Member Forum

1.  Direct Primary Care

Posted 11-21-2017 14:52

With the current ACA enrollment period in process and the significant rate hikes that patients are experiencing, we have decided to offer our uninsured patients DPC. Would anyone be willing to share how they structure this in a way that is beneficial for patients without the practice loosing their shirt? I know there will be 'super-users' but also those that really don't abuse the service.

Thank you!

Tracy Baum
Mountain Sage Family Clinic
Dubois, WY

2.  RE: Direct Primary Care

Posted 11-22-2017 06:58

That is a very interesting question.  Essentially you are taking on risk without data to know where to set the payments which would both moderate your risk and provide something affordable to your prospective patients.  If you set it too low, you lose money by provide services for free.  And if you set it too high, you lose business because the number of patients will be low.  This is what actuaries do for health plans.

I think most of the DPC community as tried to err on the side of making the prices high enough to insure they don't lose too much money and go crazy/bankrupt.  There are several ways to do this:
1) co-pays with each visit
2) separate changes for items like phone calls, filling out forms
3) pricing based on risk, eg the older you are the more you pay

Good luck and keep up posted with how it goes.

Michael Barron MD

3.  RE: Direct Primary Care

Posted 11-22-2017 08:20
well I think  this is just  cash   pay discount no? I used to offer a 30./mo, must pay it for 6mo,  then 15.00 when you came in no matter what you cam e in for,  program.   One business owner paid half of the thirty dollars a month for employees who I would see as needed It was frankly  a hassle to  remember to bill but I  did not have enough volume to set up a system
 Now I just  have any cash pay people pay then and there No billing And so the price is lower but the price is off my usual charge sheet --remember if you take medicare you can have only one fee schedule but you can discount it if you have a reason that accounts for the  discount- like no billing  So say you have 99213 charge at 105.00  Insurers pay  68- 105   So the cash price is 75.00 Done

Do take credit cards  I use square I like the chip cards because you get a row of green lights and it amuses me:)

Jean Antonucci

4.  RE: Direct Primary Care

Posted 11-26-2017 15:59
Hi Tracy,

generally practices 'cover' office procedures, plus vaccines thru their state program, and have a discount on labs/medicines.
Consider how you will run a 'hybrid' practice- the prepaid folks will have better access and get more services without visits- how will you distinguish between the the two populations?

Dr Forrest has an extensive set of DPC resources; I've attached some.
The Medicaid DPCs have been able to get by at ~$25/pmpm, w mostly younger patient populations.
The average FFS monthly DPC rate is more like $60-90 which has a lot of leeway built in.
A rate of $40-50 should be more than ok; you might want to say this includes up to 6 office visits per person a year, with some predefined rate after that.
The "average" patient makes 3.1 visits a year.  Of course we 'providers' mandate visits for lots of things that COULD be handled on the phone.

And as you know, a few very sick people use most of the health services in the US.
Office visits are MUCH LESS SKEWED than total spending.

Look at slide 4 from
Health Care's 1%: The Extreme Concentration of U.S. Health Spending
and compare the differences between top 1%, 10%  and the rest for total or hospital costs vs. office visits.  While the highest utilizers use more office visits than less ill folk, it's not as big a ratio as it is for total services.

Conclusion- taking capitation for office visits (DPC)  is much MUCH less risky than taking full capitation.

Article from 2015 on distribution of monthly fees:
doi: 10.3122/jabfm.2015.06.140337

Predicting Persistently High Primary Care Use

18% of visits are by patients using 10+/year
CONCLUSIONS: Many persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefit from psychosocial support, whereas others may be good candidates for disease management interventions."
Panel Size: How Many Patients Can One Doctor Manage?
(3.1 visits per year =>about 1800)

I hope this helps.

Peter Liepmann MD FAAFP MBA
My mission is to fix US health care
Bakersfield CA