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Tuesday May 09, 2017

Patients on high-deductible plans need primary care coverage

Our health care system has experienced many changes in the past three decades, including impactful and consequential changes in insurance design.

Insurance reforms enacted during the past 30 years, including those in the Children's Health Insurance Program, the Medicare Modernization Act (MMA), and the Patient Protection and Affordable Care Act (ACA) have increased access to health care coverage for millions. As a result of these laws, the nation's uninsured rate has reached a historic low. In fact, the uninsured rate decreased from 15.7 percent in 2009 to 9.1 percent in 2015.  

However, despite significant reductions in the number of uninsured, these changes in policy have not adequately relieved the financial pressures on individuals, families and employers. As a result of increasing economic pressures, there has been a proliferation of high-deductible health plans (HDHP). HDHPs are insurance plans with a minimum deductible and maximum out-of-pocket limit as defined by the Internal Revenue Service (IRS). Currently, the deductible threshold is $1,300 for an individual and $2,600 for a family. Under a HDHP, all medical care must be paid for out of pocket until this minimum deductible is met.

Many of the newly insured have secured their health care coverage through a HDHP.  Although the ACA drove higher utilization of HDHPs, the ACA did not create these insurance products. HDHPs were first offered by employers in 2001, but didn't experience large growth until after creation of health savings accounts through the MMA in 2003. During the past decade, the popularity of HDHPs has consistently increased among employers and individuals.  

In 2006, 4 percent of employees enrolled in an employer-sponsored HDHP. By 2015, 24 percent of employees were enrolled in such plans. HDHPs are especially appealing to younger workers. While these plans are gaining popularity in the employer-sponsored insurance market, they also are prevalent in the individual and small group markets. In fact, according to a report in Health Affairs, approximately 90 percent of enrollees in the individual marketplace have a deductible beyond the qualifying threshold for an HDHP.  

HDHPs have been an important component of our efforts to decrease the number of uninsured, but they come with significant challenges -- most notably is the simple fact that HDHPs provide a disincentive for individuals to seek primary and preventive care due to the associated out-of-pocket expenses. Recent academic literature shows that individuals with HDHPs delay or prolong seeking health care services as a result of the out-of-pocket financial obligations that exists with HDHPs.  

Delays in seeking care, lapses in maintenance, or adherence to treatment protocols lead to a worsening of an individual's health. Ultimately, providing needed care will cost the individual, their insurer and the health care system significantly more money. For example, the average cost of a visit to a primary care physician is $160. By comparison, the median charge for outpatient conditions in the emergency room is $1,233 and the average hospital stay is $10,000.

Based on these indicators, you could see your primary care physician 7.7 times for the cost of a single visit to the emergency room and 62.5 times for a single hospital admission. Furthermore, it is estimated that more than $18 billion could be saved annually if patients whose medical problems are considered avoidable or non-urgent took advantage of primary or preventive health care rather than relying on emergency rooms.  

To address this issue, the AAFP has developed a policy proposal that would expand access to primary care physicians for individuals and families who have a HDHP. Our proposal would provide individuals and families with a high-deductible health plan (as defined by the IRS) access to their family physician, or primary care team, without the obligation to meet the cost-sharing requirements (deductibles and co-pays) stipulated by their policy.

The company issuing the HDHP would be required to provide full coverage for designated primary care services for the plan year. Covered services would include Evaluation & Management (E&M) codes for new and existing patients (99201-99215) prevention and wellness codes (99381-99397), chronic care management and transition care management codes. The company issuing the HDHP policy would be responsible for paying the physician according to the contracted rate for these services.  

Patients would be required to designate a primary care physician or a primary care team.  The designated primary care physician or team would be the only site of service eligible for this benefit for the enrollment period. If a patient fails to designate a primary care physician, the insurer would be responsible for assigning a primary care physician to the patient. Our proposal defines primary care as those eligible clinicians enrolled in Medicare via the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and practicing under one or more of the following Physician Specialty Codes: 01 General Practice; 08 Family Medicine; 11 Internal Medicine; 37 Pediatric Medicine; and 38 Geriatric Medicine.

This is an important component of our efforts to promote primary care as foundational to our nation's health care system. We have started to engage members of Congress and will be working to advance this policy as part of the current health care debate.

Wonk Hard    
On May 4, the House of Representatives narrowly approved the American Health Care Act (AHCA) (H.R. 1628) on a vote of 217-213.  The passage of the AHCA brings to a close a brutal four-month effort on the part of House Republicans to fulfill their promise to repeal and replace the ACA. The legislation now moves to the Senate where its fate is unknown. It is clear from Senators' public statements that they will significantly alter the legislation. The AAFP released a statement shortly after House voted.

Comments:

I have a high deductible plan with a $12,000 family deductible. However, I can receive primary care for a copay already. Preventive care is free, PCP is $50, and specialist is $100. This is individual health coverage, and there is another option to make PCP visit $25 and specialist $50 for a higher premium "silver" plan. However, next year, BCBS Illinois may or may not be on the marketplace as they are suffering losses, or they may price these plans so highly so people cannot afford them.

Posted by Ashwani Garg on May 09, 2017 at 11:02 AM CDT #

I applaud the AAFP for taking steps to help patients with lower quality insurance get care. At the same time, it is absolutely insane that the only insurance some can afford (bronze or silver plans, costing thousands per year) leaves patients with no money to actually get the care they need, requiring more complex policies enacted to work around other already complex policy.

I can't keep up with insurance changes, and more and more of my office time is figuring out what test my patient can and can't afford, and if it's worth it to even get the test. It is time to we joined the rest of the developed world and get a single payer system that our patients and providers deserve. Even our own President applauded Australia's (nearly) single-payer system as better than our own. On that, I agree with him!

Posted by Alap Shah on May 09, 2017 at 11:35 AM CDT #

Tying reimbursement for what we do to the CPT coding system is just keeping us tangled up with the third-party payer mess. Sending bills to insurance companies is expensive and frustrating. There are a lot of patient interactions that can be very valuable, such as a text message or a phone call, that are not paid for under these codes. If we devise a scheme to get paid for primary care by insurance payers, we will continue dancing to their tune, and this has been bad for patients and physicians alike.
A simpler approach is to let patients buy direct primary care subscriptions with pre-tax dollars, and let the patients judge if the money they are spending on preventive and chronic disease care is keeping them out of emergency rooms and hospitals.

Posted by J. Timothy Ames, MD on May 09, 2017 at 11:54 AM CDT #

I like the premise of this AAFP policy proposal and I thank them for being a voice for improving healthcare. But this is a step backward in my opinion. Remember the days of $0 copays in the 90's? I can think of more than a few reasons why they are no longer around.

If we really want to remove the disincentive for seeking care AND keep healthcare costs down in the process, why not cut out the middleman? We already have a working solution for that, and one that takes the healthcare insurers out of the equation completely: Direct Primary Care (DPC) coupled with a wraparound insurance policy provided by a qualified health plan to cover major medical expenses. It's a win for insurers (they no longer pay claims for PCP office visits), the patient (all office visits are covered 100%) and for the primary care provider (who cuts down on their billing and collecting overhead). Read about the AAFP's stance on DPC here: http://www.aafp.org/practice-management/payment/dpc.html.

Posted by Cary Douglass on May 09, 2017 at 12:21 PM CDT #

I totally agree with the simplicity of DPC (Direct Primary Care) vs keeping the insurance company middlemen. I transitioned from an attending at a major academic medical center to a private, physician-owned DPC practice 4 months ago. I have seen improvement in my quality of life (much less burn-out) and major cost-savings for the patient, all with increased transparency, much less overhead, and quality visits with my patients. I can take time to teach patients without wasting time treating a computer with E/M coding. Since my patients pay a monthly fee, I can securely video-chat or email with my patients as medically appropriate, for no extra cost. This eases my clinic burden and improves their access, keeping them at work longer, thus adding to the savings to the system. I am accountable to my patients and not to a government/insurance carrier. We stock generic medications so I don't have to guess if Lipitor or Crestor is preferred, (guess wrong, fill out a PA, patient wastes time at the pharmacy, the system takes 3 days to get the PA to me, etc). I have both in stock for under $8 per month for the patient. It's a win-win for patients and physicians. HDHP with money to the patient to choose their DPC clinic would be tremendous.

Posted by John Vanderloo, MD on May 09, 2017 at 12:57 PM CDT #

LONG article. All I can say is this could have been fixed, but too many bellied up to the trough to get their piece, essentially allowing it to continue. If you expected your auto insurance (which all driver's MUST show proof of)...to cover: brake work, transmission work, new tires every 50K, oil changes, wipers, etc....you would hate the monthly premium. Yes, monthly, as this kind of preventative and repairative "care" would be extremely expensive. Why is it we expect health insurance to pay for it all, with a small deductible?

My family, for the first time in 27 years, has no insurance. BCBS of MN discontinued over 100,000 single family policies for 2017. A result of the ACA.

So, we went on "the exchange" and were told there is ONE OPTION available for SW MN. Yes, "One". And it was to cost us $2300/month in premium with a $7000 deductible. $35,000 / year out of our pocket before we'd receive help. "Affordable health care"??

The government needs to completely separate itself from the non-MA / commercially insured patients.

Then the legislators (all of their wisdom put together in a thimble, it would seem) would legislate 7-10 straight forward "rules" for ALL insurance companies to live by.

First legislated insurance company "rule" for all to work under:

1 - No insurer may in any way use or apply preexisting medical conditions. Not for deciding "insurability" nor "cost of insurance policy".

2 - All insurance companies may sell in every state. Competittion

3 - Insurance policies MAY NOT select out types of coverage, creating tailored policies (like ones which do not cover OB, etc.)....for insurance is to be a POOLING of all persons $$$$ for the good of all. Policies would cover is all, for all, by all.

4 - All insurance compainies would be required to provide "at least" one major medical policy...and the criteria for such a policy would be structured to mimic auto insurance.....meaning good major medical need assistance....for a very reasonable price. Like ~ $100 per month for a single and ~$300 for a family. The deductibles would vary...as would the linked monthly premium choice.

5 - ___________

6 - ____________

7 - ____________

and then allow the market place to work...

Posted by jeff taber on May 09, 2017 at 01:13 PM CDT #

What the heck, AAFP! A long blog post about high deductibles and not one mention of DPC?

DPC is a great solution to many of the problems patients face with the transition to high deductible plans.

Instead AAFP is pushing for the opposite, expanding insurance to include primary care with no copays, etc. Unlike DPC, that will do little for the cost of insurance or availability of primary care.

AAFP, one step forward (supporting DPC) and one step backward (trying to broaden insurance involvement in primary care).

Posted by Brian Pierce MD on May 09, 2017 at 01:16 PM CDT #

I find it troublesome that you completely neglected Direct Primary Care from your plan for dealing with HDHPs.

To continue some of your calculations: one of my patients can see me an unlimited number of times for the cost of an ER visit. They get longer visits (minimum 30 minutes) which is exceptionally useful for the more medically complex patients (ie. the ones most likely to end up in the ER/hospital multiple times).

If you remove the overhead associated with third-party payers, primary care becomes affordable for the vast majority of Americans.

Direct Primary Care can fix many of the problems with American healthcare as it stands today.

Posted by John Burrell on May 09, 2017 at 01:22 PM CDT #

This AAFP proposal is just asking for more of the same in a broken system. Primary care should be separate from insurance. Period. Save the insurance for the big things. I provide Direct Primary Care in my office starting at $50/mo. For all of their visits. The people with HDHPs love it. The uninsured love it. A CMP costs them $3.99. Their lisinopril is about $1. You can't do that with the ridiculous complexity of the insurance system. Why include a middle man? It is NOT NEEDED in primary care.

Posted by Donna Givens on May 09, 2017 at 01:23 PM CDT #

Shawn,

I agree that lowering cost barriers for patients accessing primary care is very important. So, from that motivation, this type of proposal is reasonable. (Upfront transparency of costs is actually just as important as "covered", but that's a side bar)

However, if this type of policy were widely adopted (actually not that uncommon in 1980-90s from what I've ready) it would only help to solidify many of the problems with the managed care and fee-for-service mentality. I suspect insurance companies would raise premiums accordingly -- although with the small amount they spend on primary care it may not be a huge amount for the individuals. However, there is no free lunch here.

I would also note that "free" primary care is not a cure-all for access problems. As we have witnessed with studies regarding Medicaid utilization, most patients still do not maintain a long-term relationship with PCP despite it being 100% covered.

More importantly, this proposal would do nothing to fix the fundamental problems on the provider side. I suspect such a policy would only INCREASE the amount of administrative burden placed on PCP as third-party payers would scrutinize more closely for over-utilization and billing.

Why not support a truly patient-centered proposal? It would be much more transformative to let patients control 10-15% of health care dollars (keep their own or subsidized if lower income/Medicare) to manage (via HSA type vehicle) their own primary care. The only loser in that proposal would be the people who currently control the money and have a vested interest in the politics of health care.

Posted by Ryan Neuhofel on May 09, 2017 at 01:24 PM CDT #

The AAFP's response is well-intentioned but too provincial. Do we REALLY believe there should be no financial barriers to accessing primary care but huge barriers to specialty care are fine and dandy? How would you feel about that after a diagnosis of, say, cancer or 3-vessel CAD? Research shows copays reduce utilization but equally of "necessary" and "unnecessary" care - consumers can't discriminate. (Physicians aren't necessarily great at that, after 4 yrs. of medical school and 3+ years of residency...) Research also shows that high charges are a greater driver of high costs in the US than utilization.

E&M coding, FFS payment, and multiple, competing private insurers all drive up costs, hassle, and inefficiency, while providing little to no clinical benefits. DPC is just out-of-pocket primary care capitation with responsive service.

A single-payer system would lower costs to a greater extent than any other change to our health care system, while improving access and reducing practice headaches. Getting rid of arcane E&M coding and reconsidering FFS billing could fit with insurance reform to further increase savings and decrease practice overhead/headaches.

Any system will have flaws and inefficiency. It is discouraging that the House has chosen to ignore the lessons of past failures with the AHCA. The ACA perpetuated our flawed system, buying off insurers, providers, and the pharmaceutical industry to assemble enough support to get it passed.

The AAFP should think more broadly and less provincially; if we advocate for the best interests of all patients and clinicians, we will have a better chance of success. Why not take the high moral ground?

Posted by Barry Saver on May 09, 2017 at 02:02 PM CDT #

Add me to the chorus of those dismayed by the mention of problems of access caused by HDHPs with no mention of DPC or the Primary Care Enhancement Act. This bill would clarify IRS rules and make HDHPs DPC compatible from a tax standpoint. I am an AAFP apologist and am grateful for the way that AAFP has fully embraced the DPC model. But I agree with previous commenters that the proposal described by Mr. Martin would be bad policy and not deal with the fundamental problem with HDHPs, which is that patients have no functioning marketplace with which to use their consumer-directed dollars. Funneling this money back into the high-cost, cost-opaque system would be a move in the wrong direction.

Posted by Brian Lanier, MD on May 09, 2017 at 02:12 PM CDT #

I'm glad there is already a chorus of objections to the AAFP trying to further entwine primary care with insurance. Why the sudden move to try to "fix" the problem of primary care access in a high deductible world when those of us who have already pioneered Direct Primary Care have already made great strides in fixing the problem. Insurance is necessary for unexpected and expensive medical care. Primary care is neither unexpected or expensive, especially when insurance is taken out of the mix by Direct Primary Care. And where is the money going to come from to pay for the "free" primary care? It will come from yet higher insurance rates, which will certainly be raised by more than the cost of Direct Primary Care. Patients lose and we lose. Insurance wins.

I love the AAFP, however doing something so potentially damaging to primary care, and especially Direct Primary Care, would make me drop my membership in a heartbeat. Or at least attempt to remove anyone in our leadership that is foolish enough to support legislation that would be a huge step backwards.

Posted by Andrew Hector, MD on May 09, 2017 at 02:44 PM CDT #

Family Medicine physicians across the country are tremendously dissatisfied with fee-for-service medicine and large system healthcare. Many of these physicians are AAFP members including myself. We all realize there are better business models than the FFS grind of 20-40 patients/day. Physicians are spending up to 1/2 their day pecking for payment and doing mundane administrative tasks:
http://www.aafp.org/news/practice-professional-issues/20170412desktopmedicine.html
The Health is Primary campaign is very supportive of movement away from FFS.
How is the AAFP policy proposal going to improve the current system and be a better model for physicians, patients and employers?
We need to move away from the patient/physician office visit financial transaction--patients and physicians do not like it.
DPC is a (care) solution that can be paired with the (coverage) HDHP. Patients and companies all across the country have been doing this.
"Healthcare without the middleman"
https://www.youtube.com/watch?v=Fi-pw23ivWs
In the eyes of patients, employers, politicians, Governors, physicians...DPC is a "no brainer" and should be on the table as the AAFP is speaking on behalf of it's members.

Posted by Clint Flanagan, MD on May 09, 2017 at 03:11 PM CDT #

I echo my colleagues in disgust, no mention of the growing trend of DPC with HD plans. Not a peep? We're having a Summit in DC in a month for God's sake. AAFP should be advising al its member to dump insurance now and fight for patients. After all, our oath is to patients no insurance companies. More insurance and more regulations leads to more administrative tasks and less time with patients and eventually more burnout. We need to free MDs not bind them. We need to have medical students see hope in family medicine not endless piles of paper and red
tape. Let's tell insurance to take a hike for primary care.

Posted by Shane Purcell, MD on May 09, 2017 at 05:34 PM CDT #

There is a cost associated with health insurance coverage. Right now the high deductible plans are positioned so as to generate the revenue to cover those subsidized plans so their deductibles are high and the payout is low. By 'requiring' a plan to cover primary care office visits 'at no cost' is another mandate for coverage without an avenue to pay for this coverage. Say hello to higher premiums for such plans. Even if a primary care setting is lower cost (which it is) it is still an additional cost.

The good news that can come from the attempts to repeat the ACA mandates are that the consumers of health care could feasibly choose which method to buy their insurance and their actual health care. If they see the wisdom in getting a high deductible plan and keeping all of the savings for them to be able to use to purchase health care, so be it.

I think it would be wise to couple this with a DPC plan but this should be up to the patient to decide how to purchase their healthcare. This is an economic decision and the ability to choose your priorities is absolutely paramount.

I have lived in countries with single payer plans. They are not the answer for a variety of reasons.

Posted by Dean Cranney on May 09, 2017 at 07:25 PM CDT #

Either you are completely uninformed of the current movement in primary care or are pleasantly ignorant and you have the insurance company lobby in your ear.

I might remind you that the organization you represent has a Summit on DPC in a couple months and to have no discussion of DPC in a piece on how to deal with the trend of HDHPs on primary care is unbelievable.

"HDHPs provide a disincentive for individuals to seek primary and preventive care due to the associated out-of-pocket expenses", IF the patient has a physician who has to bill that HDHP for their care. And if (like you recommend), primary care is included as a covered service in the plan then the cost of that plan will have to go up by the cost of the care that the physician office gives along with the cost of the insurance company's overhead and the expenses of all the other middlemen involved in billing, coding, processing claims, etc. They for sure aren't going to miss out on their portion. Look out for even HDHPs to become unaffordable if this option comes to fruition.

Direct Primary Care solves this problem by increasing access to a physician, improving continuity, lowering costs, and allowing patients to effectively use HDHPs for unexpected and catestrophic things. All the while, patients and physicians are directly contracted to each other and no middlemen skimming profits are needed.

The average cost for a patient to see me every day of the month if they have needs through my DPC clinic is a grand total of $40 - ONE FOURTH of the price to see an insurance accepting physician once for an average of 7 minutes. And you failed to mention that if patients are getting their 99214s covered, they still are going to have insurance bloated pricing for labs, meds, procedures, etc. All these primary care needs are effectively met in DPC.

You also failed to mention the effect DPC could have to limit administrative burden on physicians in one of your past articles. If those 99214s become part of an even bigger system, expect that admin time to be able to meet requirements to get paid to skyrocket.

I'd love to see your response to the comments here and to address why you failed to even mention DPC.

Respectfully, Nick

Posted by Nicholas Tomsen, MD on May 09, 2017 at 07:56 PM CDT #

To keep people healthy, not just treat them when they already get sick, you need unlimited access to PRIMARY care. If you give people control over their health care dollars, most of them will "save it for a rainy day". No one thinks that being overweight, not exercising, eating bad food will hurt them until it does.

High deductible plans also self limit care, which is why insurance companies love them. They raise rates to cover their butt and make sure the company remains highly profitable and keeps their share holders happy. So, they don't really want people to use their insurance.

I really am passionate about DPC-- I think it can really be the savior of the health care system. It provides us family docs with the time we need to counsel the patient on healthy behaviors. We can do more procedures we are trained to do instead of sending them out to specialists. Unlimited access with no copay at the door really works to get people in to be seen. When you have time to build relationships with the patient, they WANT to change and do better. I think the insurance industry really needs to get on board with this-- they wouldn't have to pay staff to process PCP claims, prescription costs will go down. Several DPC practices have shown you will save 20% pretty reliably across the board.

Most DPC practices are 50-100 dollars/month. Surely, someone in the insurance industry could pair a plan that carves out that amount/month to go to DPC. After all, they will still come out way ahead.

Please, AAFP, please be our champion for DPC!!

Posted by Eleanor J Host on May 10, 2017 at 07:35 AM CDT #

At a recent conference, I asked the question "why doesn't the Academy acknowledge among politicians and other "stakeholders" that coverage is not the same as healthcare," and I mentioned Direct Primary Care as the answer to physician burnout caused by administrative burden. The answer I received from the President was basically that insurance has the power in the healthcare debate at this time. The same "if you're not at the table, you're what's for dinner" argument. If we continue to bill 3rd parties, whether it's a monthly rate or fee for service, they still have the power. I agree that the AAFP's "proposal" would undermine DPC physicians and would be unlikely to solve the administrative burden crisis. The savings associated with DPC is absolutely confounding. If you haven't spent some time with a DPC doc, you should...especially if you are one of the people saying "some people cannot afford DPC." I have not found that to be true, even in KY. However, at least I can legally provide charity care since I opted out of Medicare.

Posted by Molly Rutherford, MD on May 10, 2017 at 01:39 PM CDT #

Colleagues and Mr. Martin, thank you all for this high level of active thought and sincere engagement which we all need at this time. U.S. medicine stands at a crossroads. The failure of the system (and we are part of that failed system) to produce the 'triple aim' (high quality, lower cost, better access) produced the health care debate of 2008-2010 and eventually HITECH, the ACA, MU, ACOs, PCMH, and now MACRA; as well as offshoots such as DPC. None of the above acronyms has been a windfall on the original issue of the triple aim. Meanwhile freestanding ERs, urgent cares, and our mid-level colleagues are trying to plug the holes in a sinking ship. Regulations and narrowing profit margins are squeezing more and more doctors out of the private practices.

What if we re-define ourselves in a new practice model: 24/7/365 primary care, in clinics that never close - day or night? The triple aim goals would be addressed par excellence, providing inherent value which would drive higher pay for doctors willing to commit to that kind of accountability within small- to mid-sized, physician-owned group practices. It would make the best use of facilities which usually lie fallow during night hours; and best use of pooled billing / support / mgt staff resources; and address the new reality that we live in a society and economy which knows no day / night boundaries. It is no mystery that many cases that end up in the ER could be handled by competent PCPs in properly-supported settings; and patients and doctors both need more longitudinal accountability that goes both ways.

We have an opportunity to redefine ourselves as a specialty and genre (PCP) and help a lot of people in the process. Plus, only in the last 10-15 yrs has primary care become a day job. This model can support docs who still need day hours due to family responsibilities etc., but the higher salaries would organically go to the harder-working docs. Which is the weakness, IMHO, of ACOs, much of DPC, and other popular models which fail to recognize the inherent, inescapable human nature that is motivated to work harder when there is a reward for that unit of work. 'Bundling' or subscription models of reimbursement incentivize less work - not more.

Please comment. Is anyone already doing this? Would anyone like to join a work group to look at it?

Posted by James Stefan Walker, MD on May 10, 2017 at 11:15 PM CDT #

I have been both asked and taunted to respond to my most recent posting on high-deductible health plans and a new policy the AAFP has developed to make primary care more accessible and affordable for a larger number of patients. Oddly, I read these comments after a series of Capitol Hill meetings on, you guessed it, direct primary care. Serendipitous.

The AAFP was one of the only physician organizations to signal support for the language included in the Affordable Care Act that led to the recognition of DCP as a “qualified health plan.” Since that time, we have been steadily engaged in a variety of education, policy, and advocacy efforts aligned with DPC.

The AAFP adopted its first policy on DPC in 2013 – a time when only a small handful of family physicians were practicing in the model. In 2014, the AAFP engaged with the DPC thought-leaders around the country in an effort to become better educated and more well-versed in the emerging DPC primary care delivery and payment model. After some analysis and evaluation, we took a strong affirmative stance on DPC. In 2016 we successfully ushered a policy through the AMA House of Delegates.

In 2015 we partnered to launch the DPC Summit, a highly successful and educational event that is the premier annual event for DCP practices. This year’s event will be held June 16-18 in Washington, DC. You can register here à http://www.dpcsummit.org/home.html .

A few clarifications from submitted comments for the good of the order:

1.The promulgation of this new policy does not symbolize or reflect a decrease in our support for direct primary care. We still devote a substantial amount of resources to DPC-related member education, practice transformation, and advocacy.

2.This policy does not impact DPC or DPC practices in a negative manner. This policy is designed, just as DPC is, to remove financial obstacles that exist between patients and their family physicians.

3.This blog is designed to introduce, inform, and motivate family physicians on policy and advocacy issues. The omission of DPC from this blog should not have been interpreted as “After years of supporting DPC and learning that affordable, sustainable primary care is quite possible without insurance; AAFP still can't give up its cravings for insurance paid primary care.” We recognize and understand the strong support for DPC – we share your beliefs that it is a viable primary care delivery and financing model.

4.There are over 250 million, non-Medicare, people in this country who have insurance of some type. The AAFP should and must identify a variety of policies that promote comprehensive, coordinated, and longitudinal primary care. We are a very big organization, with a very diverse membership – therefore we have to work on an equally diverse policy portfolio. I can assure you that DPC occupies a fair slice of real estate in this portfolio.

5.There is not a physician or health care organization that has done more to advance, promote, and protect DPC than the AAFP. We have worked with the DPC Coalition, state chapters, and individual family physicians to secure changes in law in over 20 states, with more coming. We have discussed the value of DPC with insurance companies, employers, patient advocacy groups, and policymakers. Not to mention two Administrations.

The following are links to a small ample of the AAFP resources on DPC:

•AAFP Policy on Direct Primary Care

?http://www.aafp.org/about/policies/all/direct-primary.html

•AAFP Resources on Direct Primary Care

?http://www.aafp.org/practice-management/payment/dpc.html

•AAFP Direct Primary Care Toolkit

?https://nf.aafp.org/Shop/practice-management-tools/dpc-toolkit

•AAFP Letter on the Primary Care Enhancement Act

?http://www.aafp.org/news/government-medicine/20170124dpcbill.html

•Summary of AAFP and AAFP State Chapter Advocacy

?http://www.aafp.org/news/practice-professional-issues/20170421dpcstates.html

•2014 In the Trenches (that’s right 2014)

http://blogs.aafp.org/cfr/inthetrenches/entry/is_direct_primary_care_right

•2016 In the Trenches
http://blogs.aafp.org/cfr/inthetrenches/entry/aafp_showing_strong_support_for

•DPC Member Interest Group (sign up if you aren’t already a member)

?http://www.aafp.org/membership/involve/mig/dpc.html

Finally, I understand that you feel slighted by the omission of DPC from this one blog. However, I would politely remind you that I have written on DPC and our work on DPC more than 5 times since this blog started. That puts the issue in the top 5 of policies discussed on this blog – in the company of MACRA, health care reform, and workforce. In addition, the AAFP and our brand has been instrumental in the growth of DPC. When other physician organizations attacked DPC – who defended you? That’s right, the AAFP.

We are all rowing in the same direction my friends. We may find ourselves in different canoes from time to time, but we are all trying to get to the same place. Sign up for the DPC member interest group, register for the DPC Summit and keep your comments coming.

Posted by Shawn Martin on May 11, 2017 at 05:04 PM CDT #

Dr. Walker,

The type of practice and PCP you desire (24/7, wide spectrum of care, small/physician-owned, above average pay once full panel) DOES exist in nearly every DPC doctor I know -- which is now in the 100's. Perhaps some DPC's do NOT meet this description, but they are the minority. I would say that a very small % of any other practice model/arrangement produces such results.

Your fear of "subscription" (retainer, capitation, etc.) payments to PCPs is misguided in my experience. Fee-for-service payment perhaps made sense 10+ year ago, but with increasing technology (remote communications, monitoring, coordination) a fixed monthly payment allows for flexibility in meeting patients needs. There is no incentive to "work less" in DPC model; rather an incentive to work smarter. If you believe physicians are somehow going to game the payment model (e.g. take money but avoid giving patients care they need), we have a MUCH bigger problem with unethical PCPs -- that no payment model can fix. Further, the fee-for-service (no doubt undervalued at primary care level) is the root of many of our problems. Do you not believe there is an incentive to push patient volume beyond what is quality care (rushed care) under FFS?

I welcome you to explore DPC further. I think you will be surprised at what you find.

Cheers,
Ryan

Posted by Ryan Neuhofel on May 12, 2017 at 09:28 AM CDT #

@Dr. Neu,
Thank you for the sincere reply and unabashed plug for DPC. I think what folks like you are doing is tremendous and here to stay, no doubt; and part of an emerging heterogenous landscape of health care that is necessary for a rapidly-changing needs portfolio in the U.S. HOWEVER, I respectfully disagree it is the full answer, and also disagree that human nature makes doctors motivated by getting paid for each unit of work done somehow unethical. Rather, I believe it keeps things very real for all parties involved when they pay something each time they get something. I also would call attention to the difference in the model I am proposing and the DPC, namely I envision a team of doctors keeping a physical brick-and-mortar clinic open continuously day and night, holidays and weekends. This unique arrangement allows for folks along the lines of your patients who wish to pay cash to do so, but also for patients with traditional insurance to have access to a clinic 24/7/365 - not be forced to seek care outside their medical home environment (at an urgent care or ER) just because no one is there at the office. There is no possible way a single doctor can be there 24/7/365 for a panel of patients in terms of a full spectrum of medical services that are within the realm of high-level primary care; it is unhealthy and physically untenable in modern times. But in a healthy 'family' of colleagues and staff working collaboratively in a physician-owned clinic - committed 100% to providing care for the shared panel of each other's patients, and with no excuses, no where to hide, just pure commitment - bilateral - but that is fully supported by a viable diverse payment system (insurance, cash), plus the additional ancillaries that are possible with a team that are not possible or feasible with a solo practitioner (full lab; radiology; procedures-capable facility; etc.). Yet not too big as to lose the family-like work atmosphere, or to become a corporation-like environment. 15-20 docs would be ideal.

Again, not saying that docs in other arrangements are necessarily unethical. But this model encourages volume and industrious work ethic by rewarding an active panel; and yet allows for physicians needing easier hours and less of a volume due to family or personal needs to work in the same practice with the busier docs, just for less financial reward.

Would love to talk / write more with folks on this. I sincerely and wholeheartedly believe this novel practice model is part of the future of mainstream primary care in the U.S., just as certainly DPC has earned its piece of the equation.

I will give a caveat however - I believe this will fail miserably if run by corporations or hospitals. Experience of the last 15 years in practice assures me that primary care has to be real; and corporations cannot be a patient's doctor. A small, physician-owned group practice, in my humble view, is the sweet spot that allows work-life balance for doctors, but still provides the one-on-one, longitudinal, committed primary care relationship that is essential for optimized care.

Posted by James Stefan Walker, MD on May 12, 2017 at 11:16 AM CDT #

This is a teachable moment as to why insurance expansions have failed where people most lack local workforce. Medicaid payments for primary care are less than cost of delivery and are least supportive where complexity of care is highest.

High deductible expansions fail for the support of local primary care. Take it or leave it worst health insurance plans (lowest payments, most hoops) are also concentrated where practices are smallest, least organized, and most likely to be family practices.

All of our "expertise" has failed to address who will care for the 40% of the population in lowest physician concentration counties - counties lowest in concentrations of physicians because the patients have the greatest concentrations of plans least paying and least supportive of local services - especially primary care. These lowest concentration counties represent the population growing fastest in numbers, elderly, demand, and complexity.

These are places where 36% of family physicians are still found serving the 40% of Americans most left behind. In less than one generation of physician workforce and 30 more years of deterioration in affordable/available housing in higher concentration settings, these lowest concentration counties will be the places of residence of nearly half of Americans with over 55% of the elderly, poor, poor children, Veteran, disabled, fixed income, lower income, less employed, lesser employed, lesser insured, and medically bankrupt populations.

If we care for half of the population and half of family physicians, we might want to address failed financial design.

Note to designers - it takes a lead time of at least 20 years to build workforce and all of this time payment policy must provide more revenue compared to the cost of delivery to support more positions and team members to deliver more care.

The current design with stagnant to declining revenue and accelerating costs of delivery will shrink care delivery where half of Americans will be found. No training intervention has been able to work for decades because of payment design. The lack of progress assures continued failure for decades to come.

Now it is very clear that the dollars for health care, for nutrition, and for disabled individuals will be decreasing most in these places. The Medicaid cuts will hit these places and their family physicians and their remaining facilities hardest.

Family physicians in lowest concentration settings will face stagnant payments, increasing costs of delivery, and increasing complexity plus declines in local resources and local spending in ways that will assure lower outcomes for generations to come.

So why do we support payment designs that already pay us the least and pay less where we are most needed and will pay even less under the new payment designs?

Posted by Robert C. Bowman, M.D. on May 24, 2017 at 12:48 AM CDT #

"So why do we support payment designs that already pay us the least and pay less where we are most needed and will pay even less under the new payment designs?"

That's the question so many of us are asking, but nobody from the AAFP wants to respond. The attitude seems to be: don't ask why, just do as you're told. Not a good way to deal with a burnt-out, demoralized work force.

Posted by R Stuart on June 19, 2017 at 04:15 PM CDT #

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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