Concierge Medicine and Direct Primary Care

Caroline Billings
Release Date- January 10, 2022
Review Date- April 20, 2022

Many Concierge Medicine (CM) and Direct Primary Care (DPC) concepts are linked, with most CM models including variations of direct primary care. These practices have contractual, membership-based billing relationships between practitioners and their patients. Patients pay their physicians directly rather than billing through insurance companies in these settings. These care models require patients to pay regular fees to retain access to their physicians. On average, CM costs $183/month per person, while DPC costs around $77/month per person. In addition, some practices give group rates for families. A difference in the payments between CM and DPC is that DPC practices do not typically accept Medicare, Medicaid, or other forms of health insurance. Instead, CM providers will charge the yearly fee and bill your medical insurance for specific services like lab tests. The membership fees of some DPC plans include the costs of x-rays and labs when needed, while other low-cost DPC plans require out-of-pocket payment for these services. However, these out-of-pocket costs are generally much less expensive than if these patients were to go through insurance.

The American Academy of Family Physicians Foundation put out a survey that suggested 89% of Americans value having a physician who understands their health history and family. These physician-patient relationships mean physicians can better understand their patients’ health histories and care needs. In addition, if specialty care is necessary, these practitioners can communicate with other physicians for improved continuity of care. This increased desire for personalized care has helped the private healthcare industry boom.

Concierge Medicine

Concierge practices, also known as retainer or boutique practices, incorporate a wider variety of medical specialties and healthcare models than direct primary care. Many primary care physicians who change to concierge medicine do so to decrease administrative overhead costs and improve patient relationships. Because of the personalization of care and cost efficiency, this practice model is becoming increasingly popular for physicians and patients alike.

Patients who pay for yearly CM gain direct access to their primary care physician, longer appointments, and shorter wait times. Because these contracts are annual, they cannot be canceled midyear. These fees allow concierge physicians to see between 50 to 1,000 patients rather than the usual 3,000-4,000 patients that doctors in traditional medical settings see. The cost of CM would include one in-depth physical with numerous screenings and usually unlimited clinic visits unless the patient purchased a lower-cost health plan. This system lets patients take a more preventative approach to their wellness.

The higher regular fee for CM makes it a typical plan for young, middle-income residents but is generally more beneficial to people ages 50 and older who may need to see more specialized physicians. This disparity between the needs of the elderly in rural communities and the cost of CM care alienates most of the older populations in rural areas. CM care can be more affordable if a patient pays for CM membership fees combined with a high-deductible insurance plan. Patients who have chronic illnesses or conditions and commonly visit the doctor may also benefit from CM plans.

These higher membership costs (compared to DPC) can result in different methods of patient involvement in their care, such as apps that allow them access to their lab test results and medical records that can be linked to existing hospital online charting tools. The insurance situation gives the provider two revenue streams while also permitting the insurance company to cover patient services not included in their CM membership fee. Fortunately, this also means that CM physicians can be considered in-network providers, so copays and other related health costs can count toward a patient’s deductible. Unfortunately, CM is not currently an acceptable non-insurance option by the Affordable Care Act, so patients must pay for both their CM membership fees and monthly insurance costs if they live in a state that requires health insurance.

Direct Primary Care

The DPC payment model is comprised of only a monthly or quarterly fee that allows the physician a regular income and more time to spend with patients. These monthly and quarterly contractual memberships mean that patients can cancel their memberships at any time. Patients’ fees cover as many appointments and services as they need at lower costs than CM and quicker access to their physician through phone calls, texts, email, video chat, and sometimes house calls depending on the practice. These advantages make DPC a popular option for older, low-income/fixed-income rural residents. However, DPC might benefit younger families who do not need specialized concierge care.

The lifestyle management and preventative medicine that DPC provides can help patients make more informed decisions about their care. Throughout the COVID-19 Pandemic, DPC practices saw an increase in prospective patients who wanted to ensure they had access to high-quality medical care in their rural communities.

Many patients who use DPC do so in place of other forms of health insurance, a problem many low-income, uninsured rural residents face. A benefit of DPC is that the Affordable Care Act considers it to be a valid alternative to health insurance, meaning that those who pay only for DPC will not be penalized by their home states for being “uninsured.” Unfortunately, because these physicians do not accept payment through insurance, some individuals will have to pay a monthly health insurance fee and their DPC costs if they need additional services. Additionally, since DPC physicians are out-of-network for insurance providers, their membership fees cannot apply toward a patient’s deductible—everything paid is out-of-pocket.

DPC practices are much more common in rural areas than CM due to physician shortages and affordability, so traditionally, rural areas significantly benefit from DPC physicians and practices.

CM and DPC Practices in Rural Areas

The benefits of CM and DPC practices have not gone unnoticed by hospitals. The Mayo Clinic, Duke Health, and Mass General Hospital have added primary care CM and DPC for their more affluent patients. On a smaller scale, Critical Access Hospitals (CAHs) in rural areas across the United States can implement CM services to complement their existing health programs, recruit new physicians, retain existing patients, and attract new ones from surrounding areas.

The financial advantages of CM and DPC systems can support the core missions of CAHs. For example, some hospitals use the profits from CM and DPC to care for uninsured patients or those who cannot afford high-quality healthcare or to add new service lines to their clinics.

However, since rural areas suffer from a more significant shortage of health professionals, adopting a practice format that limits the number of people that provider is willing/able to care for exacerbates the shortages.[/vc_column_text][/vc_column][/vc_row]