Addressing Direct Primary Care's Medicare Issues

The American Academy of Family Physicians (AAFP) hosted a successful Direct Primary-Care (DPC) Workshop in Detroit in April 2016. As a workshop faculty presenter, I collaborated with co-faculty presenter Ryan Neuhofel, a family medicine physician, to discuss DPC implementation.

By way of background, DPC medical practices essentially deliver primary care without plan reimbursement requirements or constraints. This is achieved by patients paying a monthly subscription fee for essential primary care. DPC practices aim to manage patient panels of 800-1000. Patients receive more connected primary care from a physician enabled to spend more time per patient, often with the physician directly through electronic communication..

The DPC workshop extensively evaluated whether DPC practices can or should remain in Medicare and otherwise how to manage plan interactions. DPC practices are typically “out of network” and not parties to plan contracts.

Plan Integration: The (Medicare) Fork in The Road

Federal law prohibits physicians from charging Medicare eligible patients additional fees in excess of Medicare reimbursement for covered services. Can physicians eliminate all the Medicare eligible patients from practices and engage in free enterprise? Not really. The better practice is to assume all patients are Medicare eligible, and design practice programs that fully comply with Medicare assignment.

So how can a DPC practice charge a monthly fee for primary care? There are two paths. One involves carefully crafting the services provided for the monthly fee asnot covered by Medicare. While that issue is complex and there are many variations of non-covered care models in the U.S., a typical solution involves the delivery of a routine, regardless of condition or medical necessity exam.  This routine exam is not medically necessary and not covered by Medicare. This means that electronic communication arising from the non-covered exam is also not covered.