• Matt Herren

What is DPC...and Why You Should Care!


FIRST OFF, why does a media-centric like me care about this topic? Easy, for the same reasons you should—healthcare is in the throes of a radical transformation at the intersection of tech and media (think mobile biometrics, consumable/wearable health-tech, and virtual video doc visits…more on these topics soon). Combine this with recent, definitive mind/body research validating the potential to heal our bodies through mindfulness, meditation and food...and you begin to understand the gravity of this healthcare revolution!

Now to the topic at hand—if you’ve never heard of direct primary care—you should, because it has the potential to upend our current healthcare system for the betterment of doctors and patients.

DPC – Direct Primary Care - is a model of paying for primary care outside of insurance. Similar to a gym membership, the patient (or employer) pays a monthly fee covering basic care (wellness visits, diagnostics, prescriptions). Most DPC providers say they can address 80% of most common diagnoses. This direct pay system effectively cuts out insurance companies and third party payers—eliminating claim processing costs, authorizations, coding and even reducing staff/admin needs—thereby reducing practice overhead. Savings are passed on to the patients in the form of lower fees. Doctors in turn are freed up from bureaucratic red tape to focus more on patients (30 min. visits versus 7 min.)—resulting in happier docs and healthier patients.

In short DPC achieves IHI's Triple Aim, the holy grail of patient care: improved patient experience, improved health and lower per capital costs—not to mention compensating doctors on the value of the service they provide, not on the # of patients they treat or the # of tests they perform.

Makes sense right? – So why hasn’t this model taken off? The short answer is that transitioning to a DPC practice can be a lengthy process fraught with regulatory oversight, significant initial financial investment by the practice, and legal concerns (docs can’t simply abandon existing patients who choose not to participate). The bigger challenge is convincing employers...and YOU to jump on board. We've been trained for the last 50+ years to rely on insurance companies to navigate healthcare. The idea of paying directly for care can sound expensive and that concerns most patients and employers.

The truth is that you are likely already paying exorbitant monthly premiums for a healthcare plan that requires a high deductible with out-of-pocket costs. So even if your primary care doctor visit is covered (in part or full) under your current plan—it is not free! Trust me, you are paying for it. The difference is that there is no transparency…you have no idea how the bills for services rendered are tracked, coded and managed on the backend. DPC eliminates the clutter and 3rd party processes by allowing doctors and patients to communicate openly and direct. And for employers - a prevention/wellness DPC plan has proven successful in: lowering absenteeism, reducing ER visits, decreasing employee stress & improving morale, and saving employess/time going to/from doctor's office.

This doesn’t mean patients should abandon insurance altogether. In fact H.R. 3590 (The Affordable Care Act) recognizes DPC and allows DPC Medical Homes to “offer coverage in health insurance exchanges in combination with a wraparound insurance policy provided by a qualified health plan (QHP).” Further, a few forward facing insurance companies such as Cigna are including DPC into their policies for reimbursement. For many patients, this is a smart move—use DPC for the day-to-day care and prevention and buy a catastrophic policy to cover the big stuff (ER visits, surgeries, cancer). This approach reduces monthly premiums, delivers better care (preventative), and drives down overall out-of-pocket costs.

What about Medicare patients, how can they afford DPC? Recent legislative changes to Medicare are already tackling this issue. The April 2015 repeal of SGR—Sustainable Growth Rate system that compensated physicians on fee for service basis—has been replaced with MACR—Medicare & CHP Reauthorization Act—that favors fee for value payment structure and opens alternative ways (such as DPC) for primary care physicians to offer patient services and bill (Medicare) for them.

Bottom-line – fee for service healthcare managed by a 3rd party payer is a broken system that will evolve or go extinct. Patients and primary care physicians will be on the frontline of the healthcare value chain—working in tandem to deliver optimum outcomes. In this open market, direct-care system everybody wins—more patients will have access to better care, patients and docs will reduce costs, and more trained docs will choose primary care as their career choice.

Research & citations:; Centers for Medicare & Medicaid Services; Dr. Garrison Bliss, Qliance; Dave Chase – Advisory Board Member Olive Wyman Health Innovation Center; & Medical Economics

#health #tech #digital #directprimarycare #healthcare #medicare #healthtech #wellness #primarycarephysician #medical

16 views0 comments