There May Be Hope In American Healthcare-Via Direct Primary Care
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Dear Friends & Neighbors,
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(Please click on red links & note magenta)
For many years, there are those who believe that separating primary care doctors from the insurance standards would enable the benefits to trickle down to the healthcare industry. Now there is a bill that expands direct primary care services, with this concept in mind, waiting for Governor Rick Scott‘s final approval. The direct primary care is a model such that patients pay a monthly fee to their doctors for specific care without dealing with insurance companies. Right now, these agreements are not subjected to insurance regulations, but there is no law that guarantees that. This bill waiting for Governor Scott’s approval would protect these direct care agreements.
Rep. Danny Burgess believes that this model would lead to more preventative healthcare. “With more affordable primary care, we’re going to be focusing in on more preventative medicine. Hopefully mitigating the need, more so than not, to have to present themselves to an ER, to an Urgent Care, or to other forms of potentially catastrophic situations. So Preventative care is key, and we need to encourage that, and I think this bill actually helps to do that,” Burgess states. Senator Tom Lee says this bill will not only benefit patients, but doctors by circumventing the time consuming insurance process. “We’re obviously looking for ways to be more creative, to offer different service delivery models here in the state of Florida. And this is an approach that would allow direct primary care physicians who want to take advantage of this opportunity to enter into agreements and avoid the 30% to 35% of their staff time that ends up being consumed in dealing with insurance companies,” Lee comments.
On the other side of the argument, Rep. Richard Stark is concerned that the bill could lead to more cases of patients being scammed. “Eventually people looking to begin marketing it, eventually insurance agents in the field will probably sell it, and unfortunately people who are not licensed, have no idea what’s going on in the healthcare delivery system, they may be marketing this. And we’ve had plenty of scams in the past where people buy what they call ‘discounts to see doctors’, even though it’s not…. it’s similar. And then people use this and they think they have insurance when they don’t,” Stark says.
Even though there is insufficient research or data out there to substantiate this model’s success rate, but the model has been endorsed by The Heritage Foundation and The Heartland Institute. To avoid potential misunderstanding or scams, perhaps a central or regional government web site for this model can be set up, with all participating primary care physicians available listed at the web site, including physicians’ respective experience, interest, background, their patients’ comments, and calendar for their availability for appointments (either onsite or online). At this web site, detailed explanations of the model and ultimate responsibility of both physicians and patients, and services that may be rendered by individual physicians, billings and accounts may all be clearly stated. Furthermore, much of the preventative healthcare information may be shared and made available at this web site. This would help to reduce the cost of publishing pamphlets, reduce the time physicians need to explain preventative healthcare, and reduce the chance that patients would forget the information.
What any average American can do is to have a direct primary care plan as well as a health insurance coverage plan with high deductible to insure coverage for catastrophic events.
Finally, a model with the correct incentive to keep clients well rather than being incentivized to increase billing opportunities!
Below, in italics, excerpt from wikipedia on “Direct primary care”:
In the United States, direct primary care (DPC) is a type of primary care billing and payment arrangement made between patients and providers, without sending claims to insurance providers. It is an umbrella term, incorporating various health care delivery systems that involve direct financial relationships between patients and health care providers.
Background
Direct primary care has been promoted by certain groups of physicians as a means for patients to save money on their primary care services, as well as other ancillary-performed services such as laboratory testing, etc. Often, there are no insurance co-pays, deductibles or co-insurance fees thus avoiding the overhead and complexity of maintaining relationships with insurers.
Under this model, patients may pay a combination of visit fees and/or fixed monthly fees which grant them access to a set of medical services, including same and next-day appointments, which may take the form of office visits and/or house calls.
Typically a direct primary care arrangement is paired with either:
- A high-deductible health plan, as DPC alone will not cover catastrophic health care such as most surgeries
- A health savings account, or health reimbursement account as the associated tax-benefits can generally be applied to DPC and other medical expenses.
One of the lesser known provisions of the Patient Protection and Affordable Care Act can be found in Section 1301 (and amendment Section 10104). This provision allows for direct primary care to compete with traditional health insurance options in the mandated Health insurance exchange when combined with a low cost high deductible plan.
Advantages
Direct primary care practices do not typically accept insurance payments, thus avoiding the overhead and complexity of maintaining relationships with insurers, which can take as much as $0.10 – $0.20 of each medical dollar spent. Consequently, because direct pay members are usually automatically billed a physicians practice’s cash flow can also be improved.
An emerging model of direct primary care involves the medical practice contracting with self-insured (or self-funded) employers who offer the direct primary care option as a means of accessing care for free or drastically reduced office visit fees. The employer pays the membership fees on behalf of the employee to the DPC practice directly. This option usually provides the employee same or next business day access to care. This allows workers to address evolving health concerns rapidly in order that the condition can be treated more quickly and the number of sick days or days of decreased productivity from illness might be reduced. Many DPC practices provide phone or email access to providers so that employees or patients may not even need to leave their workplace to seek medical advice.
Because direct primary care payments are typically paid over time, rather than in return for specific services, the economic incentives are such that the long-term health of the patient is the most lucrative situation for the doctor. As such, preventative care gains greater emphasis under DPC.
Criticisms
Opponents of direct primary care models assert that direct primary care is unethical, primarily benefitting providers and not patients. Opponents believe that the direct primary care model targets patients who do not have health insurance, as some insurance plans are more costly than entering into such a DPC arrangement. The Patient Protection and Affordable Care Act requires that DPC practices offering such services must include in their plans a secondary qualifying health plan (QHP) that covers other hospital services that the DPC provider may not offer if they choose to offer their DPC arrangement in the healthcare marketplace. Therefore, in cases where the DPC provider has chosen to participate in the healthcare marketplace, the patient would be required to carry and pay for an additional insurance coverage plan for catastrophic and hospital services in addition to the DPC arrangement for primary health care access if he/she purchases this plan from the healthcare marketplace. It is argued that DPC plans can be more expensive in the long term, since by design none of the payments made to the DPC provider practice are counted towards insurance deductibles because the provider neither accepts insurance nor participates in the submission and management of the insurance claims process, potentially resulting in a higher out of pocket catastrophic or hospital services cost to the patient because deductibles would not necessarily have been reached when these services are provided
Gathered, written, and posted by Windermere Sun-Susan Sun Nunamaker
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