Direct Primary Care Get back to doctoring Molly Rutherford, MD, MPH Bluegrass Family Wellness, PLLC Crestwood, KY

Disclosures Owner Bluegrass Family Wellness, Crestwood, KY

Healthcare in the US

Healthcare in the US

National Headlines Physician burnout MACRA/MIPS ACA premium increases Expanded Medicaid Patient Centered Medical Homes Physician shortages DPC getting more attention Better outcomes from independent practices Savings to patients and employers Potential to recruit more physicians to primary care

What is Direct Primary Care? Charge a periodic fee Not bill any third parties on a fee for service basis (differs from Concierge medicine) Any per visit charge must be less than the monthly equivalent of the periodic fee

Direct Primary Care Dispense generic medications at 5% or less of retail cost at a pharmacy or from PBM Viagra Ventolin Furosemide Epipen (https://www.youtube.com/watch?v=4FJZgNemJxU) Contract with Quest for “client bill” labs = 90% savings on lab testing <$18 for wellness labs (lipid panel, CBC, CMP, TSH + T4) $17 for pap smear $40 for pathology reading on skin biopsy (no extra charge at my practice for minor surgery)

Direct Primary Care EMR user friendly, no ICD-10 or E/M codes 4-5 patients daily in person (sometimes less) Interact by phone, email, texting, telemedicine Time to consult with specialists Time to find cost effective imaging options for patients with a high deductible

Legal Considerations--Medicare Opting out of Medicare Medicare Access and CHIP Reauthorization Act of 2015 repeals the requirement of having to renew an opt-out status every two years. Physician's opting out of Medicare after June 16, 2015 will need to file an affidavit to opt out of Medicare only once, and it will have permanent effect. The physician will no longer need to renew his opt-out every two years thereafter. Allows physician to contract directly with patient, but prescriptions, orders for imaging, and specialty referrals are honored (unless patient has HMO Medicare plan).

Legal Considerations--HIPAA Does HIPAA apply to your DPC practice?  If you are a hybrid then the answer is likely yes, but if you are a "pure" practice then the answer might be no.  For the original HIPAA language one should look to 45 CFR Parts 160 & 164. Electronically billing an insurance company is one of many actions that can make a physician a "covered entity."  See this detailed explanation from HHS.  Unless the DPC physician electronically transmits health information in connection with one or more standard transactions (e.g., a health claim sent to an individual or group health plan or any other federal and/or state (e.g., Medicare, Medicaid) public health care program) then the physician does not need to fear the dreaded "covered entity" label and HIPAA does not apply. 42 CFR Part 2 (Drug and Alcohol Abuse Law) applies broadly to any group that is "federally assisted."  This offers a broader and different kind of protection to substance abuse records that is totally independent of the HIPAA system.  

Legal Considerations--Medicaid In most states, it is legal to contract directly with a Medicaid patient but NOT in Kentucky If you have a Medicaid number, you may not charge a patient directly for covered services Possibly can get around this if you are charging a “membership fee” (different attorneys have different opinions) You can no charge the Medicaid patient Don’t sign up for Medicaid—becomes a problem if you want to order a test, referral or medicine for patient that is not in your pharmacy Discussions are ongoing in Kentucky to remedy this regulation which is harming people in Kentucky who would like to benefit from access to Direct Primary Care

Resources/Links www.DPCfrontier.com www.dpcare.org AAFP website AAPS website Atlas.md (DPC curriculum) www.bluegrassfamilywellness.com