LEGAL: Concierge Medicine v. Direct Primary Care: Legal Issues

By Attorney and CMT Guest Contributor, Michael H. Cohen

JULY 14, 2013 – Concierge medicine and direct primary care both raise legal issues, though they present different models in terms of how they handle insurance.

Concierge medicine and direct primary care often get confused, because both have a subscription fee.

However, in concierge medicine, patients pay for luxury medical services and access, where direct primary care (DPC) is a patient-provider relationship, in which the patient purchases primary care directly from the physician, without a physician payer.

Concierge medicine can raise legal issues from anti-kickback considerations to questions about whether a person is engaged in the business of insurance.

There are several models of direct primary care—for example:

  • Monthly fee only: covers all visits
  • Monthly fee: visits plus labs
  • Monthly fee plus a per-visit fee

Direct primary care usually does not cover specialists, imaging, institutional or facility care, or pharmacy.

Both concierge medicine and direct primary care can implicate Stark, federal anti-kickback law, and federal and state self-referral, anti-kickback, and fee-splitting laws.

Health care reform efforts actually contemplate the provision of direct primary care.   Specifically, the Affordable Care Act, Section 1301 (42 USC 18021) defines “qualified direct primary care medical home plans.”  Criteria are to be promulgated by the Secretary of Health & Human Services, so at this moment we are awaiting further regulation.

Michael H. Cohen is a thought leader in health care law, pioneering legal strategies and solutions for clients in traditional and emerging healthcare markets. He represents a broad range of healthcare …



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