic or complex conditions, as they receive personalized attention, to the point of their primary care physician accompanying them to specialty provider visits or attending to them while they are traveling or on vacation.
  10. DPCs have less overhead, as they operate solely on patient membership fees and have the administrative burden of billing insurance companies for reimbursement.

Gabby Marquez
August 14, 2018

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Employer health terminology direct care physicians need to know

The employer sponsored healthcare market is an increasingly viable opportunity for direct primary care (DPC) physicians. Employers look for ways to save money for the business and for the employees as well as ways to ensure their employees are healthy and happy. New and innovative options such as a DPC practice could be an enticing incentive for an employer to use in recruiting and retaining quality talent.

For DPC practices pursuing employers, understanding certain employer health terminology would be helpful for DPC physicians to be able to market and provide healthcare services effectively. DPC physicians should become familiar with these terms:

Benefit year – Unlike individual DPC memberships, employer healthcare plans typically span a year’s time. Often the benefit year will begin on January 1 and end on December 31. Sometimes, though, the employer will opt to begin the benefit year on July 1 and end it on June 30.

Employer contribution – Many employers contribute a portion or all of the employee’s healthcare coverage costs, which would be the membership fee for a DPC. Employers may or may not contribute a portion of the employee’s dependent coverage.

Open enrollment period – New employees are usually eligible to sign up for healthcare after starting their new job; however, current employees are typically only eligible to sign up during a specified period of time. For example, if the benefit year starts on January 1, open enrollment may occur during October or November of the previous year.

Life events – Employees are generally allowed to make changes to their healthcare coverage if certain life events occur, such as getting married or having a new baby.

Premium – Employer-sponsored healthcare plans typically charge a premium, which is the amount charged for the healthcare coverage each month. For a DPC practice, the premium would be the monthly membership fee.

Wellness programs – In an effort to provide incentives for employees to become and stay healthy, employers are increasingly offering wellness programs, such as smoking cessation classes, weight loss programs, and fitness centers, in addition to their healthcare coverage plans. DPCs may benefit from typing these wellness programs into their service offerings.

Gabby Marquez
August 3, 2018

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Scaling up and managing growth for DPC practices

One of the main attractions of the direct primary care (DPC) model for both patient and physician is the personal attention the independent physician is able to provide to the patient. DPCs typically have smaller patient panels, allowing more time for each patient during the visit and expanded availability after hours for follow-up patient communications. Even though the physician may want to scale the practice to ensure its sustainability, the DPC practice must be managed appropriately for true success.

Growing a DPC requires developing a positive reputation and ensuring that potential patients know what you have to offer them. Focusing on your patients and delivering a great experience will have a positive side effect for your practice – your patients will help you grow. Word of mouth is the most powerful marketing tool available.

Incorporating the best in health record technology can also help your DPC scale up in an efficient manner. The right electronic health record (EHR) system will enable you to manage your practice, easily review and input patient data, and communicate with your patients electronically and securely.

Managing patient expectations can be a significant factor in managing your DPC practice’s growth. The DPC model is built on the premise that the independent physician is always available for the patient, even after hours. Typically, the DPC physician wants to grow the practice but still wants to be able to provide that individual attention. Delicia Haynes, M.D., founder and CEO of Family First Health Center in Daytona Beach, FL, advises that “Besides managing the account ledger, it is important for the DPC physician to set reasonable expectations regarding their availability to patients.”

Unmanaged patient access can stretch the physician’s resources. In addition, “if you promise 24/7 access to a physician, if a patient calls and the physician does not call back right away, the patient grows frustrated.” Rather, the business mantra, she says, should be to “undersell and overdeliver” to properly scale and manage growth for the DPC practice.

Gabby Marquez
July 30, 2018

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Direct primary care and population health

A growing number of direct primary care (DPC) physicians are working with employer groups to provide healthcare for the company’s employees. The DPC model has come to be recognized as a quality alternative to traditional workplace medical insurance. When an employer contracts with a DPC to provide healthcare services to its employees, by its very nature the DPC practice becomes focused on the population health of the employer group.

Population health is a relatively new term, having been coined in 2003 by David Kindig and Greg Stoddart. They defined it then as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.”

The Centers for Disease Control and Prevention (CDC) sees population health as “an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally.” The CDC adds that the population health approach “utilizes non-traditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes.”

HIMSS emphasizes that population health “brings significant health concerns into focus and addresses ways in which communities, healthcare providers, and public health organizations can allocate resources to overcome the problems that drive poor health conditions in the population, e.g. diabetes, obesity, autism, heart disease, etc.” In addition, HIMSS states that “Information technology is a part of the core infrastructure on which population health can be assessed and addressed.”

Those partnerships referred to by the CDC and HIMSS include DPC practice and the independent physicians that run them. DPC physicians generally either began their practice or converted their practice out of a desire to focus more on each patient and, in particular, the quality health outcomes of those patients. When a DPC contracts with an employer, the physician and the practice staff naturally desire to “address the health status and health issues of the aggregate population,” as the non-profit organization HIMSS describes population health.

Gabby Marquez
July 24, 2018

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Physician perspective: DPC does not mean patient abandonment

When an independent physician decides to convert the practice to a direct primary care (DPC) model, part of the process will involve reducing the size of the patient panel. In a DPC practice, the physician sees fewer patients in order to be able to spend more time with each patient during the visit. Downsizing the practice in such a manner may leave some patients feeling as though they have been abandoned.

A recent post in Medical Economics, written by Stephen C Schimpff, MD, MACP, a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and author of Fixing the Primary Care Crisis and Longevity Decoded – The 7 Keys to Healthy Aging, explains the situation from a physician’s perspective. In essence, Dr. Schimpff states that physicians who operate DPC practices are able to devote more time to their patients, less expensively, than in a traditional practice and that is “certainly not patient abandonment.”

All of a DPC physician’s patients are not expected to follow the practice through its conversion. That would actually defeat the purpose. However, Dr. Schimpff points out that there are still plenty of traditional primary care practices operating that will take in those patients who choose not to go the DPC route with their physician.

In addition, Dr. Schimpff states that, far from decrying the physician’s move to a DPC model, “once it becomes clear that people can get better care at a reasonable cost, the general public will be the ones who will pressure their PCPs to make the conversion.”

He adds that large patient panels can contribute to physician burnout as well. “The need today is to get back to a reasonable number of visits per day. Using better technology and team functions, that number can be somewhat greater today than it was years ago but it still needs to be a reasonable number that the PCP can interact with appropriately.”

Gabby Marquez
July 9, 2018

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