Direct Primary Care Vs Concierge Medicine: Employers Should Know the Difference

Posted by Samir Qamar on 9/15/15 11:00 AM
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Direct Primary Care (DPC) and concierge medicine are rapidly growing models of primary care. Though the terms are used interchangeably, both are not the same. Such liberal use of terms, many times by even those within the industry, confuses those who are attempting to understand how these primary care models operate. As former concierge physician, and subsequent founder of one of the nation’s largest Direct Primary Care companies, I have attempted to differentiate the two based on extensive personal knowledge and experience.

First, concierge medicine. Born in the mid 1990’s, this practice design was first created by wealthy individuals who were willing to “bypass” the woes of the current fee-for-service system by paying a subscription to access select primary care physicians. This access consists of same-day appointments, round-the-clock cell phone coverage, email and telemedicine service, and sometimes, as in my previous practice, house calls. Although some high-end practices charge as much as $30,000 a month, most charge an average monthly fee of $300. In return, to allow such unrestricted access, physicians limit their patient panels to several hundred patients at most, a significant drop from the typical 2,500-plus panel size most doctors are used to. Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “access fee” is only for “non-covered” services. This results in two subscriptions paid by patients – the concierge medicine fee, and the insurance premium.

Direct Primary Care started in the mid 2000’s, and was created as an insurance-free model to serve a new patient population – the uninsured. In DPC, patients, and now their employers, are charged a monthly fee, but the fee is usually below $100 per month and there is typically no insurance involvement for primary care services. Employers and their workforce pay physician entities directly (hence, direct primary care), and because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears. Patient panels can be as low as 1,000 patients per doctor, and there is typically no physician cell phone access or house call service. Similar to higher-priced concierge practices, DPC practices also allow for longer patient visits and telemedicine. The most important characteristic of DPC practices, however, is that insurance claims are not filed for primary care visits.

Direct Primary Care’s definition, therefore, is any primary care practice model that is directly reimbursed by the employee or the employer for both access and primary medical care, and which does not accept or bill third party payers.

Confusion arises from similarities that exist in both models, such as decreased patient panels, monthly subscriptions, and longer visits. There is added confusion when a DPC physician offers house calls or email access, typical of concierge practices. Confusion is maximized when a physician is by definition practicing direct primary care, yet calls the practice a “concierge practice.” Similarly, a concierge practice may decide to abstain from participating in third party payer systems, and thus would also be a DPC practice.

The distinction is important because Direct Primary Care is explicitly mentioned in the Affordable Care Act, while concierge medicine is not. Several state laws have also recognized Direct Primary Care as medical practice models, and non-insurance entities. Many medical entities that were once concierge practices are now labeling themselves as DPC practices – a label that is sometimes inaccurate.

In summary, not all Direct Primary Care practices are concierge practices, and not all concierge practices are Direct Primary Care practices. The main question an employer should ask is whether insurance claims are being filed for routine primary care – if the answer is no, the setup is Direct Primary Care, and likely advantageous to the employees and employers. See "Three Reasons Why Employers Should Care about Direct Primary Care" for details.


Topics: Direct Primary Care, Brokers, Employee Benefits, Health Insurance, Employers, Healthcare, Healthcare Consumers