The Direct Primary Care Approach to Health Care without Insurance: A Closer Look

Last Updated: Mar 21, 2018

Direct-Primary-Care-Whitepaper-articleDirect Primary Care (DPC) – an alternative payment model where patients pay a flat monthly medical service fee or membership fee directly to the medical practice in exchange for primary care services – has been gaining national attention as more physicians continue to adopt this model.

The Pennsylvania Medical Society’s (PAMED) new whitepaper answers member questions on DPC and addresses topics such as:

  • The pure and hybrid types of DPC and how they differ
  • Current Pennsylvania bills that seek to create a framework for DPC
  • Establishing a DPC practice
  • Considerations when discussing DPC with patients
  • DPC and tax treatment
    Get the Whitepaper Here


DPC Legislation in Pennsylvania

Pennsylvania Senate Bill (SB) 926, introduced on Oct. 11, 2017, and House Bill (HB) 1739, introduced on Aug. 24, 2017, both seek to create a framework for “providing for direct primary care, medical service agreements and insurance, for medical service agreement requirements and for use of other health care practitioners.”

In January 2018, PAMED President Theodore Christopher, MD, FACEP, issued a statement in support of HB 1739. “As our country faces political uncertainty on our current health care cost configuration, DPC becomes more intriguing and worthy of further investigation and testing,” said Dr. Christopher.

More on the DPC Whitepaper and How It Was Developed

In October 2017, physicians at PAMED’s House of Delegates meeting voted to adopt a resolution to create education for members on the DPC model. The resolution was authored by PAMED member Kimberly Legg Corba, DO.

PAMED thanks Dr. Legg Corba for her contributions to the whitepaper, and the following physician members for their feedback on the DPC model: Mark Lopatin, MD; Marion Mass, MD; and Winslow Murdoch, MD.

2 comments

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  1. Jeff Wirick | Mar 23, 2018
    Thanks for your comments Dr. Winslow. I have shared your comments to PAMED's Government Affairs team.
  2. Winslow W. Murdoch | Mar 22, 2018

    Comment on the White Paper

    Great Job

    A few comments;

    Most persons who go to DPC practices have a PPO, a high deductible policy, or have Medicare or Medicaid. The patient therefore is paying for primary care through their insurance premium with pretax dollars or through government appointed third parties. The fee for the DPC practice is then added on with after tax dollars as redundant payment for primary care.

    Persons with insurance, Medicare or Medicaid still have third parties that require prior authorizations or pre certifications for most advanced diagnostic testing and prescription medications.  

    Persons who have Medicare or Medicaid who go to a DPC practice still need that DPC practice to  be certified with Federal Medicare registry through PECOS certification and enrollment, as well as PA Medicaid enrollment (as ordering and prescribing, not billing) in order to be able to refer, order diagnostic testing, and write prescriptions to have them covered by the patients government administrator.  

    Persons with insurance, Medicare, or Medicaid, especially those with a high deductible plan or an HSA are required to pay the insurer third party negotiated price, often a much higher amount than can be negotiated for a cash price, for laboratory testing, diagnostic services, radiology, PT/OT, specialty, surgical, or hospital care. If they pay a cash price up front, and don't go dollar one through the third party administrator, the cost of services are not allowed to accrue toward their high deductible nor HSA.

    Lastly, if a patient has an HMO plan, their DPC practice must be able to find a participating primary care partner to originate any and all referrals and diagnostic studies beyond routine lab testing.

    All said, the legacy systems actively create barriers and disincentives for doctors and patients to work collaboratively. PAMED should make it a priority to put a STOP to these barriers and disincentives.

     

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