Direct Primary Care

“Concierge” medical practices have existed for many years in various forms. Recently, due to changing healthcare models nationally, the direct primary care (DPC) practice is becoming more prevalent. Often referred to as “concierge medicine for the masses”, the DPC model typically looks different than traditional concierge practices, but shares some common traits with the more traditional concierge model. The term “concierge” medicine typically implies a “VIP” level of service and access, often including perks beyond medicalservices for a membership fee that can range up to several hundred dollars per month.

In contrast, DPC practices typically charge a much lower monthly fee and include basic primary care medical services and physician access in that fee. In both instances, the concierge or DPC practice charges the patient directly. Specific to most DPC practices, insurance companies are not billed for any services; rather, the relationship is directly between the provider and the patient. This factor is important for proponents of the DPC model because they contend this allows for a more meaningful physician-patient relationship and alleviates reimbursement issues.

The Patient Protection and Affordable Care Act1 (ACA) contains a specific provision related to DPC providers that is likely to further increase the prevalence of such practices. Specifically, insurers may provide coverage to patients through a “wraparound” relationship with a DPC that meets requirements established by the Secretary of the Department of Health and Human Services. Primary care is provided to patients through their relationship with a DPC and the insurer “wraps around” non-primary care services such as hospital care. The requirements for a DPC as contemplated by the ACA are not yet issued but discussion of this practice type is increasing and many companies are beginning to implement DPC models on a national level.

On a state level, DPC practices should be careful to consider potential implications regarding insurance regulation. Some states have specifically addressed DPC practices through legislation (sometimes also referred to as “retainer” practices) and have explicitly excluded DPC practices from, or included them in, insurance regulation. To date, Nevada has not addressed DPC practices in statute and regulation, but overarching laws regarding health insurance in Nevada can provide some guidance. DPC practices need to be mindful of how they structure their relationship with patients so as not to run afoul of insurance or other business laws. Specifically, examining if a DPC practice will assume risk or the type of that risk and carefully crafting the agreement between the practice and patients will help a DPC practice get off to a good start. A health care attorney familiar with the DPC practice model can help providers navigate the state and Federal legal maze. Our attorneys at Nutile Pitz & Associates would be happy to help you navigate the complex issues facing this latest primary care model.