Learn the top essential reports required to optimize revenue, predict cashflow, monitor productivity and join the 99% Club of clean claim submission. Learn RCM from the nation's top Billers and RCM experts. Join our Live Webinar Series Thursday at 3pm Eastern.

As healthcare organizations attempt to accommodate the ACA patient wave, it’s becoming more difficult for even longtime patients to see their physician for routine care. For many, getting a checkup can feel like being dropped into a “patient mill.” Physicians can’t provide optimal care in a 15-minute appointment, even for patients they’ve known for years.

A move to a concierge setup, or direct primary care, makes particular sense for primary care doctors and their patients. Overburdened physicians considering the move are motivated by some familiar factors, such as frustration with onerous insurance and regulatory requirements. Patients now faced with rising out-of-pocket costs and new health plan restrictions on the care they can receive, seem willing to directly pay their doctor for routine care.

Revenue cycle management
Direct primary care allows physicians to spend more time with patients.

These arrangements don’t cater just to wealthy patients. Increasingly, patients with more modest incomes, as well as Medicaid and Medicare populations, are gaining access to concierge service. More than 60 percent of concierge and direct primary care memberships cost less than $135 per month, according to Concierge Medicine Today.

In 2012, there were approximately 4,400 concierge physicians in the US, 30 percent more than the previous year, according to the American Academy of Private Physicians. The trend continues to build, lending credence to a prediction made in 2013: “Five years from now, if you want a personal physician for all your healthcare needs, you will need to pay for the privilege.” (Note: There is no official federal or state registry for concierge/direct primary care practices, so the number of physicians in direct-pay practices is an educated estimate.
Patients opting for direct primary care might do so to fend off high insurance costs or to access service without waiting days or weeks for an appointment. Some concierge providers make house calls. Annual costs to patients vary from a few thousand to tens of thousands of dollars for this care. These retainers may include common tests and reduced prescription costs.

Advantages and disadvantages

Direct primary care provides a more stable revenue stream from patients, saving practices money by lowering the office overhead required for insurance billing procedures. Practices often pass their lower costs on to patients in the form of lower charges for services, including those that aren’t covered by the monthly or yearly fee.
Lighter patient loads mean physicians can spend more time with their patients. This allows them to have lives outside of their practice and still provide holistic care to their patients, preventing or treating conditions that drive up healthcare costs, such as diabetes.

Revenue cycle management
Some concierge providers make house calls.

There are some downsides to the concierge approach. There have been questions about whether concierge plans are acceptable under the Affordable Care Act’s requirement of health plan coverage for all Americans. The language in the ACA says yes—under certain conditions. Direct primary-care arrangements count as ACA-compliant if they’re bundled with a catastrophic medical policy for emergencies. Physician eligibility requirements differ based on whether or not they accept Medicare and Medicaid.
According to the American Academy of Family Physicians, direct primary care practices can continue to see Medicare beneficiaries if the patients’ retainer fees do not cover services that are already covered under Medicare.

Addressing challenges

Other challenges for physicians include a scarcity of concierge-practice-specific business training. Practices that are considering a direct-payment framework must understand this model involves a fairly sophisticated marketing program to be successful. Doctors must enroll their own patients who pay with their own money.
Public perception of concierge practices, such as the idea that these practices cater only to the wealthy, can be another obstacle. Practices must get the word out that a subscription-based model might cost less than a patient’s current health plan. The practice should consider hiring experts who can contact patients and explain why this is a better model for both parties.
Converts to concierge also must do their homework with regard to Medicare patients. Medicare does allow physicians to contract with patients, but the physicians must opt out of Medicare to do so. They can’t return to Medicare for a period of two years and cannot bill Medicare for any Medicare beneficiary during that period.
The office itself may need an upgrade to reflect better customer service. Concierge patients expect services such as same-day appointments, shorter wait times, and better physician communication and accessibility. Consider removing clutter from the office and making lighting and furniture upgrades to the waiting area, including removing that glass partition between the waiting room and the rest of the facility.
Front-office staff plays a vital role in a concierge practice. Fortunately, most of the “changes” for front-office staff are things they should already be doing, such as: dressing professionally, greeting patients promptly, and following up after appointments or changes in patient medication.
Prospective concierge practices should also assess their EHR and practice management systems. Practices will need direct-payment EHR features such as:

  • Membership management capabilities that handle patient enrollment, payments, revenue, and outstanding expenses.
  • Structured fields for documenting conditions over time, which eases reporting.
  • Free-text fields for creating informative narratives.

Concierge medicine will continue to evolve with rest of US medical care. Practices that are considering the move to direct-pay care models should evaluate their physician morale and current financial state of affairs and weigh their options accordingly.

Last Updated on August 9, 2022

Create a Sandbox Account