State and Federal Policy Update...• High-functioning primary care and prevention services •...
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Transcript of State and Federal Policy Update...• High-functioning primary care and prevention services •...
State and Federal Policy Update
Phil Eskew, DO, JD, MBAJay Keese
Learning Objectives• Describe recent federal and statewide legislative trends• Evaluate the major regulatory hurdles facing new DPC
practices.• Develop and implement appropriate compliance and
mitigation strategies to minimize regulatory risks.• Evaluate the existing resources and support
infrastructure available to support physicians interested in becoming engaged with DPC advocacy efforts
Activity DisclaimerThe material presented here is being made available by the DPC Summit Co-Organizers for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or processes appropriate for the practice models discussed. Rather, it is intended to present statements and opinions of the faculty that may be helpful to others in similar situations.
Any performance data from any direct primary care practices cited herein is intended for purposes of illustration only and should not be viewed as a recommendation of how to conduct your practice.
The DPC Summit Co-Organizers disclaim liability for damages or claims that might arise out of the use of the materials presented herein, whether asserted by a physician or any other person. While the DPC Summit Co-Organizers have attempted to ensure the accuracy of the data presented here, these materials may contain information and/or opinions developed by others, and their inclusion here does not necessarily imply endorsement by any of the DPC Summit Co-Organizers.
The DPC Summit Co-Organizers are not making any recommendation of how you should conduct your practice or any guarantee regarding the financial viability of DPC conversion or practice.
Faculty DisclosureIt is the policy of the DPC Summit Co-Organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.
All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose.
The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.
June 2014 – 125 Locations
July 2015 – 290 Locations
Sept 2016 – 445 Locations
April 2017 – 620 Locations
2017 “Wins” SummaryKY #18 03/17/17WV 03/24/17 – Replaced bad law with goodAR 04/07/17 – Revised bad law with goodIN #19 04/21/17CO #20 04/24/17VA #21 04/26/17AL #22 05/26/17ME #23 06/01/17
2017 “Losses” SummaryMT – Better language, same bad governorFL – Extensive efforts, broad supportGA – died early, insurance company obstructionSC – died early, insurance company obstruction
2017 State Political Climate• DPC is Bipartisan!
– NE & WY without a single nay vote!– Reps like free market approach (5 govs)– Dems like emphasis on access to care (3 govs)
• Insurance companies manipulate both parties• No “Bad” laws enacted• Increasing DPC Interest
– Michigan Medicaid Pilot– State Employees (NC, NJ, CO)
When Approaching Republicans• Price Transparency• Free Market Pricing• Less Red Tape• Lower Government Spending• Favored by HHS / President Trump
When Approaching Democrats• DPC is already legal and growing in 47 states
– This avoids legal waste for government & Drs– Establishes consistency & predictability
• DPC does not discourage insurance coverage– Mandatory disclaimers– Promoted in the Affordable Care Act
• Ongoing primary care, not UC/ED avoidance• DPC is NOT Concierge (no double dipping)
Continued Efforts• Pennsylvania – DPC “not insurance” legislation talks are
ongoing• CA, NY, MA, AK, HI, NH, VT – All have had discussions about
DPC at varying levels• State Employee Plans (NJ, CO, NC)• Michigan Medicaid Pilot Discussions• Dispensing Hurdles
– Partial Repeal of prohibition in Utah– Ongoing Efforts in Texas
What Is Direct Primary Care?
• High-functioning primary care and prevention services
• Direct agreement between doctor and patient• Monthly retainer or periodic fee paid by individual,
employer, health plan, or other payer• No third party, fee for service billing
• Significantly reduced administrative costs• Improved health outcomes
• Medical services: Not insurance or health plan • Defined in ACA - §1301 (A) (3) and...
• 23 State Laws (e.g. WA 48.150 RCW)
Direct Primary Care in 2017
• 620 DPC Practices in 47 States + DC • Median fee about $70 per month * • Better outcomes, patient satisfaction• Savings of up to 20% *• Offered through employers, Medicare Advantage, Medicaid
* Journal American Board of Family Medicine , Nov. 2015
DPC Policy Issues:
• State Insurance Regulation• Insurance definitions in 23 states: More needed to prevent future regulation• Legislation may be needed to bring DPC to Medicaid – 1332 Waivers• State Legislatures must weigh in with Congress on HSA issues
• Fix DPC issues in the Tax Code: Health Savings Accounts • DPC not a qualified medical expense {IRC 213 (d)}• IRS considers DPC a “health plan” {IRC 223 (c)}: DPC disqualifies HSAs• Primary Care Enhancement Act S. 1989; H.R. 6015 clarifies tax code on both points
• Bring DPC to Medicare/Medicaid/VA– the nation’s highest utilizers of care
• DPC offered only with Medicaid MCOs and Medicare Advantage • No Regular FFS Medicare/Medicaid payment methodology for DPC• S. 1989 – defines DPC as “Alternative Payment Model” (APM)• MACRA payment reforms may lead to path as APM• VA Choice Program
The Primary Care Enhancement Act
• Bipartisan Bill - Reps Erik Paulsen (R-MN) and Earl Blumenauer (D-OR) Sens. Bill Cassidy, MD (R-LA) and Maria Cantwell (D-WA)
• Clarifies HSA Provisions regarding DPC in the Tax Code
• DPC is not a health plan under IRC §223 (c)
• DPC is a qualified health expense under the IRC §213 (d)
• Allows individuals with HSAs to pay for DPC services with HSAs.
1. Washington – 48-150 RCW
2. Utah – UT 31A-4-106.5
3. Oregon – ORS 735.500
4. West Virginia – WV-16-2J-1
5. Arizona – AZ 20-123
6. Louisiana – LA Act 867
7. Michigan – PA-0522-14
8. Mississippi – SB 2687
9. Idaho – SB 1062
10. Oklahoma – SB 560
11. Missouri – HB 769
12. Kansas – HB 2225
13. Texas – HB 1945
14. Nebraska – Legislative Bill 817
15. Tennessee – SB 2443
16. Wyoming – SF0049
17. Arkansas – HB 1161
18. Kentucky – SB 79
19. Colorado – HB 17-1115
20. Indiana – SB 303
21. Virginia - HB 2053
22. Alabama - SB 94
23. Maine - S.P. 472
• Laws generally define DPC as a medical service outside of state insurance regulation, offer varying levels of consumer protection
• Restrictive WV and AR laws modified in 2017• MT Bill vetoed by governor. • OR and AZ laws need updates• FL, and GA bills introduced but have not passed• PA legislation just introduced.
DPC Laws Passed in 23 States – 8 New Laws in 2017
State Legislation 2017States considering legislation:
Alabama - Signed by Governor
Arkansas– Revision Signed by Governor
Colorado– Signed by Governor
Florida – Passed House
Georgia– Passed Senate House in 2018?
Indiana – Signed by Governor
Kentucky – Signed by Governor
Maine- Signed by Governor
Montana– Passed Both Houses Vetoed
Michigan – HSA Resolution Introduced
Pennsylvania– Introduced
South Carolina– Introduced
Virginia – Signed by Governor
West Virginia – Revision Signed by Governor
Medicaid Direct Primary Care Initiative
2018 HHS Budget in Brief Page 62
Questions?
Submit your questions to: aafp.cnf.io
Jay KeeseExecutive Director, DPC Coalition(202) [email protected]
Contact Info:
Phil Eskew, DO, JD, [email protected]
Twitter @philsq
