Hawaii lawmakers have passed legislation requesting the insurance division of the Department of Commerce and Consumer Affairs to research how direct primary care and concierge medicine have penetrated the island state’s health care market.
The insurance division’s first action should be one lawmakers left undone: They should accurately define “direct primary care,” thereby distinguishing it from concierge medicine and anything related to insurance.
As introduced, House Concurrent Resolution 157—sponsored by Speaker Joseph Souki (D-Kahakuloa)—identified direct primary care and concierge medicine as essentially the same, using the phrase “direct primary care, or ‘concierge medicine'” four times. For rusty grammarians: The comma in the quoted phrase inaccurately renders “concierge medicine” just another name for “direct primary care.”
The amended Senate version of HCR 157, approved by both chambers on April 27, wins the name game by removing the offending comma. The Senate also scrubbed the House’s inaccurate definition of concierge medicine as “the practice of financing direct primary care through direct payments by consumers, usually in the form of monthly fees, and the billing of patient health insurance plans.”
Nevertheless, the improved legislation still appears to lump some direct primary care under the concierge umbrella as “lower-end concierge medicine practices,” which, according to HCR 157, “usually do not accept insurance but instead charge patients directly for treatment along with membership and may post menu-style prices for services and expect payment up front.”
State health care policy is inherently complicated, a condition exacerbated by the overreach of federal lawmakers and bureaucrats. But even complicated policies should be clear and accurate—in contrast to HCR 157. As Dr. Phil Eskew, founder of DPC Frontier, told Health Care News on May 5, “When legislators … confuse direct primary care with concierge, they just confuse everyone.”
The fact is direct primary care differs from concierge in cost, purpose, and who foots the bill—categories important to ordinary patients and doctors and, presumably, their elected officials.
Direct primary care is priced for the ordinary patient. Most direct primary care memberships cost about as much as a Hawaiian Telcom TV-internet-home phone service bundle: $50 to $120 per month, or $600 to $1,440 per year. In exchange for a modest monthly membership fee comparable to a cell phone bill, direct primary care providers offer a range of preventive care services, such as a fixed number of visits per month or year, x-rays, blood labs, and other services.
Even at its higher end, the cost of direct primary care is lower than concierge’s typical $1,500 per year starting point—and lower than higher-end concierge’s $5,000 per year price tag almost by an order of magnitude. The fee difference between direct primary care and concierge reflects different services.
A number of direct primary care providers say they spend a chunk of each day answering specific patient questions by e-mail, text, and phone. When an office visit is necessary, these doctors schedule same- or next-day appointments for patients. Such responsiveness is a foreign concept to the masses of patients who associate doctor appointment with interminable wait.
Concierge offers patients immediate access—but little more, despite its higher cost. “[Concierge] gives you a telephone number 24/7/365 so you can call your doctor anytime and get in to see him that day or the next day if you’re having a problem,” Hal Scherz told Health Care News. “The doctor will still bill your insurance for whatever they do.”
By contrast, direct primary care providers do not bill insurance. Direct primary care membership agreements are private contracts between patients and doctors. No third-party insurer is necessary. Cutting out insurers where they add no value lets some doctors reduce overhead by up to 40 percent by eliminating middle-man costs, non-health-care-related staff, and the opportunity cost of processing insurance claims instead of treating patients. Doctors can reinvest their savings into providing better patient care.
Members of direct primary practices frequently lack insurance due to cost-prohibitive insurance premiums of plans offered on the Obamacare exchanges, and many who have health insurance cannot afford to use it due to high deductibles. The average deductible increased by $207 in Hawaii in 2016, and the average Bronze plan deductible in Hawaii grew by $1,350.
In contrast to concierge, direct primary care combines preventive care services, affordability, and access for patients, whether they have health insurance or not. Hawaii officials interested in health care solutions for ordinary patients should take care to distinguish these two models.