Direct-pay primary care offers a twist on concierge -- for the uninsured

Retainer medicine doesn't have to be just for the "haves," as some policy analysts decry. According to Michael Fine, MD, managing director of HealthAccessRI, which helps primary-care practices in Rhode Island set up programs offering monthly practice memberships to uninsured patients, "if you can afford a cell phone, you can afford primary care."

A growing number of practices throughout the country are beginning to adopt that philosophy, according to American Medical News. The concept of discounted fee-for-service or direct-pay primary care programs, as they're called, is derived from concierge care, but with important differences.

First, the fees--from $25 to $75 a month with a six-month to one-year subscription--tend to be lower than traditional concierge care and well under the cost of private insurance. Most doctors offering such programs also accept insurance, and patients with insurance usually cannot sign up for discount plans. Other differences: Discount FFS doctors do not usually reduce their patient panels or provide any extra frills in exchange for the retainer. The chief perk to patients is that they're covered for a generous number of visits within the subscription period (e.g., 15 per year), usually with an additional sliding-scale fee for each visit they use.

One caveat, however, is to ensure that discount care subscriptions don't run afoul of insurance regulations. Better to approach insurance regulators first than to reduce the risk of establishing something that could be shut down later, physicians using the model warn. To avoid problems, the number of visits included in a membership may need to be capped, and the monthly fee may need to be charged at the end of the month for the past services rather than in advance.

For physicians, assuming the legal details are in order, the arrangement appears to be financially sound, as a recent experiment in Oregon revealed that practices using monthly retainer systems collected a reimbursement rate equivalent to $42.88 per relative value unit vs. statewide average Medicare rates per RVU of $38 and $34 for Medicaid. The cohort study is published in the May/June Journal of the American Board of Family Medicine.

Finally, proponents say that direct-pay models, when combined with high-deductible health plans, could hold a key place in a reformed healthcare marketplace, perhaps especially for "young invincibles" and the self-employed living on the edge of the poverty line, who many suspect will stay behind when health reform takes off.

To learn more:
- read this piece in American Medical News
- see this article in the Providence Phoenix
- check out the abstract in the Journal of the American Board of Family Medicine

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Insurers not happy with concierge medicine
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