I'm Standing Up for Direct Primary Care
As my plane's wheels touched down on the tarmac at Reagan National Airport, I thought to myself, "What possessed me to travel halfway across the country to talk with members of Congress?" (My wife, who stayed at home with our four children, was probably wondering the same thing.)
I started my direct primary care (DPC) practice in 2011 because I wasn't confident that Congress would -- or could -- fix much of what plagues our health care system, particularly primary care. In a June 2012 blog post, I wrote, "I am not waiting for another round of regulatory tweaking to improve the value, access and quality of my professional services. We all deserve better, but we are not going to get it without some disruptive innovation from the grass roots."
| Here I am with Rep. Lynn Jenkins, R-Kan. She signed on as a co-sponsor of H.R. 365 after our recent meeting about direct primary care.
So, despite my skepticism, here I was traveling to the Beltway, trying to schedule meetings with representatives, senators and their health policy aides.
The DPC market has grown tremendously in the past three years, thanks to patients and physicians voting with their feet despite virtually zero help from Washington. I have been honored to assist in that growth in many ways: leading workshops, speaking at conferences, engaging in online forums and providing personal advice to my colleagues.
One policy issue that has plagued both DPC patients and practices is a technical matter relating to health savings accounts (HSAs). Although my monthly fee covers services that are clearly traditional medical expenses (communications, office visits, many routine labs and tests, and some procedures), the arrangement that bundled monthly payment represents has confused the IRS and HHS for a couple of reasons.
First, HSAs may be funded only when paired with a single eligible "health insurance plan." The IRS has interpreted membership in a DPC practice as a second health plan, potentially voiding a patient's eligibility to contribute to an HSA.
Second, the list of "eligible medical expenses" does not specifically list DPC fees. The conflation of DPC with concierge medicine (which charges an extra retainer, in addition to traditional fee-for-service insurance billing, for "noncovered services" in most arrangements) has led the IRS to rule that retainer fees are not eligible medical expenses. Confusion has ensued.
Although this sounds like a minor, technical tax matter, it has certainly affected my patients. Many of them have high-deductible health plans with HSAs, and our services pair well with their needs, often saving them thousands of dollars per year in out-of-pocket costs. However, I cannot give them a clear or confident answer on the HSA issue. This has become increasingly frustrating for everyone involved.
Many people and organizations have proposed clarifying the HSA and DPC issue via the Primary Care Enhancement Act, which was introduced in 2015 in the Senate as S. 1989 and in 2016 in the House as H.R. 6015. Unfortunately, despite no meaningful political opposition, efforts to pass this legislation have been unsuccessful to date.
But supporters of DPC aren't giving up. A renewed effort to support this legislation, led by the Direct Primary Care Coalition and the AAFP, coincided with the 115th Congress being sworn in last month.
Several good friends who have been involved in these policy efforts have urged me to participate in previous fly-ins to Washington to advocate for DPC. In past years, I merely wished them good luck. This year, I decided to join them.
Why now? Obviously a new Congress and sense of change have overtaken D.C., but even more, I am beginning to realize that cowboy spirit alone may not be enough to make DPC a mainstream model of practice. Certainly, innovation and persistent grassroots efforts are essential to spur the beginning stages of any movement. Without some critical mass, few people will take our ideas seriously and the status quo won't change. However, it's becoming clear that influencing public policy also matters in our effort to enter the next phase of growth.
I'm a novice, but my efforts to get meetings in D.C. were largely productive even though I merely sent a few emails the week before I went. Rep. Lynn Jenkins, R-Kan., a member of the House Ways and Means Committee, spent nearly an hour in a discussion of the issue that included how the DPC model serves patients and the hiccup with HSAs. Although she is a proponent of expanding use of HSAs, the technical nature of the DPC issue was clearly new to her.
I met with the health policy aides of both of my senators, as well. Congressional aides are largely responsible for understanding details of a particular policy. They then help their bosses make decisions in that area.
During our conversations, I was struck by the fact that most of the legislators' advisers were recent college graduates. Despite being highly educated and bright, most of these aides had no discernable background in health care or health policy. Most had degrees in political science or business. It took me by surprise that people with responsibility for understanding the insane complexities of health policy were so new to these matters. As a family physician with a degree in public health, it has taken me five years of private practice to wrap my head around many of these issues. So I was glad to have an opportunity to share my perceptions with them.
The trip was a whirlwind, but I feel optimistic about our efforts. In total, our contingent managed to have 60 meetings with legislators and congressional staff during the two-day event. A few days after we left, H.R. 365 was officially introduced and referred to committee. Jenkins signed on as a co-sponsor, and the AAFP has continued to support the legislation.
Since then, traction in gaining more sponsors and moving the bill forward has been slower than we'd like. On the other hand, clauses have been added to larger health reform bills that essentially mirror H.R. 365, so that's a hopeful sign.
I understand why my busy colleagues, in all types of practice models, are leery of attempting to influence policymakers. It's certainly easier to scream solutions at the talking heads on my television set than to buy a plane ticket and spend time away from my patients. I still wonder, "How much difference can I really make?"
Although I won't be holding my breath waiting on Congress to pass H.R. 365 or to otherwise significantly improve our system without persistent grassroots efforts, I'm slowly starting to realize that being involved in the political process matters. And I might just be able to make a small difference beyond my practice and community.
More opportunities to advocate for DPC are coming, including during the DPC Summit scheduled for June 15-17 in Washington, D.C.
You also can learn more about the practice model itself at the AAFP's DPC Workshop, which will be March 11 in Atlanta. Finally, the Academy has a member interest group focused on the practice model.
Wherever you are on the DPC continuum -- from curious to committed -- there's a place for you to learn, and do, more.
Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.
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