Direct primary care and concierge medicine: They’re not the same

Direct primary care (DPC) and concierge medicine are rapidly growing models of primary care. Though the terms are used interchangeably, both are not the same. Such liberal use of terms, many times by even those within the industry, confuses those who are attempting to understand how these primary care models operate. As former concierge physician for the Pebble Beach Resorts, and subsequent founder of one of the nation’s largest direct primary care companies, I have attempted to differentiate the two based on extensive personal knowledge and experience.

First, concierge medicine. Born in the mid 1990s, this practice design was first created by wealthy individuals who were willing to “bypass” the woes of the current fee-for-service system by paying a subscription to access select primary care physicians. This access consists of same-day appointments, round-the-clock cell phone coverage, email and telemedicine service, and sometimes, as in my previous practice, house calls. Although some high-end practices charge as much as $30,000 a month, most charge an average monthly fee of $200.

In return, to allow such unrestricted access, physicians limit their patient panels to several hundred patients at most, a significant drop from the typical 2,500-plus panel size most doctors are used to. Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “access fee” is only for “non-covered” services. This results in two subscriptions paid by patients — the concierge medicine fee, and the insurance premium. Importantly, a few concierge practices do not bill insurance for medical visits, as the monthly fees cover both access and primary care visits.

Direct primary care started in the mid 2000s, and was created as an insurance-free model to serve a new patient population: the uninsured. In DPC, patients, and now their employers, are also charged a monthly fee, but the fee can be as low as $50 per month and there is typically no third-party payer involvement. Consumers pay physician entities directly (hence, direct primary care), and because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.

Patient panels can be as high as 1,500 patients per doctor, and there is typically no physician cell phone access or house call service. Similar to higher-priced concierge practices, DPC practices also allow for longer patient visits and telemedicine. The most important characteristic of DPC practices, however, is that insurance claims are not filed for medical visits.

Direct primary care’s definition, therefore, is any primary care practice model that is directly reimbursed by the consumer for both access and primary medical care, and which does not accept or bill third party payers.

Confusion arises from similarities that exist in both models, such as decreased patient panels, monthly subscriptions, and longer visits. There is added confusion when a DPC physician offers house calls or email access, typical of concierge practices. Confusion is maximized when a physician is by definition practicing direct primary care, yet calls the practice a “concierge practice.” Similarly, a concierge practice may decide to abstain from participating in third party payer systems, and thus would also be a DPC practice.

The distinction is important because direct primary care is explicitly mentioned in the Affordable Care Act, while concierge medicine is not. Several state laws have also recognized direct primary care as medical practice models, and non-insurance entities. In addition, the term “concierge medicine” causes visceral reactions in select social and medical circles, drawing criticism such as elitism and exacerbation of physician shortage.

In summary, not all direct primary care practices are concierge practices, and not all concierge practices are direct primary care practices. The terms are not synonymous, and even the basic fundamentals of either model do not overlap. The key to differentiation is whether or not a third party payer is involved. If not, then the model is a direct pay, or direct primary care model, no matter what the fees.

Samir Qamar is CEO, MedLion and president, MedWand. He can be reached on Twitter @Samir_Qamar.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I think the terminology can be simplified by observing that concierge is just a set of value added services which can be layered on top of insurance based practice and also on top of cash practice.
    Some practices, either cash or insurance based, require that patients buy the concierge services, others do not.

    Note that i did not use the term “direct” here. Direct primary care, in my opinion, is a subset of cash practice, where the payment goes directly from the patient to the treating physician. The insertion of any corporate intermediary into the payment process, whether the patient’s employer or the doctor’s employer, makes it a cash practice which is not at all “direct”.

    This may be a nuance issue, but it goes to alignment of interests, trust, and ability to freely advocate for one’s patients, all of which are (or soon will be) worth quite a bit of cash.

  • Steven Reznick

    This certainly correctly points out the differences between the MDVIP franchise concierge model and a direct pay practice. Keep in mind that MDVIP took the risk in a Medicare rich market where 75% of the patient population is on a Medicare product and expects their doctor to take their insurance. Being a Direct pay physician in this market requires opting out of the Medicare system which means that they can not get reimbursement for the care they provide to Medicare recipients and even ordering indicated care and tests becomes problematic. I wonder how many of the direct pay practices are in areas where Medicare is the dominant player

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Thanks for the response, Dr. Qamar.
    Maybe you can help me understand a couple of things about the employer model. First, are contracts with employers risk based, so that the employer pays more for sicker patients? Second, what is the difference, from a patient perspective, between this type of contract and a plain vanilla capitation agreement with an HMO? And lastly, for all of these employer arrangements, do the employers fully fund the patient’s deductible for the wrap around?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Makes sense. Thanks again.

  • Lisa

    I would like to know more about the pricing of insurance wrap plans, because the only way DPC makes financial sense to me as a patient is if I have comprehensive insurance.

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