How direct-to-employer care is driving comprehensive, affordable care

The rising cost of healthcare is a challenge for patients, providers, and employers. One effective way to help curb those costs is to focus on coordinated preventative care that reduces or eliminates unnecessary expenses. Duplicative tests, multiple provider visits, and unchecked health conditions can add to the costs as well as reduce the quality of care provided to the patient.

Direct-to-employer care enables primary care physicians to provide comprehensive, affordable care that improves the quality of value-based care while reducing costs. Revcycle Intelligence reports on one such direct-to-employer care relationship that is benefiting all involved. Vera Whole Health and Blue Cross Blue Shield of Kansas City (Blue KC) have partnered on three new primary care clinics “that blur the line between provider and payer and incentivize both sides to deliver high-quality, low-cost care to patients.”

In addition to primary care services, Spira Care Centers also provide behavioral health services, x-rays, and pharmacy services. All the services provided by the primary care clinics, except the prescriptions, are covered by the insurance component. To ensure that the primary care and the insurance model work together to provide quality healthcare at reduced costs, “Vera and Blue KC had to align their financial incentives through a value-based contract.”

The key is a capitated payment model tied to quality performance, by which Vera is reimbursed for primary care services delivered to patients at the Spira Care Centers. As Blue KC’s VP of Business Development David Olson explained, “It is a per member, per month payment contingent on them meeting quality metrics. A portion of their capitated payment is withheld pending them meeting HEDIS quality metrics, including patient satisfaction. There is a lot we have in the contract that they have to meet to ensure that they are continuing to deliver high-quality care.”

Aligned financial incentives ensure that providers “no longer have to depend on service volumes to ensure they can continue delivering high-quality care to patients.” Rather, primary care providers and patients are able to work together toward their “shared goal of improving preventative care to decrease costs.”

Gabby Marquez
November 5, 2018


How HSA reform could benefit direct care physicians

Many people choose a high-deductible health insurance plan to reduce their monthly premium cost. Those who do so are eligible to participate in a Health Savings Account (HSA) that may help offset some of the added expenses of the high-deductible plan, including deductibles, copayments, coinsurance, and certain other expenses. HSAs are also attractive because the money is set aside on a pre-tax basis.

Currently, the HSA is only available to people who have a high-deductible health plan, either employer-sponsored or obtained through the Marketplace, with a deductible of at least $1350 for an individual or $2700 for a family. Those who opt to participate in a Direct Care program are not eligible for the HSA program.

HSA reform could be on the horizon, however. A proposed bill, HR 6199, passed the House of Representatives in July 2018 and is now in the hands of the Senate. The bill would allow Direct Care patients to participate in an HSA and use those funds to pay their membership fees.

The Direct Care physician bills patients for a membership on a monthly basis, rather than billing for each visit or service provided. Patients are able to take advantage of basic primary care services as well as some treatment for illness or injury as part of their membership. Direct Care patients sometimes do secure high-deductible insurance plans for catastrophic coverage but are still not eligible for the HSA program since they participate in the Direct Care program.

The number of Direct Care practices is increasing as more patients realize the benefits and cost savings involved. To date, though, the inability to participate in an HSA or use HSA funds for DPC membership fees has been a challenge for both Direct Care patients and providers. If HR 6199 is passed, the amendments specified in Sec. 3. Treatment of Direct Primary Care Service Arrangements, will apply “to months beginning after December 31, 2018, in taxable years ending after such date.”

Krystle Thornton
October 29, 2018


Concierge medicine comes in all flavors and sizes

The image of a concierge medical practice is often that of an expensive form of personalized medical care, in which the physician is available for the patient 24/7. The traditional concierge practice does charge a membership fee that can range from $150 a month to $25,000 a year and offers the patient access outside the regular office visit. However, concierge medicine actually takes many forms, some much more affordable than many patients may realize.

A recent article in MedPage Today describes a range of successful concierge practices, including many hybrid models. Many practices are part of larger companies. One of the oldest concierge companies is MDVIP, launched in the year 2000 in Boca Raton, Florida. The practice has expanded to include 950 physicians in 43 states. Physicians in the practice “agree to reduce the size of their patient panel substantially, usually to anywhere from 300 to 600 patients.” The annual fee for the patient can range from $1650 to $1800. MDVIP boasts a 95% reduction in hospital readmission rates, as a direct result of its practice model.

Larger companies like MDVIP and Concierge Choice see their physicians as clients, for which they provide services such as marketing and accounting. Concierge Choice has concierge physicians in 24 states, serving “under 1,000 practices nationally.” In their model, “follow-up patient visits are covered either by private insurance, public programs like Medicare, or out of pocket if the patient doesn’t have other insurance.”

Independent physicians in concierge practices may also offer patients the option of enrolling under a membership fee or seeing the physician as a traditional patient, in a hybrid model. Physicians offer certain hours for each type of patient, usually spending more time during each visit with their concierge patients. For example, the independent physician may schedule two concierge patients during an hour slot but four traditional patients per hour. The traditional patients are able to continue to see their primary care physician while the concierge patients enjoy the benefits of their membership.

Gabby Marquez
October 10, 2018


The first things you need to do to start a direct care practice

The number of direct care practices is growing, as more independent physicians decide to return to the concept of patients paying their physicians directly for their care, with no insurance involved. The direct care model has helped strengthen the relationship between patients and physicians, allowing physicians more control over their patient panel sizes, practice staffing, and care delivery.

For physicians, adopting a direct care model can improve work-life balance, reduce practice overhead, bring higher per patient revenues, and maintain physician autonomy. Starting a direct care practice involves research and preparation, to ensure that the independent physician is providing the quality of care patients expect in a manner that optimizes the practice for success.

The first step for the independent physician is to learn as much as possible about the structure and management of a direct care practice. Resources such as DPC Frontier and Elation Health’s Direct Care Resources abound for the independent physician who wants to learn more. The independent physician should also:

  • Make sure the direct care practice is viable. Budgeting for a practice that runs on patient membership fees instead of relying on insurance reimbursements can be a challenge.
  • Plan the practice structure, including pricing for membership fees, office location, and a name for the practice. Basic business items such as determining the legal formation of the practice and writing a detailed business plan will help the independent physician prepare for success.
  • Research and adhere to the legalities of running a direct care practice. There are a number of legal considerations involved, including deciding whether to opt out of Medicare for older patients, complying with applicable regulations, hiring a lawyer, and securing malpractice insurance.
  • Market the practice to existing and potential clients. For the independent physician currently operating in a traditional practice, transitioning to a direct care practice will require educating patients on the change and reaching out to a new client base to build the practice.
  • Implement technology, including electronic health records (EHRs). A direct care practice has to operate efficiently. Technology that enables secure patient communication, ease of patient data input and review, and coordination with specialty physicians is key to starting a direct care practice designed for success.

Krystle Thornton
October 8, 2018


What are the consequences of rejecting insurance payment?

Direct care practices operate just as their name implies – they provide care directly to their patients, eliminating the insurance middleman. Direct care physicians focus on preventative care, with a goal of maintaining their patients’ health and well being to help prevent major illnesses and injuries. By reducing the need to secure prior approval and then insurance reimbursement, direct care physicians are better able to focus on the needs of their patients without the administrative overhead.

Rob Lamberts, MD, a board-certified internist and pediatrician with a direct primary care practice in Augusta, Georgia, writes in Medical Economics that one result of the direct care practice eliminating the insurance payments is an increased focus on reducing the cost of care. With healthcare costs rising, that can be a significant factor for independent physicians as well as for their patients.

Dr. Lamberts, who takes advantage of the benefits of Elation Health’s electronic health record (EHR) solution, notes that there are three key benefits to rejecting insurance payments:

There is an increased focus on customer service. Direct care patients enjoy more time with the physician during each visit. The wait to see the physician is often reduced significantly as well. When the direct care physician is more focused on patient care and less on insurance paperwork, the physician also becomes more accessible before and after the visit. Dr. Lamberts notes that some patient care can actually be “done via text message or phone, reducing the need for coming to the office at all.”

Patient records are freed from the coding nightmare. As Dr. Lamberts states, “Most health records hide important clinical information in an avalanche of insurance documentation compliance.” The direct care physician is able to “document for care” without the need to apply codes and secure insurance approval.

Patients trust their doctor more. Direct care physicians who reject insurance payments are winning back the confidence of their patients who “are increasingly suspicious of the motivations of their physicians, wondering if the care they get is focused on them or if it is done for increasing revenue or following insurance company rules.”

Krystle Thornton
October 3, 2018


On Base Percentage = All Cause Mortality

This week, Dr. Phillip Eskew, DO, JD, MBA shared a guest blog post for Elation Health’s direct care blog

Dr. Eskew founded DPC Frontier in Feb 2015. He is a direct primary care family physician and attorney. He joined ProactiveMD in Feb 2016 and is the company’s VP of Clinical Development and General Counsel.   Dr. Eskew has advised state and federal legislators about DPC legislation, and volunteers his time as the general counsel of the Direct Primary Care Coalition where he also serves as a member of the steering committee. He intends to use his diverse training to not only grow Proactive MD, but to support other DPC practices in the medical, legal, and policy arenas.

Baseball fans have always been obsessed with statistics.  For those that have not watched the film “Moneyball” the story focuses on how baseball analysts added up hits, runs, and RBIs for decades while ignoring (not even tracking) a more valuable statistic – on base percentage.  Deep down, health insurance companies already know that their current coding system is a garbage in, garbage out process. If you want proof, look no further than life insurance companies.  Life insurance applications commonly ask a variety of medical questions, but these are generally objective laboratory findings. These are not CPT code driven. They are simple, objective measurements related to lifestyle behaviors and chronic conditions that are easily trended over time.

As DPC physicians we can happily abandon 90% of the “data” tracked by the traditional system.  This data is not clinically useful. It doesn’t predict all cause mortality. Usage of this “fluff” data makes it easier for interlopers to argue their wasteful services are necessary.  We should track clinical information that is useful to us and our patients. Laboratory studies and vital signs related to chronic conditions are an obvious place to start. This kind of data is clinically actionable, allows for outlier identification, and can be presented in a trended view to motivate patients.

Whether they want to admit or not, life insurance companies are focused on one thing – when will someone die – or in medical speak does a number or lifestyle choice predict “all cause mortality.”  We will know that DPC has “made it” not when it is embraced by health insurance companies, but by when life insurance companies ask “are you a member of a DPC practice?” right after the question “are you a tobacco user?”

Dr. Phillip Eskew, DO, JD, MBA
October 1, 2018


What is direct care?

As the name suggests, direct care describes a relationship between a healthcare provider and a patient that does not involve intermediaries such as insurance companies. The direct care practice operates on patient membership fees and does not rely on insurance reimbursements. The independent physician in a direct care practice also does not have to wait for insurance review and approval prior to caring for the patient.

Direct care essentially harkens back to the days of the family doctor who engaged with the patient, taking phone calls and even making house calls as needed. The provider contracts directly with the patient for basic healthcare services, much as it was in the days before health insurance outpaced out-of-pocket pay as the primary revenue source for medical practices. The trend is now turning back to direct care as a preferred model of care delivery.

The number of direct care practices is growing significantly as patients learn more about the structure of the practice. Many patients do not understand or do not believe the simplicity of the model, as they are used to having to work with insurance companies for their healthcare services. Direct care providers find that they need to educate potential patients as to the direct care model and possibly even convince them that is legitimate.

Direct care practices charge a flat monthly membership fee, typically between $50 and $100 per month. Some practices have tiers of membership levels, based on age primarily. The monthly fee covers basic services such as immunizations, checkups, and visits for illness or injury. Outside services such as lab tests or hospitalizations are generally not covered. For those, direct care patients may carry high deductible, catastrophic insurance.

The direct care model of healthcare delivery benefits patients and independent physicians. For physicians, adopting a direct care model can improve work-life balance, reduce practice overhead, bring higher per patient revenues, and maintain physician autonomy. For patients, direct care can mean a greater degree of access to, and time with, physicians. Improved communication and more regular, engaged care lead to fewer unnecessary tests, less frequent hospital visits, and lower total cost of care.

Gabby Marquez
September 25, 2018


How does Medicaid apply to direct care physicians?

One way that direct primary care (DPC) physicians are able to maintain low overhead costs and to survive solely on patient membership fees is to not be burdened with administrative tasks such as filing for insurance reimbursement. While Medicaid is considered a type of insurance, the rules and regulations around how it applies to DPC physicians are complicated.

The Centers for Medicare & Medicaid Services (CMS) recently issued a request for information (RFI) through its Innovation Center. The RFI was designed to seek input on “experiences with, and perspectives on, DPC and how CMS can use DPC models to reduce expenditures and preserve or enhance the quality of care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.”

CMS received approximately 1000 responses to their RFI, from physicians as well as patients, healthcare systems, health plans, and other organizations. The responses focused on areas such as “increased physician accountability for patient outcomes, improved patient choice and transparency, realigned incentives for the benefit of the patient, and a focus on chronically ill patients.”  Additionally, the comments “reflected broad support for reducing burdensome requirements and unnecessary regulations.”

Currently, for DPC physicians who have not formally “signed up” as a Medicaid provider, “the assumption is that you are not enrolled in the program and thus you are free to privately contract with Medicaid patients for covered services.” According to DPC Frontier, depending on the state in which the DPC operates, contracting with a patient may or may not be possible. Most likely, though, orders for tests, medication, and referral will not be honored by Medicaid. “If you are not enrolled in Medicaid then the state will pretend that you do not exist … and the state will require that these orders be placed by a Medicaid enrolled physician.”

Medicaid regulations differ by state. Many states allow DPC physicians to have an “”Ordering and Referring Only” provider status; however, it is best to check with the state Medicaid office to determine how Medicaid applies to the DPC physician’s ability to contract with and receive payment from Medicaid patients.

Gabby Marquez
September 24, 2018


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


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