Concierge Care' Provides a Patient-First Health Benefits Approach

Vanessa Haas, HR director for Longmont, Colo.-based Left Hand Brewing, is convinced she would not be alive today had the brewery not instituted a kind of concierge care for its employees.

Haas, who considers herself to be active and healthy, began suffering from mysterious breathing difficulties over Memorial Day weekend. Rather than being routed to a call nurse who may not have triaged her correctly, Haas directly contacted her physician, who recognized the symptoms of pulmonary embolism, told her to come see him and had her admitted to the hospital through the emergency room within 90 minutes.

"I had a doctor who was being my quarterback," Haas said.

The brewery had adopted a creative relationship with its contracted primary care physicians, under a model called direct primary care—an offshoot of the "concierge health care" concept that touts a higher level of primary care service for enrolled patients.

With direct primary care (DPC), individuals and/or their employer pay a monthly retainer fee that allows the patient to receive all necessary primary care without further cost or involvement by insurance carriers ("primary care" here generally refers to office examinations and consultations with the primary care physician). A wrap-around health care plan from an insurance carrier or a self-insured employer kicks in beyond these services.

Typical DPC coverage costs an average of $77 per patient per month, which is significantly cheaper than other forms of concierge care sometimes portrayed as a perk for the rich and famous. The model is therefore more adaptable for employee benefits programs.

DPC's keystone feature is a lower number of patients per physician, often 70 percent fewer than in the insured fee-for-service model. Backers say this enables a much closer relationship between doctor and patient, makes more time available per appointment, facilitates phone contact with the doctor outside of office hours and in the end reduces costs by easing access to primary care.

Combined with a high-deductible insurance policy for catastrophic and major medical expenses, DPC has made true believers out of early adopters, including Haas and Mark Watson, executive director of HR for Union County, N.C.

Watson has contracted with Denver-based Paladina Health to provide DPC for Union County's 1,000 full-time employees and 2,009 insured lives. Haas said that Left Hand, which employs 123, uses Dacono, Colo.-based Nextera Healthcare for DPC services. 

Union County pays 100 percent of the monthly DPC costs, Watson said, while Left Hand pays 75 percent, according to Haas.

To take advantage of the benefit, employees must select a primary care physician within their respective DPC provider's network. Nevertheless, both Haas and Watson reported impressive take-up rates for their DPC option: Left Hand has a 62 percent DPC participation rate, while 44 percent of those covered by Union County have so far opted for DPC.

Watson also said more than 90 percent of Union County's DPC patients with two or more chronic conditions are highly engaged with their physicians, making an average of 3.3 to 5.5 visits per year to manage their health.

Million-Dollar Payoff

"I'm a skeptic," Watson said. "I really don't take things at face value when somebody tells me and doesn't show me the numbers."

In the first year DPC has been available as an option for Union County's employees and their families,  "if we had not had the DPC in place, there would have been another $1 million expense to our plan," Watson said (the figure is $929,100, to be exact). That savings was calculated based on how much the county's wrap-around consumer-directed health plan (CDHP) by itself would have cost. (For fiscal year 2016, the county's overall health benefits cost for its employees increased by 1.91 percent, from $12.89 million to $13.13 million.)

Watson has posted a YouTube video in which he discusses the cost savings associated with the county's adoption of a direct primary care option.

Similarly, Haas said Left Hand's costs are also reduced through DPC participation, "because every DPC visit is a claim not hitting the medical carrier and impacting renewal." Left Hand has not had an increased fee from its DPC provider, Nextera, since the company inaugurated the benefit in 2012. In contrast, Haas said her firm's wrap-around CDHP, provided by Cigna, will go up 5 percent in 2017.

Obstacles to Growth

These employers' positive experiences with DPC may make it sound like it is poised to boom. However, even though DPC is compatible with the Affordable Care Act, there are significant obstacles to seeing it break out of its niche. As of late 2015, Nextera owner Clint Flanagan estimated that 2 to 3 percent of primary care was being delivered via DPC arrangements and indicated that he hoped to see it reach double digits by 2020.

One hurdle is the shortage of primary care physicians. "Most developed countries have a ratio of primary care physicians to specialists of 50-50. In the US, it's about 30 percent primary care and 70 percent specialists," said Carolyn Engelhard, associate director of the Center for Health Policy at the University of Virginia. She cited the attraction of the typically much higher income in specialty medicine as a major factor.

Another obstacle is that under current IRS policy individuals may not contribute to a health savings account (HSA) if they have a relationship with a DPC plan, and employers that cover their employees in high-deductible health plans paired with HSAs may not offer DPC as a health benefit to those employees, according to the Direct Primary Care Coalition (DPCC), a trade group. DPCC's website says it "continues to have dialogue with officials at Treasury to ask for a change in IRS guidance" so that DPC coverage can be offered as a benefit complimenting HSAs. "If the administration is unwilling to make such a change, legislation will be needed," the group stated.

But perhaps the largest impediment is a lack of awareness among insurance brokers who act as the link between employers and health benefit providers. For instance, Watson has received numerous inquiries from other HR executives about how DPC works for Union County, but said "the hangup is with broker consultants: They don't know anything about it. It's too far outside the product they normally sell and they see it diminishing their income. And because they don't understand it, they can't assist their clients in taking their program and meshing a DPC component into it."

He added, "That is the biggest hurdle to DPC in this country at this point; I am convinced of that."

Alternative Approaches

There are variations within the DPC model that employers also should keep in mind. For instance Privia Health, currently based in Georgia, Maryland, Texas, Virginia and Washington, D.C., touts that for its monthly fee—which ranges from $25 to $75 per enrolled individual depending on service level—covered employees gain access to same-day appointments (or next-day appointments if it is already late in the day) with a primary doctor who is part of Privia's network, secure e-mail messaging and online consultations with their doctor through the firm's dedicated platform, and other "time-saving conveniences that decrease absenteeism and improve productivity."

However, employees rely on their insurance coverage to pay their doctors for primary care services under this approach, rendering it HSA compatible when paired with high-deductible health plans.

Privia's package also includes access to a wellness team that provides phone consultations with a wellness coach, dietitian and even a fitness trainer, all of whom work in concert with the primary care physician to help patients identify health goals and implement their doctor's care recommendations—bringing aspects of the "medical home" and concierge care models into the employee benefits space.

Greg Goth is a freelance writer covering employment issues. He's based in Oakville, Conn.