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Written by Michael Tetreault, Editor of The DPC Journal and Garrison Bliss MD of Qliance and Chairman of the Direct Primary Care Coalition (DPCC) | DPC Journal Contributor
Additional contributions from prominent DPC industry leaders are also included courtesy of The DPC Journal.
DECEMBER 17, 2014 | 3:00 PM (EST) – The recent December 2014 annual report from the Office of the Insurance Commissioner (OIC) in Washington State has created a bit of a stir in the Direct Primary Care (DPC) community … It insinuated that DPC is losing ground in terms of patients and that our monthly fees have been climbing (presumably as we head toward concierge medicine pricing).
According to industry analysis and national data summaries to be released in early 2015 by The Direct Primary Care Journal (The DPC Journal), the independent trade journal and news reporting publication observing and reporting on the national scope of the DPC industry, 90% of the interviews, surveys and DPC physician polling indicates that these practices are doing better financially than over one year ago, whereas, only 10% said they were doing worse nationwide.
“Unfortunately that report has always been a bit problematic,” says Erika Bliss, MD, President and CEO of Qliance, a Seattle-based pioneer in the Direct Primary Care (DPC) practice model. “I’m not sure that all DPC practices around the state that have emerged since the law was passed in 2007 even know about the requirement to report numbers. Our number of individual subscribers [i.e. ‘pure DPC’] have gone way down this year, but our numbers of overall patients have gone way up, so the question is, does that mean DPC is not doing well in Washington, or is it adapting and growing [as the OIC Report alludes to being the likely outcome at the end of the article]? The bottom line is, the report has not turned out to be all that valuable and there were several attempts by various folks to have the legislature lift the requirement since it was initially put in place to make sure that there were no untoward effects on access or care in the state and that there weren’t a bunch of bad actors out there taking advantage of people. That hasn’t happened and isn’t likely to at this point, so the point of the report is sort of moot.”
“I believe one of the keys to the continuing growth of Direct Primary Care (DPC) is integrating it within the employer sponsored health plans,” says Mason Reiner, CEO of R-Health, “which remain the primary means for paying for healthcare for the majority of Americans. However, for DPC to be a viable option for employers, there needs to be a critical mass of physicians offering it as an option in the employer’s geographic area. That is why we have focused over the past year on expanding our panel of affiliated physicians offering DPC in the Philadelphia region to nearly 100 (and growing), including Family Physicians, Internal Medicine Physicians and Pediatricians. The strong geographic coverage we have in the region has been a critical factor for the employer groups we have added as clients.”
“There have been considerable reductions in the number of Paladina patients as they appear to be focusing on other regions of the United States and larger self-insured companies which are not included in the Washington State DPC definitions,” adds Dr. Garrison Bliss. “Likewise, Qliance which is the largest DPC organization nationally has moved their DPC culture to monthly fee agreements with a Medicaid managed care company (Coordinated Care), the Washington State Exchanges (Coordinated Care) and with large self-insured entities (Expedia and Comcast employees most recently).”
“The outlook for DPC is much brighter throughout the U.S. than what one report may conclude,” says Michael Tetreault, The DPC Journal’s Editor-In-Chief. “No industry is full of sunshine and roses all the time and every industry needs data to benchmark success. The mission of DPC is to reduce the healthcare expenses on the individual while improving the physician-patient care service relationship — and it’s working. Data coming forth from a wide variety of industry sources in the past several months validates that it works. WeCare Clinics, Iora Health, Qliance Medical Management, MDVIP, and OneMedical have all reported reductions for total healthcare costs for their patients of 15% or more versus population norms*. However, more [DPC] doctors need to get out in front of their local employers, media and patients and talk about their own DPC data in relevant ways in the months ahead.”
Forbes reported earlier in 2014 that Most of these programs are only a few years old; there is reason to expect that results will improve as providers have a chance to deepen patient relationships and see the cumulative benefit of preventive work [in the DPC marketplace] that they have done in the past.
“There are numerous small DPC Clinics employing between 2 and 3 staff members across the country,” said Tetreault. “It is no secret that a lot of these small model operators tell us that they struggle to acquire more patients. But when we dig a little deeper and interview them one-on-one, you find that it is not because of the lack of interest in their transparent pricing or value they bring to each patient. Their slow growth is typically due to lack of proper business planning, their value proposition to the local community and undervaluing their time.”
“It’s notable that growth in the DPC industry according to physician interviews across the U.S. throughout the past 12-24-months is largely supported by consumers motivated by price and transparency,” says Catherine Sykes, Publisher and Managing Director of The DPC Journal. “We also find that most DPC patients have [and pay for] insurance and they want to use it. The questions consumers have most when approached with the value proposition of DPC is how does it work with my insurance? and how much does this cost? It is important to communicate that DPC is not insurance. If a doctors program is not properly paired with high-deductible health plan policy or a wrap-around insurance product of some kind, those low price points [and monthly premiums] compete with a lot of other expenses — which we [The DPC Journal] have found represents 14% of patients throughout the country who use DPC earn less than $49,000 per year [combined annual HH income].”
DPC offers an opportunity for employers, including the self insured, to provide their employees a superior health benefit with advanced primary care and prevention services at a low fixed cost [often $40 – $80 per member per month , age rated]. When paired with a wrap – around insurance policy, often a high deductible plan, employers can also offer what amounts to first dollar coverage in a plan for up to 20% less than the cost of a regular PPO – style health plan.
Qliance has also been actively encouraging their low income patients to join Coordinated Care which is the lowest premium option in the Washington State Exchanges and which has a monthly fee agreement with Qliance.
“Thus, the >400% growth of Qliance during 2014 was invisible to the OIC,” notes Garrison.
“We also give the appearance of having raised our monthly rates despite the shifting of substantial numbers of our patients to Medicaid and the exchanges,” adds Garrison. “This appearance of higher fees is more related to an older patient population staying in our [Qliance] standard DPC offering while younger patients moved to the exchanges.”
“I think it [the OIC Report from Washington State] is a very narrow look at what is going on nationally,” says Dr. Brian Forrest, a DPC Physician in Apex, NC. “I know that this is not consistent with what is going on in the Southeast. We [Access Healthcare] are adding patients in our network at a very steady pace and enrollments are increasing dramatically post ACA. Patients who enrolled in bronze plans have particularly increased in interest since their deductibles are in many case higher than other typical commercial plans they may have had through employers in the past. We are seeing more new patient enrollment interest than at any other time in the past. While I think it is true that DPC fees have risen over the last year, this is in response to increased demand and to mainstreaming of the model. Our network average is still about $44 per month with the lowest being $25 and the highest being $59.”
According to The DPC Journal analysis and national data summaries to be released in January 2015, on average, 68% of fees inside most DPC practices cost between $25 to $85 a month. Approximately 45% of DPC Medical Offices average between $51-$85 per month. (Source: DPC Journal Industry Summary to be released in January 2015)
“Today, everyone has to have health insurance and for all of us, it’s now the law of the land under Affordable Care Act (ACA). The $100 or less price point is very important to DPC moving forward, a line in the sand. Anything more than that [$100/mo.] you’re probably not going to get federal subsidies, managed care operations and other people that would provide wrap-around insurance to pay much more than that, particularly because they’re probably not paying more than $40 for primary care right now.” says Jay Keese, DPCC (Direct Primary Care Coalition) lobbyist. “As we move forward into the employer and individual responsibility of the ACA kicking in, people will have to have insurance. You can’t simply say ‘I don’t need to be insured because I have a DPC doctor.’ That is not a viable policy option under the ACA moving forward. What is a viable option is to have a low-cost, DPC plan [i.e. less than $100/mo] with a high-deductible insurance or a wrap around plan that could make that level of insurance fit under confines of Section 1301 A3 under the ACA a viable product. This could work with employers, Medicaid, Medicare Advantage and private insurance. I think that’s where the model makes a lot of sense.”
“I was very surprised to read this report on the decline of DPC,” said Josh Umbehr, MD, Founder of AtlasMD, a DPC practice based in Wichita, KS. “It is contrary to everything that I’ve seen over the last year. We’ve helped nearly 40 clinics launch in 2014 with more slated to enter DPC next year. We’ve heard from employers and insurance carriers in various states like Kansas and Pennsylvania. They are interested in how DPC can help them save money and lower premiums. Our own clinic [AtlasMD in Wichita, KS] has grown each month since we opened 4 years ago. We’ll may even have to have a waiting list for new patients soon or employ more physicians. The AAFP is openly supporting the direct care model and their DPC programs are very well received. I think 2015 is the year that DPC will move ever closer to becoming the mainstream model for primary care physicians because its better for the patients, physicians, employers, insurance companies and the public.”
“This is expected,” says Blaine W. Lindsey, JD, MPH, CEO of GetHealthy, Inc., a technology operator in the DPC industry providing an evidence-based health and wellness platform that develops unique solutions and services to the DPC marketplace. “Coming from a technology perspective, this is the classic “pioneers” v. “settlers” curve. Because this is such an innovative model, and because of the high level of disruption that DPC entails, we would expect the first practices out there to have the hardest time as they get a feel for the new landscape and encounter the first, big problems. What we are seeing now is that our customers who are the second and third waves of DPC practices are becoming more comfortable with the model and also more savvy partnering with employers to secure large groups of patients with longer contracts. This makes them less susceptible to consumer whims. Finally, I do not know the politics of the situation, but you always have to understand the motives of the government agency putting these reports out. There are a lot of stakeholders who are very comfortable with the status quo. And those people likely have a lot more money and influence than individual DPC doctors.”
So let me [Dr. Garrison Bliss] mention a few genuine trends in DPC worth noting:
- There is a shift of some DPC patients into the exchanges which may remove them from DPC rolls, at least temporarily. This will be primary amongst the least wealthy of our patients.
- There is a very strong move of DPC into markets that were off limits to us until the ACA was passed. There was an important line in the ACA which allowed DPC practices to partner with insurance entities to produce higher functioning lower cost offerings in the exchanges. These are in development in other parts of the country and will likely be accelerated now that the AAFP (American Academy of Family Physicians) has decided to get behind this movement and has plans for an extensive rollout of DPC training for AAFP members.
- There is another movement that will further accelerate DPC as we enter the Medicare Advantage Plan space. This undertaking has begun with a pilot arrangement between IORA Health and Humana with clinics in Seattle (WA), Phoenix (AZ) and Glendale (AZ).
- True wraparound health insurance policies that cover everything BUT primary care are in development. These will fix one of the biggest brakes on the growth of DPC, the need for insured patients to buy their primary care twice, once from their insurance and once from their primary care physician.
- DPC has finally gotten mature enough to produce useful and believable data to support our claims that we increase quality and patient satisfaction while reducing the overall healthcare spend. As the magnitude of that effect is understood by employers, insurers, unions and governments – expect an increase in the monthly fees paid for DPC. This is a GOOD thing because it will make these practices and this movement stable and viable in the long-term. It will also bring graduating medical students into primary care and graduating primary care residents into DPC.
“There were a lot of non-reporting practices and those that did report didn’t report some very important parameters, like insurance status, type of insurance, etc.,” notes DPC physician Dr. Robert Nelson, of MyDocPPS and Editor of The Sovereign Patient. “It is hard to establish cause and effect for the drop off of enrollees. Additionally, the authors are still pushing the “coverage equates to care” narrative. They allude to this when they allege that deductible burdens or not having full prescription coverage are equivalent to being under-insured … as if filing a claim is the only legitimate method for paying for health care by using a third-party’s money. They make it sound as if DPC was just shoring-up the “safety net” until which time the ACA could fill the gaps. This logic betrays a fundamental misunderstanding of the economics of DPC compared to the third party system. They approach the narrative as if DPC is just another layer of costs on top of the essential layer of insurance. Yes, a case could be made that it is the law of the land, but again, those faced with a penalty of not insuring is a very small slice of the population (< 1%). Therefore, I don’t think the ACA is entirely, of even mostly, what is driving the Washington numbers in the OIC report.”
“If you are thinking about staying in your fee-for-service practice because DPC is shrinking, I suggest that you rethink that decision,” concludes Garrison. “This movement is gathering steam and you may not want to wait until everyone else makes the transition. All you have to lose is that massive headache from fee-for-service insurance billing with its inevitable corruption and destruction of the American health care system.”
For those of you interested in reading the Washington OIC report:
Garrison Bliss, MD
Direct Primary Care Coalition