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Posted: April 29th, 2018
State and Federal Regulation of Direct Primary Care and Concierge Medical Practices
State and Federal Regulation of Direct Primary Care and Concierge Medical Practices
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Direct primary care (DPC) and concierge medicine are two alternative models of primary care delivery that aim to provide more personalized, accessible, and comprehensive care to patients. However, they also face some regulatory challenges and uncertainties at both the state and federal levels. This paper will examine the main differences between DPC and concierge medicine, the current state of regulation for both models, and the potential implications of future regulatory changes.
DPC vs Concierge Medicine
DPC and concierge medicine are often confused or used interchangeably, but they have some distinct features. DPC is a model where primary care physicians charge a monthly or annual fee to their patients, usually ranging from $50 to $150, in exchange for unlimited access to primary care services, such as consultations, exams, care coordination, and some lab services. DPC physicians do not accept any insurance payments or bill insurance companies for their services, which reduces their administrative costs and allows them to spend more time with their patients . DPC patients are advised to also have a major medical health coverage plan for scenarios outside the scope of primary care, such as hospitalizations, surgeries, or specialist referrals .
Concierge medicine is a broader term that encompasses various models of primary care delivery that offer enhanced services to patients who pay a retainer fee, usually ranging from $100 to $200 per month. Concierge medicine practices may or may not accept insurance payments or bill insurance companies for their services, depending on their specific model. Concierge medicine practices typically offer a wider range of services than DPC practices, such as preventive screenings, wellness programs, home visits, telemedicine, or access to specialists . Concierge medicine patients may also need a major medical health coverage plan for scenarios outside the scope of their practice .
State Regulation
State regulation of DPC and concierge medicine varies widely across the country. Some states have enacted laws that explicitly recognize and define DPC and/or concierge medicine as distinct from traditional insurance models and exempt them from insurance regulations. These laws may also establish certain requirements or standards for DPC and/or concierge medicine practices, such as disclosure of fees and services, contract terms, patient rights, or scope of practice . As of 2023, 35 states have passed some form of legislation related to DPC and/or concierge medicine .
Other states have not enacted any specific laws regarding DPC and/or concierge medicine, which may create some ambiguity or confusion about their legal status and regulatory oversight. In these states, DPC and/or concierge medicine practices may face the risk of being considered as unauthorized insurers or engaging in unfair trade practices if they do not comply with the applicable insurance laws and regulations . Some states may also impose restrictions on the types of services that DPC and/or concierge medicine practices can offer or the fees that they can charge .
Federal Regulation
Federal regulation of DPC and concierge medicine mainly involves tax implications and compliance with health care reform laws. Under current tax law, DPC and concierge medicine fees are not considered as qualified medical expenses for purposes of health savings accounts (HSAs), which are tax-advantaged accounts that can be used to pay for out-of-pocket medical expenses. This means that DPC and concierge medicine patients cannot use their HSAs to pay for their membership fees or deduct them from their taxable income . However, there have been several legislative proposals to amend the tax code to allow HSA-eligible individuals to use their HSAs for DPC fees .
Another federal issue that affects DPC and concierge medicine is the Affordable Care Act (ACA), which requires most individuals to have minimum essential coverage (MEC) or pay a penalty. MEC is defined as any health insurance plan that meets certain standards of coverage and affordability. DPC and concierge medicine fees alone do not qualify as MEC, so DPC and concierge medicine patients need to have another form of MEC in addition to their membership fees to avoid the penalty . However, some DPC practices have partnered with health sharing ministries (HSMs), which are faith-based organizations that offer an alternative to traditional insurance by pooling members’ contributions to pay for each other’s medical expenses. HSMs are exempt from the ACA’s MEC requirement and may offer lower-cost options for DPC patients .
Future Implications
The regulation of DPC and concierge medicine is likely to evolve as these models become more popular and influential in the health care market. Some possible implications of future regulatory changes are:
– Increased clarity and consistency of state laws and regulations regarding DPC and concierge medicine, which may facilitate their growth and expansion across the country.
– Increased recognition and integration of DPC and concierge medicine in federal health care programs, such as Medicare, Medicaid, or the Veterans Health Administration, which may increase their accessibility and affordability for more patients.
– Increased innovation and collaboration of DPC and concierge medicine with other health care stakeholders, such as employers, insurers, hospitals, or technology companies, which may enhance their quality and value of care.
Conclusion
DPC and concierge medicine are two alternative models of primary care delivery that offer more personalized, accessible, and comprehensive care to patients. However, they also face some regulatory challenges and uncertainties at both the state and federal levels. State regulation of DPC and concierge medicine varies widely across the country, while federal regulation mainly involves tax implications and compliance with health care reform laws. Future regulatory changes may have significant implications for the growth and development of DPC and concierge medicine in the health care market.
References
: Norris, L. (2023). How Does Direct Primary Care Work? Verywell Health. Retrieved from https://www.verywellhealth.com/what-is-direct-primary-care-4777328
: Blue Ocean Health DPC. (2022). Concierge Medicine and Direct Primary Care: What’s the Difference? Retrieved from https://www.blueoceanhealthdpc.com/blog/concierge-medicine-and-direct-primary-care-whats-the-difference
: TMS Health & Wellness. (2022). Concierge Medicine vs. Direct Primary Care – What’s the Difference? Retrieved from https://www.tmshealthandwellness.com/concierge-medicine-vs-direct-primary-care-whats-the-difference/
: Elation Health. (2018). 10 Differences between direct primary care vs concierge medicine. Retrieved from https://www.elationhealth.com/resources/blogs/10-differences-between-dpc-and-concierge-care-2/
: Alexander, G.C., & Kurlander, J.E. (2015). The Patient Protection and Affordable Care Act’s effect on direct pay practices: legal issues for direct pay practices under the Affordable Care Act. Journal of Legal Medicine, 36(1), 7-21.
: Direct Primary Care Coalition. (2023). State Laws & Legislation. Retrieved from https://www.dpcare.org/state-laws-legislation
: American Academy of Family Physicians. (2019). Direct Primary Care: Legal Issues. Retrieved from https://www.aafp.org/practice-management/payment/dpc/legal.html
: Internal Revenue Service. (2021). Publication 502: Medical and Dental Expenses. Retrieved from https://www.irs.gov/pub/irs-pdf/p502.pdf
: Primary Care Enhancement Act of 2021, H.R. 787, 117th Cong. (2021).
: Internal Revenue Service. (2020). help write my research paper on Publication 5187: Affordable Care Act: What You and Your Family Need to Know. Retrieved from https://www.irs.gov/pub/irs-pdf/p5187.pdf
: Kacik, A. (2019). Direct primary care providers seek new ways to expand patient base. Modern Healthcare. Retrieved from https://www.modernhealthcare.com/article/20190713/NEWS/190719975/direct-primary-care-providers-seek-new-ways-to-expand-patient-base
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