On July 1, 2020 Governor North Carolina Governor Roy Cooper signed North Carolina House Bill 471 into law making North Carolina the 29th state to pass DPC defining “not insurance” legislation. The bill was passed in a landslide without a single nay vote in the house or senate. Thank you to many DPC physicians that supported the legislation and to Katherine Restrepo for quickly championing the bill through the house and senate. The formal effort started in late May 2020 and obviously has had a quick result.
I have received some questions about the terms of the law and want to make a few clarifying statements here.
I do not believe that the language of section (a)(1) prohibits an employer from paying for DPC for its employees. It does require that a DPC practice have a contract with each individual patient (even when someone or something else might be paying the periodic fee). I do not see any prohibition to a practice still having some fee for service items (labs, meds, radiology, procedures, vaccines), or even for having a per visit fee (as long as there is a monthly fee in place). The language "does not bill any third parties on a fee for service basis" is designed to be a concierge double dipping prohibition and does not prevent a practice from charging a per visit fee with the monthly fee. If a judge one day were to misinterpret this issue though and incorrectly conclude that a DPC practice could not charge a simple per visit fee with no associated CPT code to the patient's employer, then this scenario still doesn't play out in a problematic way for the DPC practice.
Remember that one of the main reasons practices felt obligated to add this fee was to appease an insurance commissioner that the business model was not insurance. Decades ago early DPC physicians were forced by insurance commissioners to add a per visit fee on top of their monthly fees to keep the practice from being labeled unlawful insurance. Many other early DPC practices adopted this small per visit fee design as a "not insurance" risk mitigation strategy as well. So while I am actually not convinced that this language as written would exclude a practice from being defined as DPC at the North Carolina state level based on the nature of the per visit fee, even if that were to happen it would not make much difference. Since the status quo is the default then as it stands right now practices charging patients in this way (monthly fee + a small per visit fee) are not receiving any insurance commissioner threats or inquiries anyway and this is unlikely to change. If a practice does not fit into the DPC box carved out by the state, then this does not mean it is suddenly and automatically insurance. Traditional third party FFS does not fit into this DPC box and it is not considered insurance. The higher that per visit fee charge, the less likely an insurance commissioner would want to investigate the practice at all. In fact I cannot think of a single practice that has ever received an insurance commissioner inquiry when it was already charging a per visit fee.
The seven part definition under section D does not prevent hybrid practices from being labeled DPC. A "DPC physician" is defined that way on an individual patient encounter basis. It is not all or nothing. A DPC physician could be DPC for some patients, and traditional Medicare for other patients, and maybe an ER physician for other patients if doing part time ER work, etc.
As written practices could still charge for labs, vaccines, certain procedures, and medications on itemized basis. Just describe these in the scope of the DPC agreement.
Phil Eskew