This ACP position paper assesses the effect of DPCPs on access, cost, quality and other considerations; discusses ethical principles that should apply to all practice types; and proposes policies to mitigate any adverse effect on underserved patients.

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“This paper neither endorses nor opposes concierge and other DPCPs, rather, it offers ACP’s assessment of the evidence on the policy and patient care implications of DPCPs,” Dr. Riley concluded, “in order to inform discussion among policymakers, researchers, the public, and physicians themselves about the potential implications of DPCPs.”

Position Papers | 10 November 2015
Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians (FREE ONLINE FIRST)

Three basic questions can be asked of DPCPs to help distinguish among them:

  1. 1Does the practice require patients to pay out-of-pocket for some or all services rendered?
  2. Does the practice charge a retainer fee to some or all patients, and if so, how much is the fee and what services are included in it?
  3. Does the practice have a smaller and more limited patient panel than is typical of traditional practices in the same specialty field and community?
    Robert Doherty, BA,*, for the Medical Practice and Quality Committee of the American College of Physicians

Ann Intern Med. Published online 10 November 2015 doi:10.7326/M15-0366

CLICK HERE TO READ MORE about The 2015 Annual Report ... *Source: The DPC Journal, July 2015
CLICK HERE TO READ MORE about The 2015 Annual Report … *Source: The DPC Journal, July 2015

10 November 2015 – As physicians seek innovative practice models, one that is gaining ground is for practices to contract with patients to pay directly for some or all services—often called cash-only, retainer, boutique, concierge, or direct primary care or specialty care practices.Such descriptions do not reflect the variability found in practices. For the purposes of this paper, the American College of Physicians (ACP) defines a direct patient contracting practice (DPCP) as any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care. This definition encompasses the practice types previously described.The move to DPCPs is based on the premise that access and quality of care will be improved without third-party payers imposing themselves between the patient and the physician. Yet concerns have been raised that DPCPs may cause access issues for patients that cannot afford to pay directly for care.This ACP position paper, initiated and written by its Medical Practice and Quality Committee and approved by the Board of Regents on 25 July 2015, assesses the impact of DPCPs on access, cost, and quality; discusses principles from the ACP Ethics Manual, Sixth Edition, that should apply to all practice types; and makes recommendations to mitigate any adverse effect on underserved patients.

As physicians seek innovative practice models, one that is gaining ground is for practices to contract directly with patients to pay directly for some or all services—often called cash-only, retainer, boutique, concierge, or direct primary care or specialty care practices.

Such descriptions do not reflect the variability found in practices. For the purposes of this paper, the American College of Physicians (the College, or ACP) defines a direct patient contracting practice (DPCP) as any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care. This definition encompasses the practice types previously described.

This ACP position paper assesses the effect of DPCPs on access, cost, quality and other considerations; discusses ethical principles that should apply to all practice types; and proposes policies to mitigate any adverse effect on underserved patients.

Ethics and Professionalism

READ MORE ... The Four Modern-Day Distinctions of Direct Primary Care In America, (C) 2014-2015. The Direct Primary Care Journal
READ MORE … The Four Modern-Day Distinctions of Direct Primary Care In America, (C) 2015. The Direct Primary Care Journal

The ethics policies of ACP, as embodied in the College’s Ethics Manual, 6th Edition (12), state that physicians have both individual and collective responsibilities to care for all. Such ethical considerations must guide physicians in considering the types of practices they choose to participate in and what they must do to ensure their practices provide accessible care to patients in a nondiscriminatory manner. Practices that, by design, exclude certain categories of patients should be understood to create a greater potential of being discriminatory against underserved populations and require special attention by physicians to the ethical considerations involved. Practices that downsize their patient panels also must be aware of ethical and legal considerations relating to patient abandonment.

The College also believes that physicians in all types of practices should strive to take care of patients enrolled in Medicaid. Medicaid is a crucial part of the safety net for poor persons and, under the ACA, is the principal source of coverage for patients with incomes up to 138% of the federal poverty level in states that have agreed to accept federal dollars to expand Medicaid.

The ACP Ethics Manual, Sixth Edition includes various important guidelines related to patient care and our complex and changing health care system that are relevant to different practice models:

Concern about the impact of the changing practice environment on physicians and insured patients should not distract physicians or society from attending to the unmet needs of persons who lack insurance or access to care.

Physicians have an obligation to promote their patients’ welfare in an increasingly complex health care system. This entails forthrightly helping patients to understand clinical recommendations and make informed choices among all appropriate care options. It includes management of the conflicts of interest and multiple commitments that arise in any practice environment, especially in an era of cost concerns. It also includes stewardship of finite health care resources so that as many health care needs as possible can be met, whether in the physician’s office, in the hospital or long-term care facility, or at home.

The patient–physician relationship and the principles that govern it should be central to the delivery of care. These principles include beneficence, honesty, confidentiality, privacy, and advocacy when patient interests may be endangered by arbitrary, unjust, or inadequately individualized programs or procedures. Health care, however, does take place in a broader context beyond the patient–physician relationship. A patient’s preferences or interests may conflict with the interests or values of the physician, an institution, a payer, other members of an insurance plan who have equal claim to the same health care resources, or society.

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians’ considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches. When patients ask, they should be informed of the rationale that underlies the physician’s recommendation (12).

Such ethical considerations must guide physicians in considering the types of practices they choose to participate in and what they must do to ensure their practices provide accessible and ethical care to patients in a nondiscriminatory manner. Practices that, by design, exclude certain categories of patients should be understood to create a greater potential of being discriminatory against underserved populations and requires special attention by physicians to the ethical considerations involved.

CONTINUE READING FULL POSITION PAPER, Methods and Characteristics and More …

SOURCE: http://annals.org/article.aspx?articleid=2468810

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