Monthly Archives: September 2016

“Direct Primary Care”

Its pretty clear that a coalition of “direct primary care” providers is pushing Congress to recognize subscription services as a service reimbursable under Medicare.

I believe they are differentiating themselves from “concierge” care, for political reasons. The coalition says concierge care is $2000-$5000, instead of under $2000. One of the main advocates for direct primary care says that it does not seek third party reimbursement, while concierge services might.

“The Primary Care Enhancement Act of 2016” has been brought to the Ways and Means Committee, where is was referred in September, 2016 to the Health Sub-Committee.

Sponsor: Rep. Paulsen, Erik [R-MN-3] (Introduced 09/13/2016)
Committees: House – Ways and Means
Latest Action: 09/19/2016 Referred to the Subcommittee on Health. (All Actions)

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Direct primary care could get a big boost next year. Under the federal health care law, these practices will be able to operate in state-based health insurance exchanges. However, insurers on exchanges must offer a basic benefits package that includes hospital, drug and other coverage, so direct primary care practices will likely team up with other health plans.
If you’re considering a direct primary care practice, get a list of provided services and talk with a physician in the practice. Also, some practices that are similar to concierge care may accept insurance but charge a monthly fee for extra services. For options in your area, visit the Web site of the Direct Primary Care Coalition (www.dpcare.org).

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The Primary Care Enhancement Act of 2016  proposes to amend the tax code so consumers can use their health savings accounts (HSAs) to pay physicians in direct primary care (DPC), bypassing insurance. H.R. 6015 would also enable Medicare enrollees to pay for direct primary care using Medicare funds, rather than pay out of pocket.

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http://www.dpcare.org

Senators Bill Cassidy, MD (R-LA) and Maria Cantwell (D-WA) have introduced bipartisan legislation which clarifies that DPC is a medical service for the purposes of the tax code regarding Health Savings Accounts. The bill also creates a new payment pathway for DPC as an alternative payment model (APM) in Medicare. “Co-sponsors are important. They show Senate leaders that there is widespread support for the legislation,” said Sen. Cassidy when he addressed the DPCC Fly-in Sept. 24. We need your help today to ensure that S.1989 moves forward.  Please contact your Senators and urge them to co-sponsor the Primary Care Enhancement Act today.

On the Move in the States with DPC
16 States Move to Clear Regulatory Hurdles for DPC 
Legislation  defines DPC outside of Insurance.
 
As of June, 2016, 16 states have adopted Direct Primary Care legislation which defines DPC as a medical service outside the scope of state insurance regulation. 
 
The DPCC has developed model legislation to help guide legislators and their staffs on the best way to accomplish  this important reform. Click here to see the model bill.
States With DPC Laws:

• Washington – 48-150 RCW
• Utah – UT 31A-4-106.5
• Oregon – ORS 735.500
• West Virginia – WV-16-2J-1
• Arizona – AZ 20-123
• Louisiana – LA Act 867
• Michigan – PA-0522-14
• Mississippi – SB 2687
• Idaho – SB 1062
• Oklahoma – SB 560
• Missouri – HB 769
• Kansas – HB 2225
• Texas – HB 1945
• Nebraska – Leg. Bill 817
• Tennessee – SB 2443
• Wyoming – SF0049

Current as of June, 2016

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Direct Primary Care is an innovative alternative payment model in primary care model embraced by patients, physicians, employers, payers and policymakers across the United States.The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. In DPC unwanted fee-for-service incentives are replaced with a simple flat monthly fee. This empowers the doctor-patient relationship and is the key to achieving superior health outcomes, lower costs and an enhanced patient experience.
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http://medicaleconomics.modernmedicine.com/medical-economics/news/bill-could-allow-health-saving-account-use-dpc

Direct primary care physicians charge patients a monthly fee for care and access to a package of services rather than by fee-for-service or insurance. The subscription model can grant patients increased access to doctors, discounted drugs and laboratory services. 
According to Meigs, the proposed law will allow people with high deductible plans to use their HSA to pay for primary care, given that people with high deductible insurance plans can use their insurance for catastrophic coverage and hospitalizations, and cost-effectively tap their HSAs for primary care.  

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Direct primary care and concierge medicine: They’re not the same

Direct primary care and concierge medicine: They’re not the same
SAMIR QAMAR, MD | PHYSICIAN | AUGUST 24, 2014
Samir Qamar
Direct primary care (DPC) and concierge medicine are rapidly growing models of primary care. Though the terms are used interchangeably, both are not the same. Such liberal use of terms, many times by even those within the industry, confuses those who are attempting to understand how these primary care models operate. As former concierge physician for the Pebble Beach Resorts, and subsequent founder of one of the nation’s largest direct primary care companies, I have attempted to differentiate the two based on extensive personal knowledge and experience.

First, concierge medicine. Born in the mid 1990s, this practice design was first created by wealthy individuals who were willing to “bypass” the woes of the current fee-for-service system by paying a subscription to access select primary care physicians. This access consists of same-day appointments, round-the-clock cell phone coverage, email and telemedicine service, and sometimes, as in my previous practice, house calls. Although some high-end practices charge as much as $30,000 a month, most charge an average monthly fee of $200.
In return, to allow such unrestricted access, physicians limit their patient panels to several hundred patients at most, a significant drop from the typical 2,500-plus panel size most doctors are used to. Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “access fee” is only for “non-covered” services. This results in two subscriptions paid by patients — the concierge medicine fee, and the insurance premium. Importantly, a few concierge practices do not bill insurance for medical visits, as the monthly fees cover both access and primary care visits.
Direct primary care started in the mid 2000s, and was created as an insurance-free model to serve a new patient population: the uninsured. In DPC, patients, and now their employers, are also charged a monthly fee, but the fee can be as low as $50 per month and there is typically no third-party payer involvement. Consumers pay physician entities directly (hence, direct primary care), and because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.

Patient panels can be as high as 1,500 patients per doctor, and there is typically no physician cell phone access or house call service. Similar to higher-priced concierge practices, DPC practices also allow for longer patient visits and telemedicine. The most important characteristic of DPC practices, however, is that insurance claims are not filed for medical visits.

Direct primary care’s definition, therefore, is any primary care practice model that is directly reimbursed by the consumer for both access and primary medical care, and which does not accept or bill third party payers.
Confusion arises from similarities that exist in both models, such as decreased patient panels, monthly subscriptions, and longer visits. There is added confusion when a DPC physician offers house calls or email access, typical of concierge practices. Confusion is maximized when a physician is by definition practicing direct primary care, yet calls the practice a “concierge practice.” Similarly, a concierge practice may decide to abstain from participating in third party payer systems, and thus would also be a DPC practice.
The distinction is important because direct primary care is explicitly mentioned in the Affordable Care Act, while concierge medicine is not. Several state laws have also recognized direct primary care as medical practice models, and non-insurance entities. In addition, the term “concierge medicine” causes visceral reactions in select social and medical circles, drawing criticism such as elitism and exacerbation of physician shortage.
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In summary, not all direct primary care practices are concierge practices, and not all concierge practices are direct primary care practices. The terms are not synonymous, and even the basic fundamentals of either model do not overlap. The key to differentiation is whether or not a third party payer is involved. If not, then the model is a direct pay, or direct primary care model, no matter what the fees.
Samir Qamar is CEO, MedLion and president, MedWand. He can be reached on Twitter @Samir_Qamar.

Frederick Goff Vision

Frederick Goff: The Vision for a Community Foundation
Over 100 years ago, Frederick Goff, acting as the President of the fast-growing Cleveland Trust, set up the Cleveland Foundation. It was the first community foundation in the U.S., established in 1914. Indianapolis followed in 1916, Chicago in 1919, and New York in 1920. By 1931 – 74 communities had established community foundations.
What made such a rapid expansion possible? The answer lies in the powerful vision of Frederick Goff. It was Goff that saw the need for an institution that addressed two great societal forces: the urge of donors to give, and the unmet needs of fast-growing communities.
Day after day, as a banker, Goff worked to serve his high net worth clients with ways to maximize their impact as philanthropists.
Day after day, as a civic leader, Goff also saw unmet needs in his community, Cleveland. These needs were met neither by the marketplace nor by government. Examples were everywhere: churches, colleges, hospitals, and homeless shelter were just the beginning of a long list of more-than-worthy causes with unmet needs.
Out of this work, as a banker and as a civic leader, Off formed a compelling vision: His vision was to create a “permanent enduring institution”, a “community chest”, which could match the needs of donors to the needs of the community. The community trust (now called a community foundation) was perfectly suited to serve in this way.
His vision was a way for community needs to be met, as well as a way to facilitate donor giving.
In a sense, Goff fused philanthropy after death to living philanthropy. Where others saw estate planning and living philanthropy as two separate issues, Goff saw them as seamlessly connected, through a “permanently enduring organization” – a community trust.

While some wealthy people, along with their estate planners, toiled to describe in excruciating detail how fortunes were to be used in the future to advance community well-being, Goff asked a much simpler question: can a donor give his or her wealth to a permanently enduring organization that the donor trusts?
He conceived of this “permanently enduring organization” – this “community trust” – as a way to enable both a “living trust” and decision-making about the use of funds when the donor was no longer able to make those decisions.
Goff expressed his vision beautifully in Colliers magazine:

“How fine it would be if a man about to make a will could go to a permanently enduring organization –  what Chief Justice Marshall called an ‘artificial immortal being’ – and say: ‘Here is a large sum of money. I want to leave it to be used for the good of the community, but I have no way of knowing what will be the greatest need of the community 50 years from now, or even 10 years from now. Therefore, I place it in your hands, because you will be here, you and your successors, through the years, to determine what should be done with this sum to make it most useful for people of each succeeding generation.’”

The early visionaries called them “community trusts”. Now called “community foundations”, they were a product of people, places, and policy innovations.
Goff foresaw an institution that could be capable of great stewardship, that could respect the wishes of donors, deceased and alive. For the deceased, the institution would need to be capable of carefully respecting donor wishes as detailed in wills and other expressions of intent. And for the living, he also saw – in that same institution – a capacity to listen to donors, to earn their trust, and abide by their wishes for their hard-earned money.
Goff envisioned a living and breathing organization, in touch with present-day needs of the community. This would be not simply an institution that was administering the wishes of people who had long since died. It would be an organization with the capacity to hold a “trust’, or an endowment, for the “community”. Indeed, in the early days these organizations were called “community trusts”.
The Mayor of Cleveland strongly backed Goff with this assertion about the value of a “community trust”:

“…The Community Trust is an endeavor to substitute contemporary wisdom for foresight; and that is particularly important when we reflect that we are living in a world which has changed more rapidly and in more of its fundamental conceptions within the past dozen years that it has ever done before in as many centuries.”
Newton D. Baker, Mayor of Cleveland, and former Secretary of War