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What is it that Americans really want from their health care system? Do they want high-deductible insurance plans, 80-20 insurance, PPOs, HMOs, or something else entirely?
Most consumers do not even bother to think of these things when envisioning their ideal medical system, as these are primarily insurance concepts—as opposed to health care concepts. Despite policymakers’ obsession with them, these insurance concepts do not reflect what most patients deal with daily.
Here’s what people really want: a well-trained, high-quality, caring doctor who will listen to them, accurately and compassionately address their concerns, and be available when needed. Direct primary care (DPC)—in contrast to third-party-payer models—achieves just that.
Decades ago, when a patient was too sick to go to the doctor’s office, the doctor made a house call. Though this practice seems old-fashioned now, most people would agree that the current system often leaves much to be desired. The exception could be the emerging concept of direct primary care and integrated health.
These days, when someone gets sick, they call their primary care doctor and, sometimes days later, they have a 15-minute appointment, which leaves little time to ask difficult questions or build a connection. The current system also does little to connect various different physicians, nurses, imaging centers, hospitals and beyond to each other, making the health care journey less efficient, less personal and more costly. A more personalized health care experience could improve the health and well-being of most people—and save employers money. Direct primary care could help us get there.
HSAs are a type of savings account that allows people to set aside money before taxes to pay for qualified medical expenses such as deductibles, copayments, and coinsurance. Some in Congress want to extend those qualified medical expenses to include dues that members pay to direct primary care practices. Because DPCs don’t accept insurance or payment from third-party payers, they can offer unlimited primary care for typically less than $100 per month.
Bills Would Broaden HSAs
Sen. Marco Rubio (R-FL) introduced S. 12, the Health Savings Act of 2019. Cosponsored by Sen. Lisa Murkowski (R-AK), the legislation would expand what qualifies as a valid expense for the use of HSAs. Under current law, the Internal Revenue Service handles DPC fees differently from insurance premiums and copays, which are qualified expenses.
In the House, Rep. Mike Gallagher (R-WI) introduced H.R. 603, the Health Savings Account Expansion Act of 2019. The legislation would increase the maximum allowed contribution amount, repeal the restriction on using HSAs for over-the-counter medications, remove the requirement that a person with an HSA also be enrolled in a high-deductible health insurance plan, and allow the use of HSAs to pay for health insurance premiums and direct primary care service arrangements.
Nicole Hemkes was growing tired of being another employee doctor.
The Madison-area physician spent much of the past decade employed at hospital or group health care facilities, much like the vast majority of her peers in medicine. In fact, less than a third of physicians identified as private practice owners, according to a 2018 survey by the Physicians Foundation and Merritt Hawkins.
Hemkes had had her share of insurance-based medicine, seeing her standard 30 patients a day, spending more time on paperwork than with the people she is supposed to serve.
“A 10- or 15-minute appointment is just not enough,” she recently told MacIver News Service. “You’re kind of hooked to the computers because you have to have so much documentation done that you need to submit to a code that is going to bill for that visit, and that’s the way the health system gets paid.”
“So much of what we do seems to be more focused on the billing and the payment rather than the patient,” the physician said.
Classifying DPC as not being insurance means these providers are not subject to insurance regulations that drive up the cost of health care. Direct primary care practices charge a flat fee for unlimited service. The providers can offer lower prices because bypassing the insurance system reduces administrative costs substantially. Members often supplement their care by buying insurance coverage through health-care sharing ministry programs which cover hospitalization and specialty care at a fraction of the price of traditional insurance plans.
According to DPC Frontier, an online resource for the DPC movement, 25 states have laws that define DPC as not insurance. This year, insurance definition bills emerged in Arizona, Georgia, Hawaii, Maryland, Minnesota, New Hampshire, South Carolina, and Wisconsin.
The Arizona governor signed into law SB 1105 which addressed ambiguity in previous law by now specifically stating DPC plans are not insurance. Georgia became the 26thstate this year to not define DPC as insurance with the passage of SB18.
Recently, CMS introduced its latest payment reform proposal, titled the “Primary Care Initiative.” This is the latest in a long line of federal schemes to try to rein in the cost of medical care and introduce appropriate incentives.
Sadly, despite its many efforts, CMS and federal lawmakers have continued to miss the elephant in the room: Regardless of the model CMS imposes, whenever third parties manage transactions, as health insurance companies and governments currently do throughout our health-care system, many normal market forces are hopelessly distorted.
This is because third-party transactions can never replicate the normal free-market incentives that occur viscerally and free of charge when a patient controls the resources devoted to his or her own care.
Many of the principal problems with the current health-care system started in the 1960s, when health insurance and then government became the primary payers for medical services. After the advent of Medicare, there was a veritable price explosion, as providers took advantage of the blank check that had been written by CMS. Patients were no longer incentivized to pay close attention to the cost of care and in most cases, they stopped caring about health-care prices altogether.
Health-care policy is often portrayed as a fight between government and insurance companies. But one of the most effective cost-saving measures is to cut out both and allow patients to deal directly with doctors.
If Todd Gibbons from Poulsbo, Wash., has an aching shoulder or needs a physical, he can call and schedule an appointment on a day’s notice, maybe the same day. His physician is also available for phone consultations and even makes house calls. It all costs Mr. Gibbons $150 a month to cover his family of five.
Costs are so low and coverage so good because the Gibbons family goes to Vintage Direct Primary Care—a medical practice that treats patients for routine care and procedures for a monthly membership fee. Virtually every routine service—from electrocardiograms and pap smears to stitches and physicals—is included. There are no office-visit fees or copayments. All physician services and procedures offered at Vintage are covered, and all without the use of health insurance.
Ever-rising drug costs are a huge problem for many Americans and a major reason for patient nonadherence to treatment recommendations.
In-house medication dispensing often can save patients money and improve medication adherence. Patients also report that they appreciate the convenience of in-house dispensing.
Forty-four states allow physicians to dispense medications directly to patients. While each state has its own rules regarding physician registration and compliance, in general, the requirements are not excessively burdensome.
Where I practice in Florida, dispensing physicians must register with the Florida Board of Medicine and pay a $100 fee. Physicians must also follow basic safety methods to ensure proper storage of medication, accurate labeling, and patient counseling.
Often, the most effective way to make a point is to tell a story. And that’s what NPR does in its new report on high-deductible health policies (HDHPs) that are keeping too many Americans out of their doctors’ offices.
Susan, who carries a gene that makes her predisposed to breast cancer, has one of those policies. The deductible of $6,000 meant that when she got her first MRI and a mammogram to screen for breast cancer, she paid $3,800 out of her own pocket. It cost so much in 2017 that she was forced to delay her screening in 2018.
She’s not alone; a new study shows that many American women are forced by high deductibles to delay detection and treatment of breast cancer. These aren’t women who are uninsured; they’re women who have health insurance policies fully compliant with the Affordable Care Act.