Molly Rutherford, M.D., M.P.H., a family physician in Crestwood, Ky., enjoys the increased interaction with patients she has in the direct primary care practice she started in 2015.
Direct primary care (DPC) is gaining legal momentum at the state level as a viable means for physicians to provide primary care to patients at a lower cost than traditional practice models.
For years, physicians who wanted to adopt DPC had to battle with insurers and state regulators, but now 18 states have enacted laws that recognize the practice model and make it easier for physicians to implement it. Just this year, Kentucky passed new legislation, and West Virginia and Arkansas revised their statutes regarding DPC. Eight other states have pending legislation, and in three of them -- Indiana, Colorado and Alabama -- the legislation is awaiting only the governor's signature.
The DPC model once was widely treated by states and the federal government as health insurance. But as a federal bill to address this problem awaits action, many states have moved to exempt DPC practices from unnecessary insurance regulations and to establish rules governing the model, such as restrictions that prohibit these practices from billing insurers for consultations on a traditional fee-for-service basis.
- Eighteen states have enacted laws that recognize the direct primary care (DPC) practice model and make it easier for physicians to implement it.
- The model has even spread to most of the states that have not passed DPC legislation, leaving only North Dakota, South Dakota and Iowa with no DPC practices in their borders.
- Three percent of AAFP members practice in a DPC setting, and the Academy is co-sponsoring a DPC summit in Washington, D.C., June 15-17.
Three percent of AAFP members practice in a DPC setting, and the Academy is co-sponsoring a DPC summit(www.dpcsummit.org) in Washington, D.C., June 15-17.
Philip Eskew, D.O., J.D., a family physician and attorney who is licensed in several states, tracks legislation regarding this practice model nationwide on the website DPC Frontier.(www.dpcfrontier.com) He also assists state legislators in understanding the model, and explains the practice model to regulators and policy analysts.
"In my opinion, DPC is already legal in every state and always has been," Eskew said. "Even without legislation, it is possible to do it anywhere, but it requires an understanding of insurance law, which physicians don't have. That's why we are pursuing this legislation to clear everything up."
Indeed, the practice model has spread to every state except North Dakota, South Dakota and Iowa.
DPC practices charge patients a membership fee that is commonly about $70 a month, but it can range from a low of $30 to as high as $500 a month. Patients are encouraged to have high-deductible insurance plans that cover health care services not included in the DPC agreement, but they receive most primary care services -- including chronic care management -- for no additional payment when they need it.
"Our society has an insurance addiction," Eskew said. "That has contributed to inflating the cost of primary care."
Advocates of the DPC model say insurers, large hospital systems and pharmacy benefit managers often oppose their price transparency efforts, and insurance carriers have presented the strongest opposition to legislation. But Eskew pointed out that DPC practices are able to save money for the health system at large.
"There is potential for big savings in chronic care management because we are keeping diabetes patients out of the hospital by prescribing medications that are more efficient and affordable than the rest of the health care system," he said.
Pioneering the DPC Model
West Virginia was the first state to pass a law that eased adoption of the DPC model. The legislation came in response to one family physician's attempt to implement elements of DPC before the term even existed.
Vic Wood, D.O., speaks with Alischa Earnest, a radiology technician in his office. Wood began a direct primary care practice in West Virginia in 2003.
That physician, Vic Wood, D.O., wanted to create a practice that would help chronic care patients who could not afford insurance.
"I was trying to get my patients access to health care, and they asked me to come up with something," he said.
In 2003, he began a "clinic-based health care" practice with membership fees. He set the monthly fee at $83 for individuals and $125 for families -- prices that remain unchanged today.
Initially, state regulators were skeptical about the practice model, thinking that the upfront payments closely resembled an insurance premium. Wood said the state insurance commissioner even warned him that he was operating as an unlicensed insurer. The initial state legislation that passed cleared up that issue, but the law came with restrictions on advertising and patient panels, and it cost $10,000 for practices to apply for the designation.
"They made the application process so labor-intensive and expensive that people dropped out," Wood recalled.
The revised legislation that West Virginia adopted this year is an improvement, Wood said, and it will make it easier for physicians and patients who are interested in the DPC model to enjoy its benefits.
Wood's practice now has 500 patients in the DPC model, which accounts for 15 percent of practice revenue. These patients pay two months up front and sign contracts that they can cancel with 30 days' notice. Their fee covers unlimited access to the physician's office, clinics, necessary X-rays, lab tests and antibiotics. Chronic disease medication generally costs $3 to $10 per month.
Some physicians worry that patients who have such easy access to physicians will make excessive office visits, but Wood said that concern is unfounded.
At his practice, patients receive a physical and necessary lab work at their first visit. Those with chronic conditions who were uninsured or did not receive regular care typically average eight visits during the first year and then drop to four visits annually until their conditions are controlled.
"Most patients don't want to sit in your waiting room," Wood said. "After the first year, they get comfortable just knowing you're there."
Finding More Time for Patient Interaction
Molly Rutherford, M.D., M.P.H., vice president of the Kentucky AFP, started a DPC practice in 2015 so she could practice medicine in a way that allows for more interaction with patients. She has a panel of 385 patients that she plans to cap at 500, and she manages her own practice in office space she shares with another physician.
After completing her residency, Rutherford worked in a hospital system in rural Indiana as part of the National Health Service Corps loan repayment program. She later moved to a busier independent practice in Kentucky where she had to see as many as 25 to 30 patients each day in addition to dealing with billing pressures.
She said switching to DPC, which was made easier for other physicians in Kentucky under legislation the state passed this year, increased the time she could spend with patients. The change also made it possible for her to practice addiction medicine in her office and boosted her career satisfaction.
"It was a personal decision based on my level of burnout," she said. "I wasn't doing a better job for my patients, and it's always most important for me to be able to spend time with patients and truly help them. The health care system and the bureaucracy were interfering with my ability to do that."
In her Crestwood, Ky., office, Rutherford now consults about 10 patients per day. Their monthly fees -- $10 for children, $50 for adults ages 18-45, $75 for adults ages 46-65 and $100 for older patients -- provide access to most primary care services.
"It's not as complicated, and (it's) more personal," Rutherford said, noting that patients appreciate the greater attention. "They feel like somebody is listening to them."
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