AT RISK: Bill to Let Patients Use HSAs for DPC

Earlier this week we heard the good news that H.R. 365 was finally going to be considered by the House Committee on Ways and Means, bringing the use of Health Savings Accounts (HSAs) for Direct Patient Care (DPC) one step closer to reality.

Then we learned “a few small changes” had been made to the bill. Unfortunately the “few small changes” have greatly damaged the legislation.

You can read a copy of the latest bill here: https://goo.gl/B6imgQ.

Under the new language, DPC practices would have to comply with several federal requirements in order to become HSA-eligible. One provision limits the care provided under the agreement to specific CPT codes.  Another would prohibit DPC arrangements priced over a certain threshold from being HSA-eligible. Others further limit how the pricing can be structured and what care can and cannot be included. Specialists would be blocked from offering innovative HSA-eligible monthly membership payment arrangements.

To us, these changes are unacceptable and might be worse than no bill at all. If the bill passes in this form it would put practices that don’t comply with the federal rules at a competitive disadvantage to practices that align their model to satisfy DC instead of their patients.

One more problem:  these changes were tucked in at the last second barely a day ahead of Wednesday’s mark up session of the Bill in House Ways and Means.  That’s right, the new bill is headed to be pushed through committee with little chance for public input.

Today, AAPS sent a letter to every Ways and Means Committee member, and the committee staff, expressing our concerns about this bill and a few other bills the committee will consider on Wednesday, July 11.  Overall, we like a number of the bills under review, because they do expand HSA flexibility. But there are several key problems that tilt the playing field to the advantage of corporate medicine. Read more in our letter here: https://goo.gl/XYutr5.

What can you do?  Please send the committee a message ASAP before Wednesday at 2pm Eastern.  Here are the steps:

1) Copy the following text:

Dear Chairman Brady, Ranking Member Neal, and Members of the House Committee on Ways and Means,

Tomorrow you will be considering replacement language to H.R. 365, the Primary Care Enhancement Act. The addition of improper requirements means the new bill will not accomplish the goal of allowing patients to use their Health Savings Accounts to see the Direct Patient Care physicians of their choice.  I encourage the committee to consider adopting H.R. 365 as written, while rejecting the recent changes. In addition I encourage you to please consider AAPS recommendations about this bill and others you are considering today. The AAPS letter to the committee is available at https://goo.gl/XYutr5.

2) Visit https://waysandmeans.house.gov/contact/ and paste the comment in to the appropriate field and modify as desired.

2a) You can also fax your comment to the committee: (202) 225-2610

3) If your representative is on the Ways and Means Committee, email the note to the Health Legislative Assistant for your Member of Congress. A list of committee members and their health staff contact information, sorted by state, is available here: https://goo.gl/8iqw3u.

Thank you for speaking out!

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One Easy Hack @RealDonaldTrump Can Use to Ignite a Consumer-Directed Revolution in American Medicine

Options are about to multiply for 12-million Americans trapped in ObamaCare plans, the 12% uninsured, and others ACA victims, with coming new proposals from the Trump administration.  After signing “Right to Try” into law Wednesday, President Trump hinted that these changes are mere weeks away.

Once the new policies are in place, new lower cost and flexible insurance alternatives will be unleashed, freeing Americans from disruptive (in a bad way) ObamaCare rules that drive up costs and decrease patients’ and workers’ choices.

Here are the two expected policies plus one hack that will floor the accelerator on their impact:

First, the Department of Labor is set to expand the availability of Association Health Plans. These will give Americans with common connections the ability to join together in plans they control.  Less regulation is not the only advantage of AHPs, although savings will be significant: an estimated $9,700 a year less compared to the individual market by 2022, reports Avalere.  Escaping state-based mandates is another advantage; these plans can be sold across state lines. In addition, association plans will allow employees to more readily keep their plan if their work situation changes.

The second anticipated policy, this one from the Department of Health and Human Security, will increase access to short term health insurance plans that are almost completely free of failed ACA requirements. Under President Obama, these plans were limited to 90 days of coverage, but Secretary Azar is expected to extend the limit to 364 days.  Coverage in such a plan would costs on average $342 a month, vs. $619 per month for an exchange plan, reports Michael Cannon of CATO. Mr. Cannon also suggests the administration should allow short term plans to offer guaranteed renewability or even sell the guarantees separately (he estimates the average cost at $86/month).  Renewability options would not only help consumers retain these plans long term, but would also inhibit expensive enrollees from being pushed back into the ACA exchanges.

Both of these proposals are going to help Americans; however the Trump administration could turbo-charge these good ideas with one simple hack. One sleek additional change to federal policy would lower costs even further, while increasing patients’ access to high quality care.

What else should the Trump administration do immediately? It’s simple: let patients use Health Savings Accounts (HSAs) for Direct Primary Care (DPC).

Most people already know about HSAs but, perhaps aren’t yet familiar with DPC, a direct arrangement between doctors and patients, that cuts the red tape out of health care, kicks the bureaucrats out of the exam room, and is set to sweep across the U.S.   Dr. Marilyn Singleton explains DPC like this: “The Direct Primary Care (DPC) model is burgeoning as patients yearn for quality time with their doctor at an affordable price. Here, all primary care services and access to basic commonly used drugs at wholesale prices are included in a fixed transparent price,” often around $50 to 75 per month.

The bottom line is DPC saves money for patients and downstream payers (like Medicare), increases quality of care, and it relieves physicians of counterproductive red-tape hassles that are driving them out of practice. DPC is a win-win-win.

You’d think everyone would agree that encouraging the use of DPC is a no-brainer. Shockingly, the Internal Revenue Service is blocking the use of this innovation for the 30 million Americans with HSAs. Thanks to a letter issued by Obama’s IRS commissioner, John Koskinen (yes the same one who stonewalled efforts by Congress to investigate IRS retaliation against conservatives) patients are prohibited from contributing to their HSA if they are in a DPC practice. To add insult to injury, HSA funds cannot be used for DPC.

As the public becomes aware of this flawed IRS decree —deserving of a blue ribbon in the Health Policy Hall of Shame—momentum grows for change. Just last month, Senators Ted Cruz and Ron Johnson wrote Treasury asking for a reversal.  In addition 1,125 patients and doctors have asked Congress to pass the Primary Care Enhancement Act (HR 365/S 1358) and force the IRS to change its misguided interpretation of law.

Disrupting (in a good way) Koskinen’s obstruction of patient freedom must be a priority for the Trump Administration as it moves forward with other reforms to remedy past policy disasters.  Allowing patients to use HSAs for DPC will turbo-charge the ability of patients with short term and Association-based plans to make their health care dollar go even further and get the best care from the physicians of their choice.

Need one last reason, President Trump? DPC will boost your plans to lower prescription drug costs.  A 72-year old female patient with multiple chronic conditions purchases all nine of her medications through a Direct Primary Care office in Allentown, Pennsylvania for $14.63 per month. Through Medicare “coverage” her cost would be $294.25 per month.

There is simply no legitimate reason for blocking patients with HSAs from DPC physicians … unless you are a middleman profiting off the status quo.

Don’t get stuck in ER surrounded by flu victims. Joining a concierge practice is a no brainer.

Dr. Tom LaGrelius writes in:

Joining a concierge practice is a no brainer, unless you want to sit surrounded by coughing masked flu victims in a packed ER unable to treat you with antivirals anyway. The hospitals are using Tamiflu only on patients so sick they are in the ICU. And in most of those cases they need not have bothered. They got their first dose long long long after the effectiveness window had closed. They should save it for the ones ill less than two days when it actually works!

The hospitals are currently swamped with flu victims and have no beds or ER space.  Continue reading

Alexander-Murray Exacerbates Flaw in ACA’s “Catastrophic Plans”

DPC physicians and patients take note!

An aspect of Alexander-Murray will exacerbate an under-appreciated flaw in ACA requirements for plans considered “catastrophic plans.”

Alexander-Murray will allow anyone to have a “catastrophic plan” as such plan is defined by ACA. ACA limits enrollment in these plans to enrollees under 30 years of age or enrollees who have a waiver. Alexander-Murray would do away with these limitations. So far so good.

Another ACA limitation on these plans — found in  ACA section 1302(e) — is that the plans will provide no benefits until the enrollee’s annual out of pocket limit has been reached, except that the plan must cover “at least 3 primary care visits.”

This will harmful to patients of DPC practices and is bad policy. It essentially forces primary care to be handled in-network — great for the insurance companies but not for the patients orthe doctors.

Ideally the requirement should be struck from ACA.  Alternately, a small change along the lines of this or something similar [in brackets] might help fix this problem:

(B)the plan provides—
(ii)coverage for at least three primary care visits, [unless the enrollee is separately contracted with a direct primary care physician, in which case the plan will refund to the enrollee an amount equal to the value of such coverage.]

CMS wants your comments on market-based Healthcare innovation. Deadline Nov. 20.

CMS has caused quite a stir this week by announcing they are shaking up their CMMI “Innovations” office.
They are looking for input on “Consumer-Directed Care & Market-Based Innovation Models”  that might be beneficial to Medicare and Medicaid patients.
“What options might exist beyond FFS and MA for paying for care delivery that incorporate price sensitivity and a consumer driven or directed focus and might be tested as a model and alternative to FFS and MA?”
Here’s a link to the full request:
The deadline for submitting comments is November 20 and the link to their webpage on this is here:
And the response form is here https://survey.max.gov/429625

Insurance Contracts that Respect the Patient – Physician Relationship?

Friend of IP4PI Charles “Chip” Smutny, DO writes in:

Does anyone think about or have we even tried to come up with our own physician based contract proposal to insurers that could be a way of negotiating our independence as an alternative to their railroading contracts? Since we know that DPC works, cost less and provides better care more efficiently and that insurance will morph to continue to keep its revenue stream, perhaps we should offer up a contract of our own.

Since we don’t like their offer should we have a counter proposal that requests what we want in a legal document that can be validated and support legal recourse in “a partners agreement” instead of the current “employee-employer contract” and that the insurers must be accountable to in court to this new contract?

Simply stated it might read something like this (with 11 pages of legalese from our lawyers that structures the responsibilities and supports the clarity of the following):

  • patients come first
  • physicians have a right to receive pay for services rendered.
  • insurers pay patients according to their contracts, not physicians
  • patients pay physicians directly
  • patients have the right to decide what they will accept as personal risk in their health and in their financial circumstances.
  • insurers may not interfere in any way with the decision making of the patient in concert with the physician.
  • insurers may not set pricing restrictions on physicians. They may however set limitations in their service contract with the patient on what they will cover in their contract.
  • physicians have the privilege and the right to support their patients in their efforts to obtain quality healthcare delivery and insurance coverage
  • physicians have the right to personal privacy and protect patient privacy by only allowing data stripped of unique identifiers to be collected and stored centrally.   Centralized charting must not contain any unique identifiers other than the physicians delivery of care office information.

Please add on or discuss as you see fit!

This discussion might lead to some sort of standardized counter offer to insurers since so many physicians are afraid to leave that system which has steadily moved toward indentured servitude.

Leadership: Let patients decide what quality and value means to them

Michael Strickland, MD writes in:

In the face of CMS’ own predictions, Andy Slavitt says “Despite what the table shows, our data shows that physicians in small and solo practices can do just as well as those in practices larger than that.”

I’ll believe that he, and others like him, know what they are talking about when I see them start picking up charts, seeing patients, and relieving their danger and distress, while using the systems they are so eager to mandate. I have medicaid and medicare patients who pay me cash, because they have problems they cannot get solved by their ‘providers’ who are being directed by these people, and I openly invite Andy Slavitt, President Obama, Hillary Clinton, Zeke Emmanuel and anyone else advocating this to visit my office in Cincinnati and show us how it’s done. Continue reading