Is the Direct Primary Care Model for You?

By Dina Petrutsas, CPA
Friday, May 31, 2019

Dina Petrutsas, CPA

Many physicians may recall years ago when commercial insurance payers paid a percentage above the CMS Allowable, and Medicare was one of their lowest payers. Today, for many small groups and solo physician offices, Medicare is their best payer. This change has caused physicians to worry about revenue not keeping up with rising expenses. Some primary care physicians in San Antonio are turning to the direct primary care (DPC) model and decreasing their reliance on third-party payers.

According to Medical Group Management Association, “Concierge medicine is often confused with the DPC model; however, a key distinction is that DPC is explicitly mentioned in the Affordable Care Act as an acceptable option for receiving medical care without insurance, while concierge medicine is not.” Concierge medicine charges a membership fee and bills the “member’s” insurance for the medical care provided during the visit. DPC charges an “access” fee and the patient’s insurance is not billed for the visit. A DPC patient typically pays $50–$100 per month for unlimited access to the physician and healthcare team.

DPC models started in the late 1990s and early 2000s. DPC allows the physician to focus more on the patient visit and emphasize wellness and prevention to keep the patient healthy. Many physicians using the DPC model are pleased to have unlimited time with patients, decreased practice overhead, less exposure to risk, fewer medical errors and zero insurance filing.

Because there is no insurance involved, the patient doesn’t pay copayments to see the physician. So, what’s the difference between a typical family practice and DPC?

DPC is a great option for patients with higher deductibles; however, a patient should be well informed of the advantages and disadvantages of the DPC model before making a change from traditional insurance.

Advantages of the DPC Model

  • Better health outcomes through better access to physicians
  • Lower, transparent costs based on a flat rate
  • Enhanced patient experience by creating a relationship between provider and patient by offering unrestricted access to treatment across a variety of platforms
  • Available access regardless of age, pre-existing conditions, insurance coverage or nature of the illness
  • Less administrative burden, generally allowing for longer interactions

Limitations of the DPC model

  • DPC agreements do not cover specialists or hospital stays
  • As primary care physicians see fewer patients under the DPC model, access will be limited
  • Patients with Medicare, Medicaid or ACA plans will have limited funds
  • For practices exclusively offering DPC, their only source of revenue are those patients who receive this care

Many physicians are able to reduce their patient panel size by changing to the DPC model due to the new expected revenue from the monthly membership fee. Contact Concordis Practice Management LLC at 210-704-1014 if you would like to discuss changing your practice to a DPC model.