Not new, no gimmicks, just simple. Karl N. Hanson, MD

Transcription

1 Not new, no gimmicks, just simple

2 FAAFP LSU Medical School 1984 LSU New Orleans Family Medicine 1987 Alpha Omega Alpha Medical Honor Society Founder: Infinity Health Direct Primary Care Founder: Louisiana Direct Primary Care Coalition Solo Practice 1 st recipient of Gerald R. Gehringer, MD Award

3 Objectives: Practitioners will be able to Define a DPC practice Compare DPC with conventional insurance-based practices Define the legal status of DPC Define the legislative status of DPC

4 Agenda: Encourage Private Practice (Specifics under a different lecture) Save Family Medicine

5 Q: Who does Family Medicine? A: Docs who would not think of doing anything else. These are exciting times for Family Medicine. A time to take back what we do best.

6 Nutshell Definition Simple way of billing, monthly membership fee No per visit charges (or minimal) NO insurance contracts or participation or billing Less patient volume = more care/patient Enhanced satisfaction

7 Wish List for Family Medicine Take care of patients Check off boxes in my EMR and upload data Contract for insurances to pay me less than I am worth Assume administrative burdens Burn out after 30 years Help insurance companies make more money (PAs)

8 Can we break out of Stockholm Syndrome? 1. Avoid billing hassles and overhead and collections? 2. Reject reduced negotiated rates? 3. Remove the third party from most interactions? 4. Avoid burnout? 5. Reject administrative burdens imposed by others? 6. Become Patient-Centered in the true sense?

9 What does Insurance mean to Family Medicine? 1. We sign an insurance contract. 2. We accepted a discounted amount for payment. 3. We accept that we are now the billers and take on the task as billers/collectors.

10 What does Insurance mean to Family Medicine? 4. We are responsible for collecting co pays. 5. We are responsible to verify patient participation in insurance. 6. We must learn and submit CPTs and ICD-10

11 What does Insurance mean to Family Medicine? 7. We are required to follow insurance-defined rules. 8. We obtain Prior Authorizations thereby perform the administrative function that benefits the insurance.

12 What does Insurance mean in general? 1. Having no health insurance is NOT the same as not being able to have health care. 2. Health INSURANCE is a commodity, not a right. 3. Health CARE is a responsibility of the patient first (hygiene, behavior), the doctor second.

13 What does Insurance mean in general? 4. Primary reason for ANY insurance is protection from catastrophic events. 5. Not typically for first dollar coverage

14 What does Insurance mean in general? 5. Consider Homeowners and Auto insurance. a) Typically cover big-ticket items b) We don t use them for primary care of car/house. c) People buy celery, but they don t have celery insurance.

15 New wrinkles in insurance-cms 1. CMS as a base considers that we have no merit. 2. We have to participate in QPP in order to prove our merit. If we don t, we get penalized. If we do we get rewarded. 3. With MACRA our administrative burden just increased ten-fold.

16

17 All is well with us in Family Medicine? 1. Burnout 2. Shortage 3. Malpractice 4. Loss of Control: Administrators (Not Family Medicine) driving health care.

18 What s all this burnout? 1. Why are FP s burning out? 2. FPs don t burnout from taking care of people, that is a privilege, fun and rewarding. 3. FPs burnout because of the burden of wasted time and effort (and money) with non-patient care.

19 Family Medicine Shortage

20

21 Family Medicine Shortage 1. FM shortage by 2035 will be 33, of 3378 spots matched in Of those, only 1,530 were US Medical Seniors

22 Family Medicine Malpractice 1. Multiple studies have shown that malpractice claims are meritless about 80% of the time. 2. In those case Patient or Family Perception is cited as the cause of stirring up the claim or lawsuit.

23 Family Medicine Malpractice 3. Communication problems include the patient feeling Devalued, Discounted, Deserted with information being Delivered poorly. 4. Claims are high in Family Medicine

24 Family Medicine Loss of Control 1. Our fates are being determined by others 2. Decisions made by people who do not take care of patients daily 3. MPH, MBA, JD or undefined bureaucrat s input with precious little MD/DO input

25 Is there another way? Has the government solved the FM problem for us? Have commercial insurances and CEOs made FM more palatable for us? Have our own medical organizations solved the issues for us?

26 Is there another way? 1. How about respecting that trained and certified physicians have intrinsic merit. 2. How about contracting directly with patients, leaving the middle man/third party out? 3. Is it possible to spend your entire day focusing on patient care and not third parties?

27 Is there another way? Thought you d never ask!

28 Grass Roots Movement-Direct Primary Care 1. The response at the grass roots level is there is another way called Direct Primary Care. 2. Doctors are enjoying their practice. 3. Doctors are patient-centric (there is nothing else). 4. CMS and Insurances virtually do not exist at the primary level.

29 Grass Roots Movement-Direct Primary Care 5. Direct Primary Care describes a model, not a national entity, corporation or legal structure. 6. A doctor does not need to be a DPC member or join any DPC organization.

30 Philosophy 1. Full attention directed at patient 2. Off the grid 3. No insurance company hassles 1. Not subject to MACRA/QPP reporting 2. Not tethered to billing overhead

31 Definition (Act ) 1. Direct Agreement (Contract) Patient-Physician 2. Does not accept payment from Insurances 3. Provides Primary Care Services 4. Charges a periodic fee (gym)

32 Benefits to physician 1. Much less office overhead 2. More time with/for patients 3. Greater control of your own practice 4. Solo/small-group friendly 5. You set it up like you want.

33 Benefits to physician 6. No calling an insurance company 7. Can delete all MACRA/QPP references 8. CPT codes & ICD-10 codes become a curiosity. 9. Fewer patients/longer visits if needed 10. The alliance is direct

34 Benefits to patient 1. Physician on retainer. 2. Full access 3. ULTIMATE in privacy: No claims (with diagnosis codes) are sent to ANYONE 4. They can keep their same doctor regardless of their insurance status

35 Benefits to patient 5. Same day/next day appointments 6. No waiting in a waiting room 7. Early treatment avoids UC visits

36 Payment 1. Is a retainer-based concept 2. DPC practices charge a small monthly fee 3. That fee covers essentially ALL primary care services that doctor delivers. 4. Fee is drafted from a credit card or checking account usually

37 Payment 5. Contract between physician-patient ONLY 6. Any per-visit fee must be lower than the monthly periodic fee (otherwise it looks like an Urgent Care or Fee-for-Service practice)

38 Is NOT Concierge in the typical sense. 1. DPC practices charge a small monthly fee 2. DPC practices do NOT bill insurances (there are rare exceptions). NO requirement for insurance. 3. If a patient has their own insurance policy DPC ers do not collect copays or deductibles. 4. NOT related to MD-VIP

39 What is often offered? 1. In-office dispensing 2. Discounted labs 3. Texting, Telemedicine, Video visits, Direct cell phone contact with doctor

40 Why would a patient not join a DPC practice? 1. They are paying for insurance (or their employer is providing) and PCP visits have always been free. 2. They don t see doc that much so paying a practice several hundred dollars as a retainer doesn t add up.

41 Why would a patient not join a DPC practice? 3. Relatively new concept 4. May know a friend or family member who joined a more expensive concierge type of practice. The MD-VIP model labels themselves as Direct Primary Care in their marketing.

42 Why would a patient not join a DPC practice? 5. Misconception: I can t see you any more doc since you are not on my insurance. (Insurance Addiction)

43 Legal stuff 1. Is it a form of insurance anyway? 2. Is DPC real or a figment? 3. Law 4. IRS 5. Pertinent Federal Legislation

44 Is NOT an insurance in Louisiana and many states. 1. Membership Fee covers no other doctor or hospital. 2. A patient is still encouraged to have their own insurance for expensive and catastrophic events. 3. In 2014 Louisiana Act 867 (SB 516) codified DPC as NOT an insurance. (a good thing)

45 Typical Scenario 1. Patient visits, no copay minute visit (if desired), no rush 3. Leaves with a deeply discounted medication 4. Brief entry into the medical record

46 Personal Reflections 1. Breaking my own addictions 2. Happier, more fulfilled 3. A sense of control returned 4. Patient care now front and center. After 30 years, realized why I went to medical school.

47 Is DPC real or a figment? 1. ACA 1301 (A) (3) recognizes DPC 2. Over 24 states formally recognize DPC. Others have active legislation. (as of August 2017) 3. CMS is working on a demonstration project. 4. There are several DPC practices in LA.

48 IRS Confusion 1. A patient paying a periodic DPC fee is purchasing a GAP policy. [IR Code 223 (c)(1)(a)(ii)] 2. Therefore they no longer have a qualified High Deductible Health Plan [IR Code 223 (c)] 3. Therefore they are not eligible to contribute to a Health Savings Account

49 IRS Confusion 4. But the IRS simply says that they don t have enough information to recognize DPC-an agnostic approach. 5. They need legislation to define that for them.

50 IRS Confusion 1. IRS feels that a period DPC fee is NOT a qualified medical expense. [IR Code 213 (d)] SO...a patient may fail an IRS audit if they pay their monthly DPC fee from their HSA. There are ways around this and for FSA s.

51 Legislation (Federal) 1. Patient Freedom Act of 2017 (S.191) (1/23/17) Cassidy 2. Health Savings Act of 2017 (H.R.35) (1/23/17) Burgess 3. Primary Care Enhancement Act of 2016 (H.R. 6015) (9/13/16) Paulsen 4. Primary Care Enhancement Act of 2015 (S.1989) Cassidy 5. Small Business Health Care Relief Act of 2016 (H.R.5447) (6/10/16) Boustany

52 National Organization 1. AAFP 2. DPC Frontier

53 State Organization 1. Louisiana Direct Primary Care Coalition (LADPCC.com) 2. Louisiana State Medical Society

54

55 SUMMARY..If you would like to: 1) Avoid insurance hassles 2) Avoid billing and collecting and coding 3) Avoid insurance mandates and Medicare reporting 4) Spend more time with patients Give DIRECT PRIMARY CARE a look

56 Questions? Contact Cell

57 END