Since launching in early 2018, the DPC Alliance has quickly grown to over 300 members. In this process, we have gathered some valuable information about DPC physicians (or soon to be) and practices nationwide. While this does not represent all DPC practices (estimated at over 900), we believe this is the single largest, broad survey of DPC physicians & practices to date. (Data as of Sep, 11, 2018)
Average age = 43
Average year of medical school graduation = 2004
MD = 79.4%
DO = 20.6%
Family Medicine = 71.9%
Family Medicine w/ OB = 5.2%
Internal Medicine = 11.4%
Med/Peds = 4.2%
Pediatrics = 2.3%
STAGE OF DPC PRACTICE
Active (open) DPC practice = 197
Planning on DPC practice in 12 months = 70
Considering DPC practice = 37
Monthly fee (average per patient)
$50-75/mo = 65.5%
$76-100/mo = 14.6%
$49 or less/mo = 10.8%
$101-150/mo = 5.7%
Provides some charity care = 85%
Average age of practice = 2 years
States of practice = 45
Recently, the Direct Primary Care (DPC) movement has attracted a lot of attention in the op-ed pages of reputable publications. Given our swelling ranks, I guess the attention was inevitable. A few of these opinion pieces been have filled with misunderstandings about the DPC model, but Timothy Hoff, Ph.D. healthy policy professor at Northeastern University, recently took his critique of DPC model and physicians to another level in STAT News.
As always, DPC physicians are happy to educate people about primary care and the DPC model, so I will respond to Timothy’s concerns directly and point-by-point.
“Some view it (DPC) as a panacea, others as snake oil. I’m not sure what it is...”
I don’t know a single DPC physician who believes that the DPC model is a “panacea” for all of the problems in the health care system; nor does anybody believe DPC is a replacement for health insurance or public assistance.
“Snake oil”? I would expect somebody with a Ph.D. working for an academic institution to use less empty and inflammatory rhetoric. Are you suggesting that DPC practices are perpetrating actual fraud? Or are you just reporting other people believe that?
Timothy, you definitely proved you don’t know what what DPC is repeatedly in this ill-informed opinion. Perhaps you should’ve just stopped there, instead of baselessly attacking it?
“direct primary care is a model for delivering primary care, and only primary care.”
And only primary care? Yes, it is right there in the name...Direct Primary Care.
You then state that primary care cannot care for “more extensive management of a chronic disease”. Sir, you have no concept of what primary care physicians do-- DPC model or otherwise-- around this nation on a daily basis. We care for nearly every common chronic disease you could name (and many you couldn't); as well as provide care for a patient's’ symptoms of uncertain origin, acute needs, and psychosocial problems-- often all at the same visit. I realize you didn’t go to medical school, so if you need a comprehensive list of problems and diseases I diagnosis and manage, I’m happy to provide it for your review.
Sadly, your perspective about the limited role of primary care is all too common. I suppose this view has some validity as the American health care system that has undermined our value for many decades. (If you aren’t familiar with why, I'd suggest you read up on the AMA RUC) This low valuation slowly warped the nature of primary care itself. Too often, rushed primary care physicians are forced in to being a referalist, rather than an actual clinician.
The DPC model has many benefits, but most importantly is that it provides an opportunity and environment for PCPs to provide a higher level of care than is possible with 10 minute visits and juggling a panel of 2000 or more patients.
“the physician or practice will charge the patient extra fees to cover those services (chronic disease management).”
I am not sure where you got such information (I know a few DPC doctors in Boston area and you certainly didn't chat with them), but DPC fees nearly universally cover management of chronic disease without “extra fees”.
At least you recognize-- sort of-- the problems primary care physicians face with “burn out” (I prefer the term moral injury), administrative hassles, and lack of time with their patients; leading to poor doctor-patient relationships. And, you admit that DPC might be a better in those respects; as well as appealing to patients.
But, you must believe improving those issues is not significant enough to be a net positive. I guess it’s easy to downplay this since they don’t affect you personally. Although, I would note that unhappy doctors often provide inferior care to patients.
Besides, would you like your personal doctor to be miserable? As long as they are in your insurance network, maybe that is an acceptable trade-off to you?
“From a numbers standpoint, direct primary care is self-limiting in how many patients it can serve.”
I didn’t realize primary care physicians in traditional models could take on unlimited numbers of patients. What is the first question many patients ask upon calling a new doctor's office? "Are you taking new patients?" They ask because many PCPs in traditional models cannot and do not take on new patients.
The DPC model is not defined by an exact number of patients per physician, but indeed, most will carry a smaller panel size than a traditional, modern PCP.
If you think caring for fewer patients is inherently a bad or unethical decision, can you please provide us with an exact minimum number of patients (e.g. panel of 2387 or 23 visits/day) so that we can be certain to be in professional good standing with your standard?
Besides, are more patients per PCP better? Would you like your personal PCP or specialist of choice to be responsible for 5,000 other people’s care? or 10,000? Or are those volumes just okay if it’s other people's’ doctor?
“They likely include a disproportionately high percentage of healthier, “worried well” individuals.”
This is an enormous amount of speculation for a person in an academic position. You provide zero data to support such a presumption. But, let's consider this from an economic incentive perspective:
The number of factors that lead a patient to choose their PCP is numerous and not exclusive to the DPC model. Ultimately, most patients will voluntarily choose their PCP based on personal preferences. Anecdotally, patients choose DPC practices (versus other options for primary care) for a variety of reasons, but namely for reduced out-of-pocket costs, and/or improved access and experience.
Given the flat monthly fee for services, the value proposition for chronically ill patients-- needing frequent visits and savings on ancillary services (labs, meds, etc.)-- is obviously higher. Given this, the bias for patients seeking care in the DPC model would lean towards sicker patients; not towards healthy people who don’t expect to have great medical needs. Most DPC docs I know report high numbers of patients with chronic illness and unresolved problems. There is some practice level data on this and larger efforts to study demographics and health status of DPC patients are underway.
“direct primary care physician or practice functions as an insurer.”
No, they do not.
DPC practices, functionally and legally (based on 25 state laws), are not “insurance”. The DPC practice agrees to provide a certain set of services (namely the physicians time) to a patient for a fixed monthly fee. While some DPC practices will include services such as EKGs, procedures, less expensive labs, and point-of-care tests, for no additional fees, these costs account for a tiny fraction (< 1%) of a practice’s operating expenses. I doubt you know this Timothy, but band-aids don’t actually cost $50 a piece as is often found in hospital charges. So, appropriately structured, there is no real financial risks to a DPC practice.
If you are worried about practices functioning as insurance, I would take a look at those participating in Accountable Care Organizations (ACO) which are assuming actual financial risks based on total patient health costs.
“The direct primary care model can get expensive for patients, making it a model that caters to the affluent and potentially worsens inequities.”
You have a Ph.D. in health policy, so I’m sure you realize the per capita spending on health care in America is now over $10,000/year. Most of those dollars are sunk in to insurance premiums (often hidden by layers associated with employer-based coverage and taxes), but an increasing number of Americans have high deductibles and "out-of-pocket" (after the premiums) expenses.
In 2017, the average individual plan's deductible was $4,358, and for a family plan it was $7,983. Some large employers are still maintaining low deductible plans (at the expense of lower paychecks for employees) but even those plans are increasingly rare.
If you are keeping tally, many American families now pay $12,000-18,000 (individuals $6,000-12,000) of their own money in a given year prior to their insurance plan picking up a dime of the tab; and they still usually owe 20% of costs after that to some astronomical "out-of-pocket maximum".
But, you may say, "yeah, but at least insurance protects a person from financial ruin." You'd be wrong there too. Studies have shown that 70% of bankruptcies related to medical care debt occur in people with insurance! And many more insured people worry about being able to pay their medical bills.
In that context, a membership fee of $50-100/mo ($600-1200/yr) for comprehensive, high quality primary care services doesn’t seem so expensive. Many patients who choose DPC are exactly the same people suffering financially under the status quo.
“patients’ paying $1,500 a year in retainer fees”
Perhaps you didn’t have time to research much, but the vast majority of DPC practices are much less expensive than $1500/year. The DPC Alliance has over 200 active practices and over 90% of those practice have fees under $100/mo ($1200/year); two-thirds charge $50-75/mo, but many are less than per person when considering child and family discounts.
“direct primary care model places greater responsibility on patients to know their medical insurance inside and out. They must also become the liaison between their direct primary care physician or practice and their insurance plans….direct primary care shifts a lot of the insurance paperwork and administrative burden onto the patient.”
First, do you have any idea of how much paperwork is traditionally required of patients when they visit a doctor’s office using insurance? Have you ever been? If not, patients are typically flooded with forms upon arrival; every time they go. Subsequent, patients often receive confusing bills and explanation of benefits months after care that even doctors have trouble deciphering. The usual system is hardly devoid of paperwork or administrative burdens for patients!
With respect to DPC, in most cases, a patient chooses DPC in lieu of their options for “in network” primary care services. Patients do not submit DPC fees for reimbursement from an insurance plan. Simply, there is no extra paperwork required if patient opts for DPC.
On the contrary, a DPC clinic is likely the only place that provides patients upfront, easy-to-understand pricing and payment on a wide array of medical services. If a patient does require care outside of the the DPC practice, we can now serve as a stronger advocate for our patients because we are afforded such time. If a patient prefers, they can opt for a network speciality provider when needed as usual-- although many patients will find those things (radiology, medications, etc.) more affordable with a direct pay option. Either way, a DPC physician can be helpful in navigating those options.
“In the very best case, direct primary care could make some doctors and patients feel more connected to each other, and might even help produce a better care experience. But given significant problems with the model, I don’t expect to see direct primary care taking on a significant number of patients across the country any time soon.”
Again, how can you downplay the significance of better relationships and patient experience? If that doesn’t matter, what does?
“There’s a bit of smoke and mirrors here, as direct primary care tries to convince patients that the rest of the health care system, like hospitals and specialty physicians, doesn’t really exist.”
Huh? I'm not sure if you are being literal here, but...
Compared to our small, quaint clinics, most hospital systems have giant, multimillion facilities, so it’s pretty hard to hide their existence.
“And as long as many patients have to deal with the rest of that system on a consistent basis as they acquire more serious conditions and have constant needs throughout their lives for complex diagnostic and treatment care, direct primary care will be of limited help.”
Timothy, I have seen lots of policy wonks view primary care physicians as less important than their speciality peers, but your disdain is beyond the pale.
Despite your skepticism, the DPC movement is growing in every corner of this country; now over 900 DPC practices, with steady growth year to year. You may not understand why anyone would choose an independent DPC physician over an insurance-managed provider, but frankly, that doesn't matter to our patients. We are showing them the real benefit of high quality, transparent primary care every day.
W. Ryan Neuhofel, DO, MPH
President, DPC Allliance
Dear Direct Primary Care Alliance Member,
It has been a busy eight months! The DPCA Board of Directors thanks you for your support of the DPC Alliance. We now have more than 300 members. We have collaboratively navigated a number of health policy challenges this year including CMMI’s inquiry about a direct primary care pilot for Medicare and the continued work on utilization of HSAs for medical-membership fees. Our members have led the charge at DPC conferences and online through Facebook groups, news articles and on major television networks. We had a tremendous turnout at the AAFP’s DPC Summit where we sponsored happy hour and managed to corral around 60 physician members for our first, formal (but not so formal), group picture! Thank you for for sharing our vision of a physician-led physician organization.
Elections are around the corner! We are writing to inform you of upcoming elections including open positions, the process for nominations and elections and the timeline for participation.
Who is being elected?
There are three openings this fall in our Advisory Committee. We will also be choosing our President-Elect.
What is an Advisory Committee Member?
The DPCA has nine Advisory Committee Members. Advisory Committee Members make up the Board of Directors along with the Executive Committee. The Advisory Committee Members serve three year terms, advise and work with the Executive Committee on all major Alliance decisions and head up sub groups within the alliance (such as the Membership Committee, Social Media Committee, etc..) Advisory Committee Members may be re-elected indefinitely and have no limits on number of terms served. At minimum, Advisory Committee Members must participate in a 2-3 hour quarterly call with the entire Board of Directors.
Who can run for Advisory Committee Member?
Any DPCA member in good standing, in active DPC practice may be nominated for the Advisory Committee.
Who can nominate and vote for an Advisory Committee Member?
Any DPCA member in good standing, in active DPC practice may nominate and participate in the election process. Medical students, resident physicians and physicians not in active DPC practice may neither nominate nor vote in elections. Self-nomination is permitted.
Who are the current Advisory Committee Members?
At the time of incorporation, nine advisory committee members were selected. Three members are serving 3 year terms, three members are serving 2 year terms and three members are serving a one year term. This was done upon establishing the Alliance to create long-term continuity among the Advisory Board by staggering elections.
Present Advisory Committee members include: Drs. Jeffrey Gold, Doug Farrago, Michael Caimpi, Lisa Davidson, Jennifer Harader, Vance Lassey, Kylie Vannaman, Josh Umbehr and Kimberly Legg-Corba.
Drs. Vannaman, Umbher and Legg-Corba are presently serving one year terms and their seats are up for nomination this election cycle.
What is the timeline for this process?
The timeline for nominations and elections is outlined below.
How is the President-Elect chosen?
The President-Elect candidates shall be nominated by the Board of Directors and chosen by majority vote of the DPCA Voting membership.
The timing and electoral process is outlined below. We encourage all voting members to attend to these dates and actively participate in the nomination and election process.
Open for Nominations. Nominations may be sent to email@example.com after this date. Nominees will be contacted on a rolling-basis to confirm their interest in becoming an Advisory Committee Member. September 20th: Nominations are closed September 23rd: Nominees announced. September 23-Oct 1: Nominees will provide DPCA Vice President with a document of interest (1 paragraph) and qualifications (1 paragraph) via firstname.lastname@example.org. These will be available to members on the DPCA website October 1- October 20th along with a 1-3 minute video of each candidate discussing their interest in the open position. October 18th-19th: Elections via anonymized online poll. Voting members will receive an emailed link to access voting. More information on these details will be available on the Alliance website soon.
New Advisory Committee Members will assume their duties November 1, 2018. The President-Elect will join the Board of Directors November 1, 2018 and assume President duties January 1, 2020 - January 1, 2022.
Thank you for your commitment to direct primary care, to the DPCA and to physician-drive healthcare solutions. We look forward to your involvement and continued growth of the DPCA!
Julie K. Gunther, MD, VP
Douglas Farrago, MD
DPCA Advisory Committee, Elections Sub-Committee
DPCA & The Executive Leadership of the DPCA
In reality, DPC is already “scaling”, or rather replicating, all over the nation-- now nearing 900 practices in just about every type of community imaginable. There are now a handful of DPC conferences every year that continue to grow in attendees. The DPC Alliance launched just a few months ago and already has 300 members.
So, despite Dr. Adashi, et. al, skepticism, more and more physicians and patients are showing that DPC is the solution to many of their problems.
The Direct Primary Care (DPC) Alliance serves the DPC community through education and advocacy. Our membership is made up of over 270 primary care physicians and physicians-in-training from across the nation. The majority of them are already practicing in a DPC model; of those, nearly all (over 95%) are owners or part-owners of a small, community-based DPC practice.
The DPC model has proven a practical and functional option for a wide variety of primary care physicians and their patients. However, we do recognize some hurdles for patients wishing to participate in a DPC practice, including the IRS treatment of DPC fees (periodic fees for bundled primary care services) for persons holding a Health Savings Accounts (HSA). Current tax laws have created confusion on this matter and we strongly support legislation that explicitly allows a patient to use an HSA to pay DPC fees.
Our members desire a simple legislative solution that doesn’t introduce unnecessary regulations, confusion, or unduly restrict the scope of primary care or value within a DPC arrangement. The complex nature of the tax code makes this fix less than a straightforward process. The original version of this legislative fix was the Primary Care Enhancement Act (HR 365) which had received broad bipartisan support for a number of years.
The language of the Primary Care Enhancement Act has undergone a number of revisions and is now included in HR 6199 (Section 3) which is pending for a vote in the full House of Representatives. The bill also contains many other HSA reforms. Although our membership is not in full agreement on every aspect of this bill, the Alliance supports passage of HR 6199 through the House.
To strengthen the DPC aspect of this bill, we would suggest Congress consider a few changes and clarifications, including:
State that DPC fees are a "qualified medical expense" under IRC 213(d), and not under a more vague categorization of “service arrangement” under IRC 223(d).
Make it clear that a patient may use an HSA to purchase prescription medications on a fee basis (outside of DPC bundled fees) from a DPC practice.
The bill places a $150 cap of DPC fees under IRC 223(d). We do not believe that price should be a defining feature or legal definition of a DPC practice and suggest removing a price cap altogether. But, if such a cap is required for budgetary reasons, this limit should be an expense cap (maximum deduction) under 213(d).
There will not be a silver bullet to fix all of the problems in the American healthcare system, but maximizing patient-centered options such as HSAs and Direct Primary Care is a big step in the right direction. This bill-- hopefully with suggested changes --will help ensure Americans access to independent, physician-owned DPC practices. We will continue to monitor this legislation as it moves through the Congressional process.
Dr. W. Ryan Neuhofel, DO, MPH
President, DPC Alliance
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Administrator Verma,
The Direct Primary Care Alliance is a membership organization of Direct Primary Care (DPC) physicians who own and operate small, independent DPC practices. The Alliance was born from a grassroots network of practicing DPC physicians looking to provide resources and a unified voice for fellow DPC physicians. From 50 founding members-- pioneers and leaders of the DPC movement-- we have quickly grown to over 200 physician-members from across the nation; mostly family physicians who own and operate small, community-based DPC practices.
Thank you for the opportunity to submit comments in response to the CMS Center for Medicare and Medicaid Innovation Request for Information (RFI) on “Direct Provider Contracting” models. The information we are sharing here is intended to help CMS better understand the perspective of our members.
The RFI has a stated goal to “empower beneficiaries as consumers, increase choices and competition to drive quality, reduce costs and improve outcomes.” We absolutely agree with this objective and believe the DPC model is already doing exactly that. We are doing so without any external incentives or directives. By freeing ourselves from many of the burdens associated with the traditional complexities of third-party billing, we are able to better focus our time and efforts on improving the care and experience of our patients, including Medicare beneficiaries. There is not a better example of putting “Patients Over Paperwork” as you have suggested as a priority for CMS initiatives.
For a number of years, the DPC community has been communicating with CMS about how DPC practices are serving patients in this innovative model. The DPC Alliance Board of Directors value CMMI's inquiry through this RFI. We believe physicians in active DPC practices are most suited to provide input into programs that involve payment initiatives and direct primary care. Below we have outlined our specific concerns and suggestion about the RFI as it stands. In the remainder of the document, we address each question specifically.
The Direct Primary Care Alliance respectfully requests the following:
Please rename the program. “Direct Provider Contracting” is new terminology but mirrors the D.P.C. acronym associated with “Direct Primary Care”. While we understand taking a broad view on alternative payment models, the phrase “Direct Primary Care“ and the acronym DPC has a long history of use dating back to late 2000’s. There are over 800 Direct Primary Care practices nationwide using the DPC phrase and acronym. Also, Direct Primary Care was codified in the Affordable Care Act (section 1301a), and to date, 25 states have legislation defining the “Direct Primary Care” model. It is for this reason that the use of “DPC” in the remainder of this introductory letter will specifically mean direct primary care, not direct provider contracting.
So, it would seem appropriate to avoid creating a new phrase with a DPC acronym as it may create confusion among physicians, policymakers, state legislators and patients (including Medicare beneficiaries).
We encourage CMS to create a program with a truly innovative approach built around direct payment from beneficiaries to the DPC practice via a subsidized personal account. The best option to do this within existing Medicare programs would seem to be “Medical Savings Accounts” (MSA). However, to fully maximize the use of MSAs within DPC practices, several alterations would be required. First, MSAs should be untied from private Medicare Advantage plans. Allowing the beneficiaries to choose a subsidized MSA within traditional Part B coverage would be the simplest approach. Alternatively, a new type of personal account could be created by CMS that was geared towards primary care services or specifically the DPC model. Either way, this account could be used to pay a DPC provider simply via a standard electronic transfer (debit or EBT). With any type of account, we suggest maximum beneficiary ownership and flexibility of those dollars; including clarification that DPC fees are an eligible expense.
The RFI references the existing Alternative Payment Models (APMs) of CPC+ and ACOs. While a broader frame of reference is reasonable, these models are fundamentally different than the DPC model as it’s widely practiced. The majority of DPC practices are built upon a simple, direct relationship with a patient with limited to no involvement from third-party payors. We do not believe building upon the framework of the CPC+ and ACOs programs to be in-line with the principles of the DPC model.
The majority of our physician members would not be inclined to participate in a capitation payment program, nor an ACO.
For maximum physician participation, the opt-out status of existing DPC providers will need to be addressed. The vast majority of members of the Direct Primary Care Alliance have opted-out of Medicare so that they may freely enter into private DPC agreements with Medicare beneficiaries. While this is a necessity under current Medicare rules, it’s less than ideal for both physicians and beneficiaries.
The opt-out decision creates a dilemma for physicians who are sometimes required to remain a Medicare participating provider for employed positions as their DPC practice is growing. During this stage, these physicians cannot legally enter into private agreements with Medicare beneficiaries for DPC services.
CMMI will need to address this matter without mandating these physicians be full participants in traditional Medicare. We suggest allowing any physician and Medicare beneficiary to enter into a “private contract” arrangement for DPC services on a case-by-case basis irrespective of the provider’s participation in the Medicare program.
Thank you for considering a program that empowers high-quality physician-patient relationships and reduced cost of care. We hope that CMMI will create a transformational program that supports the patient-centered ideals foundational to Direct Primary Care while retaining its revolutionary simplicity. This type of innovative solution is necessary for Medicare beneficiaries, primary care physicians, and the nation. The Direct Primary Care Alliance is eager to engage with CMMI on this project and are happy to assist in any way possible.
Direct Primary Care Alliance
Ryan Neuhofel, DO MPH | President
Julie Gunther, MD | Vice President
Amy Walsh, MD | Treasurer
Allison Edwards, MD | Secretary
Michael Ciampi, MD | Lisa Davidson, DO | Douglas Farrago, MD | Jeffrey Gold, MD | Jennifer Harader, MD | Vance Lassey, MD | Kimberly Legg-Corba, DO | Josh Umbehr, MD | Kylie Vannaman, MD
Answers to the specific questions within RFI
Questions Related to Provider/State Participation
1. How can a DPC model be designed to attract a wide variety of practices, including small,
independent practices, and/or physicians? Specifically, is it feasible or desirable for
practices to be able to participate independently or, instead, through a convening
organization such as an ACO, physician network, orother arrangement?
Given that small, independent practices encompass 70-90% of the DPC market, this is a crucial consideration. The majority of DPC practices operate with very low-overhead and employ very few staff members; often having no clerical or billing staff. Most DPC practices bill their patients through a monthly recurring, automatic transfer of funds via credit/debit card or checking account-- similar to subscribing to Netflix or paying for a gym membership. Several electronic billing/payment systems are used to streamline this process. As such, very little time is spent on matters of billing or payment within DPC practices.
To make any CMS program viable for these practices, there must be a very simple payment mechanism that mimics current DPC operations. We recommend giving Medicare beneficiaries an option for “personal account” (as described in other places in this document) to use for payment of DPC services. The EBT system at grocery stores works well for people receiving food assistance. We see no reason why it couldn’t also work for Medicare beneficiaries paying for DPC services.
Any type of third-party payment (from CMS, network manager, or ACO) to DPC practice would not be an ideal, or perhaps even acceptable, to majority of our members. Inevitably, these arrangements add administrative complexity, overhead cost and detracts from patient care.
2. What features should CMS require practices to demonstrate in order for practices to be
able to participate in a DPC model (e.g., use of certified EHR technology, certain
organizational structure requirements, certain safeguards to ensure beneficiaries receive
high quality and necessary care, minimum percent of revenue in similar arrangements,
experience with patient enrollment, staffing and staff competencies, level of risk
assumption, repayment/reserve requirements)? Should these features or requirements
vary for those practices that are already part of similar arrangements with other payers
versus those that are new to such arrangements? If so, please provide specific examples
of features or requirements CMS should include in a DPC model and, if applicable, for
which practice types.
Physicians are heavily regulated through state licensure, medical boards and, often, their local physician community and medical staff credentialing office. To date, approximately 25 states have set legal definitions of DPC-- namely to clarify it as “not insurance”-- and most of them provide consumer protections for participating patients. We are supportive of these existing laws and protections, but would not suggest extra layers of accreditation or verification of physicians practicing in the DPC model.
3. What support would physicians and/or practices need from CMS to participate in a DPC
model (e.g., technical assistance around health IT implementation, administrative
workflow support)? What types of data (e.g., claims data for items and services furnished
by non-DPC practice providers and suppliers, financial feedback reports for DPC
practices) would physicians and/or practices need and with what frequency, and to
support which specific activities? What types of support would practices need to
effectively understand and utilize this data? How should CMS consider and/or address
the initial upfront investment that physicians and practices bear when joining a new
The DPC movement has grown organically in the past 7 years from about a dozen to over 800 PCPs without investment from CMS or any large entities. These physicians have taken the financial risk of starting and building a practice independently which is a testament to the entrepreneurial nature of Direct Primary Care.
The burden of sorting through current medical history and documentation is tremendous. This is particularly true for primary care providers attempting to play quarterback for patients with multiple providers. To improve this process, we are in favor of physicians having better access to clinical data (diagnosis list, results, etc.). The best way to accomplish this would be continued efforts to support interoperability of electronic health records, but also returning patients to a custodial role of their own health records when feasible.
While billing and claims data (centered around CPT coding) may be useful in a systemic analysis, this data is not helpful with clinical decision making nor does it facilitate collaborative care among providers. We do not recommend this be a significant aspect of this program at the provider level.
4. Which Medicaid State Plan and other Medicaid authorities do States require to implement
DPC arrangements in their Medicaid programs? What supports or technical assistance
would States need from CMS to establish DPC arrangements in Medicaid?
The structure and regulation of Medicaid is unique to each state, but we would suggest following the principles we outline here for each of those states considering DPC.
5. CMS is also interested in understanding the experience of physicians and practices that
are currently entirely dedicated to direct primary care and/or DPC-type arrangements. For
purposes of this question, direct primary care arrangements may include those
arrangements where physicians or practices contract directly with patients for primary
care services, arrangements where practices contract with a payer for a fixed primary care
payment, or other arrangements. Please share information about: how your practice
defines direct primary care; whether your practice ever participated in Medicare; whether
your practice ever participated in any fee-for-service payment arrangements withthird party
payers; how you made the transition to solely direct contracting arrangements (if
applicable); and key lessons learned in moving away from fee-for-service entirely (if
The majority of our members have launched DPC practices as personal entrepreneurial ventures. Most of them have done so after practicing in traditional, fee-for-service settings both as practice owners and employees. It is widely recognized that the administrative burdens and time-crunched nature of traditional models of primary care are contributing to physician “burnout”; our members echo this sentiment.
Most of our members are familiar with caring for Medicare beneficiaries under available payment models; including many of the “innovative” programs discussed in this RFI. These limitations are largely what have driven them to pursue the DPC model.
Questions Related to Beneficiary Participation
6. Medicare FFS beneficiaries have freedom of choice of any Medicare provider or supplier,
including under all current Innovation Center models. Given this, should there be limits
under a DPC model on when a beneficiary can enroll or disenroll with a practice for the
purposes of the model (while still retaining freedom of choice of provider or supplier
even while enrolled in the DPC practice), or how frequently beneficiaries can change
practices for the purposes of adjusting PBPM payments under the DPC model? If the
practice is accountable for all or a portion of the total cost of care for a beneficiary,
should there be a minimum enrollment period for a beneficiary? Under what
circumstances, if any, should a provider or supplier be able to refuse to enroll or choose
to disenroll a beneficiary?
We support giving Medicare beneficiaries freedom of choice of where and how they receive primary care, including the ability to choose a DPC practice or a traditional FFS practice. The simplest way to ensure this freedom of choice is to provide Medicare beneficiaries a subsidized personal account that can be used to pay for primary care services. There is variation among DPC practices--including variation in monthly rate, enrollment charges, etc..--but most DPC clinics charge monthly memberships with no minimum enrollment requirement. In this arrangement, the DPC practice must constantly prove their service and value to patients. Quality is assured by the inherent understanding that a patient who feels they are not receiving proper care may leave the practice at any time and find a different provider.
This is why DPC works. DPC models support the absolute right of a patient and physician to enter in to a primary care relationship. If the relationship is not a good fit or a patient is dissatisfied with access, the care provided and even with the charges, the patient is empowered to find a clinic that suits their needs.
7. What support do practices need to conduct outreach to their patients and enroll them
under a DPC model? How much time would practices need to “ramp up” and how can
CMS best facilitate the process? How should beneficiaries be incentivized to enroll? Is
active enrollment sufficient to ensure beneficiary engagement? Should beneficiaries who
have chosen to enroll in a practice under a DPC model be required to enter into an
agreement with their DPC-participating health care provider, and, if so, would this
provide a useful or sufficient mechanism for active beneficiary engagement, or should
DPC providers be permitted to use additional beneficiary engagement incentives (e.g.,
nominal cash incentives, gift cards)? What other tools would be helpful for beneficiaries
to become more engaged and active consumers of health care services together with their
family members and caregivers (e.g., tools to access to their health information,
mechanisms to provide feedback on patient experience)?
We believe it is the responsibility of the DPC practice to actively recruit patients within their communities. This education and outreach is part of building a strong community-based clinic and DPC practices are comfortable in that role. If CMMI were to launch a program, we would expect existing DPC practices to grow to meet that demand. We also expect new DPC practices to open. If CMMI were to be involved in marketing this program, we would suggest a simple notification to Medicare beneficiaries that DPC fees are an eligible expense using this new benefit.
8. The Medicare program, specifically Medicare Part B, has certain beneficiary cost-sharing
requirements, including Part B premiums, a Part B deductible, and 20 percent
coinsurancefor most Part B services once the deductible is met. CMS understands that
existing DPC arrangements outside the Medicare FFS program may include parameters
such as no coinsurance or deductible for getting services from the DPC-participating
practice or a fixed fee paid to the practice for primary care services. Given the existing
structure of Medicare FFS, are these types of incentives necessary to test a DPC
initiative? If so, how would they interact with Medicare supplemental (Medigap) or other
supplemental coverage? Are there any other payment considerations or arrangements
CMS should take into account?
We suggest that DPC practices not be entangled in any of the payment systems currently existing for Medicare beneficiaries. Any care that a patient receives outside of a DPC practice including subspecialty referrals and hospitalization will be paid under the customary plans available.
Questions Related to Payment
9. To ensure a consistent and predictable cash flow mechanism to practices, CMS is
considering paying a PBPM payment to practices participating in a potential DPC model
test. Which currently covered Medicare services, supplies, tests or procedures should be
included in the monthly PBPM payment? (CMS would appreciate specific Current
Procedural Terminology (CPT®1)/Healthcare Common Procedure Coding System (HCPCS) codes as examples, as well as ICD-10-CM diagnosis codes and/or ICD-10-PCS
procedure codes, if applicable.) Should items and services furnished by providers and
suppliers other than the DPC-participating practice be included? Should monthly
payments to DPC-participating practices be risk adjusted and/or geographically adjusted,
and, if so, how? What adjustments, such as risk adjustment approaches for patient
characteristics, should be considered for calculating the PBPM payment?
As a comprehensive primary care model, the vast majority of DPC practices offer a wide spectrum of care, including preventive care, acute care for illness and injuries and chronic disease management. The vast majority do all this in exchange for a fixed, recurring monthly membership fee without additional charges (e.g. co-pays) for any visits or communication.
In addition, DPC practices have negotiated for and provide their members with access to heavily discounted services, including procedures, lab work, radiology (imaging) and generic medications. These services are heavily discounted because the burden of third-party reporting, billing, and filing is removed. One of the reasons we favor a subsidized “personal account” benefit (payment to beneficiary) is to allow those dollars to be used flexibly within the DPC practices to pay for these ancillary charges. This would be the best way to utilize the full value of the full DPC model for CMS and the beneficiary.
Regarding a list of specific covered CPT codes within the primary care sphere, we simply suggest that any list would be inherently overreaching and not intended to guide the services of the DPC practice. One of the benefits of the DPC model is that primary care providers do not need to think about what is a billable encounter or not. We can flexibly meet the needs of our patients independent of whether the care provided is ‘codable’ or not..
We have not found DPC pricing to vary considerably enough regionally to advocate for geographic adjustments in this program. This project could be ‘over-thought’ with small details adding unnecessary complexity and unnecessary administrative burden at increased expense without improving the care of Medicare beneficiaries. We advocate for the simplest program possible.
As primary care physicians, we realize that health and wellness often comes with peaks and valleys. For this reason, we believe access to quality primary care should be a paramount goal for all patients regardless of their current health status. While a certain subset of patients will be chronically very ill, there is significant turnover in the high-utilizer group from year to year.
Risk-adjusted benefits- e.g. giving a higher monthly subsidy to an individual deemed to be in poorer health-- would be extremely complicated for a number of reasons and is something we currently recommend against.
10. How could CMS structure the PBPM payment such that practices of varying sizes would
be able to participate? What, if any, financial safeguards or protections should be offered
to practices in cases where DPC-enrolled beneficiaries use a greater than anticipated
intensity or volume of services either furnished by the practice itself or furnished by other
health care providers?
If this program is structured around individual beneficiaries, there would no need to vary the program based on size of DPC practice or market. There may be some DPC practices with a large number of providers, where others will be solo practice or small group. Regardless, the beneficiary should be able to free choose a DPC practice that provides the best value and service for them.
Utilization considerations are fundamental to any membership-based business. While DPC practices must be mindful of utilization and pricing for business success, we do not suggest added safeguards for practices related to utilization. We do not believe this program-- more Medicare beneficiaries utilizing DPC clinics-- will impact this dynamic.
11. Should practices be at risk financially (“upside and downside risk”) for all or a portion of
the total cost of care for Medicare beneficiaries enrolled in their practice, including for
services beyond those covered under the monthly PBPM payment? If so, what services
should be included and how should the level of risk be determined? What are the
potential mechanisms for and amount of savings in total cost of care that practices
anticipate in a DPC model? In addition, should a DPC model offergraduated levels of
risk for smaller or newer practices?
DPC practices should not be penalized or rewarded for the total or downstream (non-primary care) costs of care. Asking primary care physicians to ‘share risk,’ via ACO or other means, has not been shown to improve the quality of care or patient-outcomes. Rather, we believe an opportunity to provide great primary care is tremendously important; the DPC model affords PCPs exactly that.
Multiple efforts have been undertaken to define direct primary care as not related to nor similar to insurance-like, risk-adjusted models. 25 states have laws stating exactly this. Direct primary care practices offer as-needed access to the primary care doctor without consideration of risk pools or the burden of billing and coding. The physicians job is to care for their patient. Adding other responsibilities, covered services, and risk adjustments mutates this clear objective and relationship.
12. What additional payment structures could be used that would benefit both physicians and
As suggested above, harnessing the transformative nature of DPC, a Medical Savings Account (MSA) plus a modified version of Part B coverage could be revolutionary model for Medicare beneficiaries.
Questions Related to General Model Design
13. As part of the Agency’s guiding principles in considering new models, CMS is
committed to reducing burdensome requirements. However, there are certain aspects of
any model for which CMS may need practice and/or beneficiary data, including for
purposes of calculating coinsurance/deductible amounts, obtaining encounter data and
other information for risk adjustment, assessing quality performance, monitoring
practices for compliance and program integrity, and conducting an independent
evaluation. How can CMS best gather this necessary data while limiting burden to model
participants? Are there specific data collection mechanisms, or existing tools that could
be leveraged that would make this less burdensome to physicians, practices, and
beneficiaries? How can CMS foster alignment between requirements for a DPC model
and commercial payer arrangements to reduce burden for practices?
We recommend monitoring Medicare beneficiaries through spending via their personal account. These debit transactions will contain basic financial information to assure program compliance and monitor for fraud. This type of monitoring has proven quite effective within food assistance programs via EBT (SNAP) cards at grocers. The rates of fraud within those EBT driven programs are much less than exists within current Medicare third-party payments.
14. Should quality performance of DPC-participating practices be determined and
benchmarked in a different way under a potential DPC model than it has been in ACO
initiatives, the CPC+ Model, or other current CMS initiatives? How should performance
on quality be factored into payment and/or determinations of performance-based
incentives fortotal cost of care? What specific quality measures should be used or
The ability to objectively measure “performance” or “quality” of primary care has proven extremely challenging. To date, the vast majority of attempts at doing such have proven invalid. This is widely supported in the literature (N Engl J Med 2018; 378:1757-1761, https://www.nejm.org/doi/full/10.1056/NEJMp1802595?query=TOC).
We are happy that the discussion about quality has moved away from burdensome measures of process and now focusing on health outcomes. However, this also poses dilemmas and potential moral hazards. Given 70% or more of health outcomes are based on lifestyle and socioeconomic factors, medical care providers are limited in many respects. With great primary care, it is possible to move a patient or group of patients towards better health and less downstream spending. However, comparing the outcome of one patient or group of patients to another is often not helpful. Even with risk-adjustments-- a complicated and imprecise process-- defining good outcomes or benchmarks is often murky.
To measure the financial success of this program (a wider adoption of DPC), we would suggest monitoring the downstream costs of participating beneficiaries. While some benefits may be realized quickly, we would suggest a minimum of 3 years to allow for variances in utilization, increased costs of care at start-up and challenges intrinsic to anything new. Cost-savings data amortized over 3 years across a number of existing DPC practices can be anticipated to be 20% of total healthcare spend per beneficiary.
15. What other DPC models should CMS consider? Are there other direct contracting
arrangements in the commercial sector and/or with Medicare Advantage plans that CMS
should consider testing in FFS Medicare and/or Medicaid? Are there particular
considerations for Medicaid, or for dually eligible beneficiaries, that CMS should factor
in to designing incentives for beneficiaries and health care providers, eligibility
requirements, and/or payment structure? Are there ways in which CMS could restructure
and/or modify any current initiatives to meet the objectives of a DPC model?
As currently structured, we do not believe the majority of our membership would find any utility in participating in existing Medicare Advantage plans. However we are open to solutions that are elective, simple, transparent and cost-effective.
Questions Related to Program Integrity and Beneficiary Protections
16. CMS wants to ensure that beneficiaries receive necessary care of high quality in a DPC
model and that stinting on needed care does not occur. What safeguards can be put in
place to help ensure this? What monitoring methods can CMS employ to determine if
beneficiaries are receiving the care that they need at the right time? What data or
methods would be needed to support these efforts?
See answer to Question 14.
17. What safeguards can CMS use to ensure that beneficiaries are not unduly influenced to
enrollwith a particular DPC practice?
If Medicare allows the beneficiary to control these dollars via a personal account, DPC practices will need to market to these patients within their community. This is no different than is currently done under traditional Medicare programs. We do not see any unique moral hazards for DPC practices in this regard. If a patient is dissatisfied with their care or a DPC practice is not providing a good value for those dollars, the patient can transfer their care elsewhere. Market forces will correct poor business practices.
More than anything, beneficiaries who are allowed to independently choose their own DPC practice will have far more freedom than what occurs in the status quo to choose between providers and move freely within the healthcare system.
18. CMS wants to ensure that all beneficiaries have an equal opportunity to enroll with a
practice participating in a DPC model. How can CMS ensure that a DPC-participating
practice does not engage in activities that would attract primarily healthy beneficiaries
(“cherry picking”) or discourage enrollment by beneficiaries that have complex medical
needs or would otherwise be considered high risk (“lemon dropping”)? Whatadditional
beneficiary protections may be needed under a DPC model?
As DPC physicians, we are already taking care of people with complex medical needs. We see this everyday in our practices. Often we are more capable of meeting these patients needs because the extra time and communication the DPC model affords us. Also, patients with complex needs see a better value in our services. After nearly a decade, we have not seen the fear of “cherry picking” within DPC practices come to fruition; if anything, the opposite has occurred.
The only way we could forsee cherry-picking is with programs that reward or penalize outcomes or downstream utilization (clinical or financial). It’s one of the reasons we are skeptical of such approaches.
19. Giving valuable incentives to beneficiaries to influence their enrollment with a particular
DPC practice would raisequality of care, program cost, and competition concerns.
Providers and suppliers may try to offset the cost of the incentives by providing
medically unnecessary services or by substituting cheaper or lower quality
services. Also, the ability to use incentives may favor largerhealth care providers with
greater financial resources, putting smaller or rural providers at a competitive
disadvantage. What safeguards should CMS put in place to ensure that any beneficiary
incentives provided in a DPC model would not negatively impactquality of care,
program costs, and competition?
If this program is appropriately structured--with beneficiaries managing funds--we feel that DPC practices of all sizes and varieties will be on a level playing field. Beneficiaries themselves are in the best position to make a determination of which practice, including services and pricing, would best meet their needs. Many DPC practices do provide creative services, such as health coaching and educational events, as part of their practice. These type of novel approaches to improving patients’ lifestyle and health should not be restricted. However, providers participating in this program should continue to follow any and all rules about prohibiting “incentives” (gifts, etc.) to beneficiaries.
20. How can CMS protect beneficiaries from potential risks, such as identity theft, that could
arise in association with a potential DPC model?
This has not been an issue to date within the DPC model. If anything, a simple direct relationship reduces chances of fraud and identity theft vs. third-party billing practices.
Questions Related to Existing ACO Initiatives
21. For stakeholders that have experience working with CMS as a participant in one of our
ACO initiatives, how can we strengthen such initiatives to potentially attract more
physician practices and/or enable a greater proportion of practices to accept two-sided
financial risk? Whatadditional waivers would be necessary (e.g., to facilitate more
coordinated care in the right setting for a given patient or as a means of providing
regulatory relief necessary for purposes of testing the model)? Are there refinements
and/or additional provisions that CMS should consider adding to existing initiatives to
address some of the goals of DPC, as described above?
Most DPC physicians have opened independent practices at their own personal financial risk. They do this because existing payment models often do not allow them to provide high quality care and are often financially unsustainable. As DPC physicians we are able to curate great relationships with our patients. These relationships alone motivate us to provide better care and DPC model provides that opportunity. As caring professionals, we don’t believe that financial “risk” of bad outcomes provides any extra incentive to provide quality care. Thus, we expect very few DPC practices to have any interest in joining an ACO.
22. Different types of ACOs (e.g., hospital-led versus physician-led) may face different
challenges and have shown different levels of success in ACO initiatives to date. Would
a DPC model help address certain physician practice-specific needs or would physician
practices prefer refinements to existing ACO initiatives to better accommodate physician-led
Our members prefer a simplified, no attestation, low-cost model of care delivery. Direct payment from patients with the physician's time spent in direct care of the patients is what makes direct primary care revolutionary for patients and physicians.
Dear DPC Alliance Members,
First, we wanted to thank you for being a member of this young organization. There has been a significant amount of work in laying the foundations for future growth, but we have been working steadfastly behind the scenes. Many of you are already helping in those efforts. Thank you.
This is the first of our Board of Directors letter which is planned to be quarterly-ish. We feel that several topics need to be addressed promptly so this will be a bit longer than future BOD letters.
CREATING RESOURCES & TEAMS
We have formed some organizational structure and outlines for future member resources and projects; an updated “Resources” page on our website reviews much of those plans. We have formed a number of teams for projects. Many more are in the pipeline. We will have a more formal list of those opportunities available soon. If you are eager to get more involved, the DPCA Slack page is a great place to start.
DIRECT VS. CAPITATION MANAGERS
Although the Alliance’s main focus is giving our members’ tools to help grow their practices, we also serve as an advocate for an authentic version of independent DPC practice. To do that, we must understand how the system around us is changing. Many of these things may influence the operations of DPC practices and our larger goals.
As our movement has grown and gained legitimacy, many outside parties-- people other than you and your patients-- are starting to recognize the amazing potential and far-reaching impact of the DPC model. These entities take many forms, including employers, organizations, brokers, consultants, managers of all sorts, insurance companies, and government agencies. Some of them are merely cheerleaders of our cause; while others are engaging in business directly with DPC practices.
Recently, a number of companies are attempting to connect large groups of patients with DPC practices; typically through larger employers or collections of employers. The basic function of these companies is to manage a portion of these healthcare dollars and subcontract out primary care services through networks of DPC practices. Structurally, these management companies are very similar to a traditional Managed Care Organization (MCO, e.g. Aetna or Coventry), but restricting their management to primary care. We don’t yet have a label for this type of company, but “Primary Care Management Organization” (PCMO) seems an apt description.
So what does this mean for DPC practices? In the next couple years, we will undoubtedly be given sales pitches of “We can bring your DPC practice 500 new members!” Sounds like a great way to grow a practice, but in the midst of these discussions, we must remember the core principles of Direct Primary Care and what truly distinguishes us from the status quo managed care system.
The essence of the DPC model has always been about putting our patients back in control of their health care, including their dollars. As much as we applaud PCPs being freed from red tape and bureaucratic distractions, just as importantly, DPC empowers patients. As a patient chooses us freely on our own merits and value, It’s the ultimate “engagement” tool that has long been missing. This direct, transparent partnership has tangible benefits that people not in the exam room often can’t comprehend or measure.
Given the modern nature of primary care, moving away from fee-for-service payments is a good thing. But the Direct Primary Care model is much more than clinics charging a flat monthly fee. In the purest version of DPC, a practice works exclusively for the individual patient as individuals; not for an outside company or plan managing the health care dollars of those individual patients, especially when these individuals are grouped together on a plan.
Historically, the latter is called capitation and not a new idea whatsoever. Whether they be private (e.g. HMOs) or government organizations, capitation arrangements have traditionally been fraught with problems for primary care. Despite this, capitation proponents claim the next iteration will be better; promising to properly value primary care and minimize the administrative hassles.
Even if you are trusting enough to believe that, the PCMO concept is fundamentally adding a layer of management and cost to the simplest version of DPC. Some would argue it is not Direct Primary Care at all. Regardless, attempts to organize patients and practices through PCMOs is well underway.
CMS “DPC” PROJECT
CMS recently unveiled a “Request for Information” (RFI) for a potential “DPC” project. Unfortunately, CMS retooled the DPC acronym as “Direct Provider Contracting”. The warping of the DPC acronym was frustrating, but the content of the document was also met with much consternation and concern.
The RFI heavily references an existing Medicare payment model (Comprehensive Primary Care Plus, or CPC+) which is a partial capitation payment to PCPs. The payment methodology with CPC+ is complicated (120 pages) but slowly moving towards nearly full capitation with adjustments for “performance” (presumably via reported metrics).
In this context, CMS described their version of DPC as, “CMS would pay these participating practices a fixed per beneficiary per month (PBPM) payment to cover the primary care services”. The RFI also mentions “an opportunity to earn performance-based incentives for a total cost of care and quality.” If you are wondering how this description is much different than CPC+ program, so are we!
Further, the RFI discusses how the CMS version of “DPC” could or should (?) be combined with Accountable Care Organizations (ACOs). If you are not familiar with ACOs, the basic concept is that all providers and companies involved assume financial responsibility for a population of patients. If it sounds complicated to organize such a thing without red tape and moral hazards, that’s because it is. The adoption and promised savings of ACOs are falling way short of expectations despite heavy investments from the federal government.
In the 9 pages of the RFI, there is only one brief mention of “direct primary care”; described as “where physicians or practices contract directly with patients for primary care services.”
Although the tone and content of the RFI were disappointing, the CMS project is still in the early stages of formation. We will continue to engage in this process to make sure your voices are represented and encourage our members to do the same. In the coming weeks, we will be sharing a full detailed response to the RFI, including suggestions to create truly patient-centered options for people to choose innovative models like DPC.
ADVOCACY & PROFESSIONALISM
As the Alliance and DPC community engages in advocacy within a changing landscape, we want to affirm that the Alliance believes in collaboration and professionalism per the ABMS standards. We recognize and respect that our members have many different views on matters related to DPC and other issues. Our passion and diversity of views can cause friction at times among each other and when interacting with other organizations.
Even when not officially representing the Alliance, we encourage our members demonstrate that we are esteemed, educated, compassionate, and thoughtful professionals. We must remain mindful that unprofessional behavior can be destructive to the Alliance and the DPC movement’s larger goals.
PRIMARY CARE ENHANCEMENT ACT & LOBBYING
There are many individuals and organizations still pushing for the Primary Care Enhancement Act (HR 365) to be passed in the U.S. Congress. This Act will clarify a few matters regarding Health Saving Accounts (HSA) and membership in a DPC practice. The bill now as 30 cosponsors in House and remains bipartisan.
The DPC Alliance is not a political or lobbying organization but we recognize many of our members will engage in such activities as individuals or as part of other organizations. We encourage members who desire to be involved with legislative process around Direct Primary Care (including HR 365) to inform themselves about options for involvement through organizations designed for such activities. A few of these options that have lobbied on behalf of DPC matters include state medical societies, DPC Coalition, AAPS, AAFP, ACOFP, AID, AMAC, PWT, and NFIB.
DPC Alliance Board of Directors
Big thanks to Paradocs Podcast for interviewing Dr. Belén Amat, MD. Great perspective on “loving” Medicine again!