Primary Care Direct Model: 'Neither Insurance nor Health Plan'

A new model of health care delivery ­­ direct primary care ­­ could be déjà vu for some Californians, a retreat to the past when insurance wasn't a part of the health care equation. Direct primary care emphasizes prevention and a reduction in the use of "downstream services" ­­ treating symptoms rather than the problems themselves. The new approach involves monthly payments for primary care ­­ similar to the way insurance covers health care, but without the insurance. Instead of filing claims through an insurer, participants ­­ individuals and employers ­­ pay a monthly membership fee directly to their health care providers. "Direct primary care is simply an atypical payment arrangement between patient and doctor for primary care services rendered," said Michael McClelland, an attorney with McClelland Advocacy in Sacramento. "It is neither health insurance nor a health plan and is not marketed as such." McClelland, former chief prosecutor for the state Department of Managed Health Care who now is running his own law firm, said some states are skeptical about the direct primary care model because it might place too much risk on physicians. The California Legislature earlier this year rejected a bill to establish a statewide framework for the direct pay model. McClelland also said in some states, the direct practice model might be equated to concierge medicine, a model in which patients also pay monthly or annual fees for increased access to their providers. Concierge medicine, also known as boutique or retainer­based medicine, comes in a variety of packaging ­­ with and without insurance, with and without pervisit payments ­­ just as direct primary care models do. The most significant differences, proponents say, are that direct primary care puts more emphasis on family physicians instead of specialists and generally costs less than most concierge offerings