MedCity Influencers, Patient Engagement, Payers

Direct primary care has the same goals as MACRA without the complexity

MACRA has three goals for our healthcare system: better care, smarter spending and healthier people. MIPS measures these goals and links fee-for-service payments to quality and value. Direct primary care is quite similar.

primary care doctor
When I first heard about the federal government’s new value-based Quality Payment Program for physicians, I was struck by the similarities with direct primary care, a grassroots movement that seeks to establish a straight financial relationship between patients and providers, cutting out private insurance carriers and Medicare. The premise of direct primary care is that patients pay providers directly, usually in the form of a low monthly subscription.

The Medicare Access & Chip Reauthorization Act of 2015 (MACRA) has three goals for our healthcare system: better care, smarter spending and healthier people. The new Merit-based Incentive Payment System (MIPS) measures these goals and links fee-for-service payments to quality and value.

DPC is quite similar. This is from the website of the Direct Primary Care Coalition:

The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. Empowering this relationship is the key to achieving superior health outcomes, lower costs and an enhanced patient experience.”

The ways these goals are achieved by direct care and MACRA/MIPS are incredibly similar. Both approaches focus on: enhanced access to the practice; proactive care for chronic conditions and preventive diseases; patient and caregiver engagement; and coordination of care across the medical neighborhood. But the ways of administering care and measuring results is dramatically different.

Direct primary care is growing in popularity, fueled by physician discontent with the traditional fee-for-service model that encourages 15-minutes-or-less exams with an overwhelming number of appointments. Patients typically join a DPC practice as a “member” and pay a flat monthly fee (about $75) for virtually unlimited primary care, including extended in-office visits, as well as non-face-to-face care via email, phone and text. As a result, patients visit DPC doctors more often and develop stronger personal bonds.

Patients are often motivated by the high-deductible Affordable Care Act insurance plans that really cover only catastrophic care. A consumer with a $3,000 deductible is paying out-of-pocket for routine care anyway, so why not spend $1,000 each year for broad primary care without limits? This is an economically driven solution that exemplifies the best of capitalism and the free market.

In contrast, MIPS is administered by the Centers for Medicare and Medicaid Services and governed by a complex set of rules and requirements. This translates into lots of government mandates that intrude on the doctor-patient relationship.

For example, a single MIPS composite score will factor a physician’s performance in four weighted categories: quality (outcomes); resource use (cost); clinical practice improvement activities; and meaningful use of electronic health records. It starts to get complicated as each category breaks down into a myriad of requirements and choices.

DPC is the complete opposite in terms of government mandates because there really aren’t any requirements to speak of. There are no commercial insurers nor the office overhead required for fee-for-service billing. Physicians simply make a pact with their patients to provide high-quality primary care in exchange for a fixed cost per period of time.

Perhaps the government should consider that the grassroots DPC movement has the same goals as MACRA/MIPS, with a less complex approach. Support for DPC physicians would be a great place to start, and could be demonstrated through acts such as allowing consumers to use pre-tax dollars in health savings accounts to pay for DPC membership fees.

Photo: Flickr user Eva Blue

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