Regulatory Backdrop for Direct Primary Care: The Future of Concierge Medicine Under the Accountable Care Act.

How does the Accountable Care Act deal with cash practices?

Actually, quite well. Well, sort of.

The ACA authorizes HHS to permit qualified health plans (QHPs) to provide coverage through a qualified “direct primary care medical home” plan. The plan has to provide coverage that meets certain criteria (as developed by the Secretary of HHS) and that the QHP, meeting all other applicable requirements, ensures coordination of such services with the entity offering the QHP. Huh?
With respect to implementing guidance, this provision was addressed in 2012 in CMS Exchange/QHP final regulation, in which CMS codified the treatment of direct plans. The provision authorizes QHP issuers to provide coverage through a direct PCMH that meets the standards established by HHS, provided that the QHP meets all standards otherwise applicable. CMS in its final rule addressed comments raised during the proposed rule-making process relative to what those standards might look like, noting in the final rule that direct PCMHs need not be accredited in order to participate in QHP networks. However, CMS “encourage[d] QHP issuers to consider the accreditation, licensure, or performance of all network providers.”

CMS opted in the final rule not to set firm requirements or thresholds
that would necessitate that QHP issuers contract with a specified number or percentage of direct PCMHs. Thus, CMS in its final rule, does not direct that Exchanges create incentives for contracting with direct PCMHs; instead CMS “encourage[s] Exchanges to promote, and QHP issuers to explore innovative models of delivery along the care spectrum.” Thus, there does appear to be an opportunity for Exchanges and QHP issuers alike
to promote and include such models, but per the final guidance on this provision, there is no obligation to do so.

In California, Covered California does not explicitly recognize direct primary care.  There are attempts in the legislature to allow for these cash practices. However, it is generally agreed that practices that accept monthly payments for primary care — similar to the way insurance covers health care, but without the insurance—will pass muster in the state. Instead of filing claims through an insurer, participants — individuals and employers — pay a monthly membership fee directly to their health care providers.

The newer primary care models could come in many flavors:

• Hybrids that offer fee-for-service insurance or a flat monthly fee (not insurance);
• Access model, which charges members an annual or monthly fee for providing enhanced services and bills insurance companies; and
• Qliance’s brand of care, the direct practice model, which charges a flat fee for unrestricted access to primary care services and does not bill insurance.

Does the cash practice make sense?  Take a look at the practices on Yelp that have taken the leap.

By Matt Kinley, Esq.