Update: AAFP Should Stand Up for Patient Access to Independent DPC and Withdraw Support for HR 3708

Update: Here is Mr. Shawn Martin’s reply. He granted permission for IP4PI to share it with the understanding that it should not be considered an official statement from the AAFP.

On Oct 25, 2019, at 7:17 AM, Shawn Martin wrote:

Craig-

Thank you for your email. I hope you are doing well. Your email outlines several areas of concern that we share and have been communicating to the various bill sponsors and Committees. We are working to make changes to the bill and I am confident that we will be able to do so.

AAFP policy only speaks to the allowable use of HSA funds for the periodic payment for primary care DPC practice. The bill language meets this objective. We are, however, very concerned with the exclusionary definition of services, specifically pharmaceuticals. Family physicians are not homogenous and the inclusion of a standardized definition and payment rate for “primary care” is concerning. We also are concerned that the allowable periodic payment amount is established irrespective of the patient and their health condition(s).

The other concern we are advancing is the simple fact that the language would apply the permissible use of the HSA to the periodic payment and not the patient themselves. This is nuanced, but basically the permissible amount should apply only to the patient/HSA holder and should have no impact on the practice or the practice’s financial operations.

There are other structural issues, but these are the big items we are working on.

Have a nice weekend – SM

Update 2: From: Shawn Martin, Date: October 25, 2019 at 2:06:39 PM EDT

October 25, 2019 at 2:06:39 PM EDT

I think the challenge in the next few weeks is this – is there a pathway to codify the permissible use of HSA funds for the explicit purpose of periodic membership payments and, if yes, what is the scope of services for such a permissible payment.

The relationship between not permissible (current) and permissible at $x (as proposed in legislation) is not the point in my mind.  The point is providing clarity in statute that an individual may use their HSA funds for a defined purpose – in this case periodic payments to a DPC practice.  Any limitation on the amount of a permissible expenditure is secondary to the permissibility question more generally.  There are defined limits on tax advantage accounts broadly – FSA, CTC, mortgage deduction, SALT, etc.

Its an interesting policy question that I have been kicking around since the ACA.  The HRA is cleaner because it is a defined contribution.  Anyway – look forward to the call with you and others.


10/24/2019 letter from IP4PI founder Craig M. Wax, DO to AAFP Senior Vice President for Advocacy, Practice Advancement and Policy, Shawn Martin:

Dear Shawn

Long time no see, or hear for that matter. I hope you and your family are well and that you landed safely at another entity. I’m writing to express concern about HR 3708 in the House and AAFP support of it. AAFP has been supportive of DPC in recent past and that support is much appreciated, but this bill, as written, would do more harm than good.

Enacting an aggregate cap on patient use of HSA funds for access to value-based care would be a bad precedent and the proposed prohibition on the ability of physicians to include medications in a DPC agreement is contrary to the best interests of patients.

In addition, all specialties, not just primary care, should be permitted to arrange innovative direct payment arrangements with the patient, eliminating the middleman and optimizing care with reduced cost.  HR 3708 appears to preclude the ability of a patient with diabetes from using HSA funds to pay for a monthly arrangement with an endocrinologist, for instance.

The bill also seems to risk the potential for States and others to misclassify DPC as an insurance plan by not properly and clearly defining DPC as medical care.

In its current form, this bill is unacceptable and I am disappointed that AAFP is supporting it. The previous Primary Care Enhancement Act from 2017 (HR 365) was an excellent template, while HR 3708 is flawed.

Please let me know what can be done to revoke AAFP support for this harmful legislation, and work for better options to support DPC and empower both physician and patient independence.

Best wishes for good health,
Craig M. Wax, DO
Family Physician
Independent physicians for patient independence
National Physicians Council on Healthcare Policy member
Host of Your Health Matters
Rowan Radio 89.7 WGLS FM
Twitter @drcraigwax 


Help Stop Blatant attempt to Blur Lines Between Physician and Non Physician

Amy Townsend, MD of Physicians for Patient Protection writes in:

Certified Registered Nurse Anesthetists (CRNAs) are working to get the Idaho Board of Nursing (BON) to officially change their name from nurse anesthetist to NURSE ANESTHESIOLOGISTS.  

This is a blatant attempt to blur lines between physician and non physician and to deceive the public.  The American Association of Nurse Anesthetists (AANA) plans to do this in every single state.  

It is important that we all stand up to these assaults on our colleagues in every specialty.  

Please help by spreading this information and signing this letter (after modifying it to your satisfaction).

Transparency in healthcare is critical.  And this name change is the exact opposite of what healthcare needs.  

Link to Letter: https://asahq.quorum.us/campaign/22999/

Cost transparency in BILLING!

By Paul Kempen, MD, PhD

Price transparency is a fallacy regarding posting of lists of costs when insurance is involved. Perhaps transparency in BILLING is more reasonable to create individual outrage regarding outrageous bills. Please consider the following:

Cost transparency in BILLING!

I want to hear if anyone sees the following proposal as useful in separating physicians out from the “cost of care”. The issue of transparency is nebulous “going into” getting care for a number of reasons. Patients are often ill, in urgent need, in a “closed market” and poorly educated.  Perhaps it  would be useful to push for legislation creating transparency of ALL BILLS, especially those produced by insurance companies which serve to foster that impression that insurance somehow actually pays for care.  Insurance controls payments through ”negotiated prices”, limitation of care delivery and other aspects. I question if it would it be useful to have laws which Demand EVERY “This is NOT a bill” produced by corporate entities include the following data:

HOSPITAL AND INSURANCE STATEMENTS

1) Itemized price charged (i.e. charge-master and/or “full billed price”)

2) Amount ACTUALLY PAID by insurance independent of  patient portion separated from negotiated deductions

3) What Medicare would have paid for every BILLED service in A) HOSPITAL and B) regional Doctor’s office

4) All facility fees separated from total cost as a separate component

Imagine if everyone SEES the “facility fee” and recognizes that doctor offices are CHEAPER!!

If everyone sees the hyperinflated insurance/hospital costs over physician offices

If everyone sees that the PATIENT is paying for care via the deductible and sees just how LITTLE insurance companies are paying from the large premium and this is NOT hidden in the “negotiated deductions” which gives an appearance of “saving money” for patients.

Anyone producing a bill MUST have access to such data and making everyone aware of these realities would create pressure on OVERCHARGES

Debunking Myths that NPs Increase Rural Access and Lower Costs

The “increased rural access” and “lower cost” rhetoric used to support nurse practitioner autonomy is a complete fallacy and there is zero data to support these claims.  

1.  The market factors that make it difficult for physicians to practice in rural, underserved areas is not any different for NPs than it is for physicians.  NPs are not independently more altruistic than physicians.  Poor payer mix and the expense of excessive regulatory burdens will make it difficult for anyone to keep their doors open in these areas.  

2.  Look at the states that have allowed NP independent practice for decades, like Arizona.  NPs are practicing in the exact same places as physicians.  They do not go to rural areas.  There are maps available from AMA that show this quite clearly.  

3.  There are multiple studies that show NPs make more referrals to specialists, order more inappropriate radiology studies, and perform more skin biopsies than physicians.  This all INCREASES cost to the healthcare system.  In practice, I see NPs ordering tons of worthless tests in order to try to bridge the gaps in their knowledge.  They order tests and then have no idea what to do with them which leads to more tests and more referrals.  At a time when we are focused on decreasing unneeded healthcare waste, how does it make sense to use these undertrained non physicians.  

4.  If they are arguing for pay parity, how exactly do they decrease healthcare costs?

Data references demonstrating NPs increase cost and lower quality:

NPs order more biopsies: https://doc-10-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/f3drubbtuuasggve85q8h4dmet2ru2n5/1570492800000/11904212300552749650/00862855625573411785/1Oa8BCwnGYyN8Qwxg4bk6NYPdEeaQETHw?e=download&nonce=5nnu0081r77o6&user=00862855625573411785&hash=rldhsra0pp9qca2lt28lrf0ccab5h8f2

NPs order more imaging: 
https://doc-04-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/8gvilblg17297cb1rr7h0rg62tem57o5/1570492800000/11904212300552749650/00862855625573411785/1khlK1Uaw9ZKBES85GxnAICJW9_QUS4qi?e=download

NPs make more referrals to specialists: https://doc-0c-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/pd0vv46pqfms4l8gfhefl9rtbjsjbnl9/1570492800000/11904212300552749650/00862855625573411785/1BYA0yZwLoHB0ozC8vOL6NVrHnDYj18MI?e=download

Prescribe more antibiotics =more antibiotic resistance: 
https://doc-00-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/v0hj5lspvacc5qch9p312rn4hruf6b9u/1570492800000/11904212300552749650/00862855625573411785/1ifSQYhGKCQAzwqNWefUS5x7PA2G8HC5C?e=download

More general resources  https://drive.google.com/drive/mobile/folders/1FF7sTKg4XZa_L5mXpW2puGjlMU3BuwcO/1IwfXD0e5Lxk9BuJoPtD2egwQySsozxdS/1z-L86XfVOzW6KPFpolF13ltCEWrI3Vv5/1S3iJlDPUcGBiLZmVgK7CYolis8eiv41i?sort=13&direction=a

 

Nurse Crusader Admits Her Dreams for “Doctor Nurses” Have Been Shattered.

Dr. Alieta Eck writes in:

I encourage everyone to read about a fascinating article from the infamous Mary Mundinger, former Dean of Columbia University’s School of Nursing, the nurse crusader who championed to put nurses on a more equal footing with doctors. The piece is titled: “Potential Crisis in Nurse Practitioner Preparation in the United States.”

Basically, this article reads like a tell-all novel about how her dreams for “doctor nurses” have been shattered.

Essentially they reviewed all the DNP programs since inception in 2005.

85% of DNP programs are nonclinical (ie admin and policy) and do not require ANY new clinical skills.

Only 18% of the programs are clinical and DO require clinical skills beyond masters level MSN or BSN.

She says the public good requires clinical programs but says they haven’t developed because it’s too difficult and expensive for schools to develop clinical tracks.

Her final conclusion is that nursing education is failing to prepare most DNPs for clinical practice. Finally an admission that the DNP degree, by having 2 entirely different educational tracks, is meaningless.

75 Years After D-Day It’s Time to End a Failed WWII-Era Economics Experiment … and solve the surprise billing quagmire too

It’s a sign of the divisive times: even the American business community is throwing its own under the Congressional bus. In a letter to the Senate HELP committee, a broad coalition of employers, including the National Restaurant Association, Auto Care Association, and the National Association of Wholesaler-Distributors, is calling on Congress to impose price controls on others that they would not tolerate being placed on themselves.

Yes, even the “Small Business & Entrepreneurship Council,” is joining this coalition, whose arcane name is a throwback to 1970s era overregulation—ERIC, the ERISA Industry Committee—to ask for legislation that is anything but entrepreneurial.  

These businesses are part of the growing chorus asking Congress to “do something” to address “surprise” medical bills. But instead of focusing on the root causes of the problem, ERIC, and others are demanding heavy handed price controls that will harm the physicians who render life saving medical care — often small businesses themselves. 

And putting the squeeze on physicians with government set fees, that may not even cover costs bloated by complying with a sea of federal regulation, ultimately harms patients’ ability to obtain high-quality, timely care in situations where care is most needed.

Let’s take a closer look at the real cause of the problem, and solutions that will put patients in the driver’s seat instead of putting their access to care on the hot seat.

“Surprise, your insurance plan is not going to cover the care you received,” is another way to describe the situation. Of course, insurers want to limit their costs, as any business would, and those who provide care want to be paid well for their services. 

But how much should emergency medical care cost? In a functioning marketplace prices are determined through an immeasurable number of mutually beneficial transactions between customers and producers, not by federal fiat. 

But American medicine is anything put a healthy market. 

The fact that ERIC is demanding price controls points to a big reason this is the case. Employers are stuck between employees and their medical care thanks to the downstream consequences of wage controls in WWII that spawned tax-deductible employer-funded health benefits. D-Day was 75 years ago, and while Europe was freed, flawed government economic decisions from the War are still trapping Americans “in-network” with soaring medical prices, deductibles, and co-payments, not to mention premiums.

Because employers and other third parties are often in charge of paying the bill and negotiating costs, patients have lost their leverage and pricing becomes untethered from the marketplace mechanisms that, for instance, have put not just a chicken in every pot, but supercomputers in the pockets of virtually every American over age 13, and a car (or two) in nearly every garage.

It’s time to begin extracting the employer from the health care equation. ERIC and its members can be freed from the burden of overseeing and paying for their employees’ care. Employers don’t like shouldering this responsibility and employees shouldn’t want their employer interfering in the exam room or operating suite.  And, sorry Berniacs, Medicare for All is not the right way to go about winding down employer-based coverage.

One answer is to give patients better options to become independent of their employer for their care, like through expanding Health Savings Accounts with the flexibility to be used to buy catastrophic coverage or pay Direct Primary Care (DPC) arrangements.

Another more long term goal, but one in line with the American spirit of freedom and individualism is to end the $280 billion tax exclusion for employer-based insurance benefits altogether. Increase wages and salaries proportionately and cut taxes across the board. Employees can then decide for themselves how to spend their hard earned dollars, whether on insurance, directly on care, or however they choose.  

This would be a win-win-win, for employers, employees, and all patients. A re-energized marketplace will unleash more competition and more facilities and practices emulating the likes of the Surgery Center of Oklahoma (knee-replacements can be 50% less than through “coverage”) , Atlas MD (unlimited primary care for $50/month, $2 lab tests, and wholesale cost prescriptions), and Green Imaging (home of the $250 MRI) where direct-to-patient pricing, that eschews insurance contracts, is a fraction of what “in-network” options charge for the same care. And yes, competition even works to lower the cost of emergency care, as demonstrated by lower-cost transparent physician-run ER and urgent care options already popping up in Arizona, Oklahoma, Texas, and elsewhere across the U.S.

So instead of a surprise bill, patients will be pleasantly surprised at how affordable and accessible high-quality medical care is even for emergencies, when they, not their employer, insurance CEO, Member of Congress, or government bureaucrat are the customer.


Action Item: Visit https://action.stoppricefixing.org/ and learn how to make an immediate difference in the fight to stop flawed legislation.

Market Institute Unveils National #StopPriceFixing Effort

The Market Institute is informing voters around the country about a price fixing scheme that Republicans are considering in Congress.

Sign petition today at: https://action.stoppricefixing.org/

The awareness campaign is taking place in over 25 Media Markets across 7 States (North Carolina, Tennessee, Arizona, Utah, Idaho, South Dakota, and Wyoming). The effort includes Broadcast and Cable Television; Radio; Online and Social Media Advertising Campaign with a price tag of over $1,000,000.

The focus of the ad campaign is a bill that is currently under consideration in the United States Senate Committee on Health, Education, Labor, and Pensions (HELP) that includes price controls and will further erode the doctor – patient relationship, S.1895. 

Charles Sauer, President of The Market Institute, says, “Surprise medical billing is problem that must be solved. However, S.1895 will put more control of our healthcare decisions in the hands of government bureaucrats and the big insurance companies. This price-fixing-scheme is a prescription for fewer doctors, longer wait times, and less access to care. Government bureaucrats and insurance companies should not be standing between patients and their doctor.”

The team at The Market Institute is delivering signatures to elected representatives in Washington, DC. Organization volunteers are also reaching out to registered voters through phone calls and text messages encouraging members of Congress to oppose price fixing in S. 1895.


For more information, please visit:
Organization Website: www.MarketInstitute.org
Project Website: www.StopPriceFixing.org
Facebook: www.Facebook.com/StopPriceFixing