Lecture: Direct Primary Care Direct Primary Care Terminology, Legal,

Transcription

1 Lecture: Direct Primary Care Direct Primary Care Terminology, Legal, and Legisla ve Issues DPC: In the Trenches Pu ng the Joy Back into Family Medicine Philip Eskew, DO, JD, MBA Brian Forrest, MD

2 ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: ACOFP 52nd Annual Convention and Scientific Seminars Dates and Location of CME Activity: March 12-15, 2015, The Cosmopolitan Las Vegas, Nevada Lecture: Direct Primary Care -Direct Primary Care Terminology, Legal, and Legislative Issues (Eskew) -DPC: In the Trenches- Putting the Joy Back into Family Medicine (Forrest) Saturday, March 14, :00-4:00pm Name of Faculty/Moderator: Brian Forrest, MD x DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services. B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care goods or services. Please check the relationship(s) that applies. Research Grants x Stock/Bond Holdings (excluding mutual funds) Speakers Bureaus* x Employment x Ownership Partnership x Consultant for Fee Others, please list: Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper: Organization With Which Relationship Exists Clinical Area Involved 1. Access Healthcare Direct Network-CEO 1. Practice Transformation to DPC Model 2. DPCMH.org /DPCMH Association-President 2. Not For Profit providing information and resources on DPC 3. Access Healthcare, P.A.-Practicing Physician 3. Owner and Employee at Practice 4. Get Healthy Inc-Chief Practice innovation Officer 4. DPC Health Care and Wellness Portal and Software 5. Twin Oaks Software Development-Consultant 5. DPC Membership Management software 6. NCAFP/AAFP/multiple state chapters 6. Expert Faculty/Speaker on DPC *If you checked Speakers Bureaus in item B, please continue: Did you participate in company-provided speaker training related to your proposed Topic? Yes: No: x Did you travel to participate in this training? Yes: No: x Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No: x Did the company pay the travel/lodging/other expenses? Yes: No:x Did you receive an honorarium or consulting fee for participating in this training? Yes: No: x Have you received any other type of compensation from the company? Please specify: Yes: No: x When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation and/or lecture handout materials? Yes: No:x Will your Topic1 involve information or data obtained from commercial speaker training? Yes: No: x DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS x A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational uses of products or devices. B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated below: I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement. Signature: Date: 1/6/15 Brian Forrest, MD

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4 Direct Primary Care: Terminology, Legal, and Legislative Issues Philip Eskew, DO, JD, MBA Family Medicine Resident PGY-3 Heart of Lancaster Regional Medical Center ACOFP Annual Convention - March 14, 2015 DPC Terminology, Legal & Legislative Issues Learning Objectives: A) Obtain an understanding of common DPC Terminology B) Appreciate the diversity of DPC offices and locations across the US C) Medicare considerations opt out vs fee for non-covered service D) Awareness of the Business of Insurance hurdles E) Review state and federal DPC regulatory & policy considerations 1

5 Questions We Will Answer How may we define Direct Primary Care (DPC)? What about Concierge medicine? How many physician groups are really doing this? How does DPC interact with Medicare? (and Medicaid?) What are the legal hurdles? Which states have DPC legislation? Does the Affordable Care Act impact DPC practices? Direct Primary Care Defined For a practice to be defined as DPC, it must be a: primary care practice that 1) charges a periodic fee for services, 2) not bill any third parties on a fee for service basis, and 3) any per visit charge must be less than the monthly equivalent of the periodic fee. 2

6 Defining Direct Primary Care Retainer Medicine / Membership Medicine Direct Primary Care Split / Hydbrid Concierge / Boutique DPC = a periodic fee with no double dipping Concierge is synonymous with the fee for non-covered services model Concierge Care Defined A primary care practice that 1) charges a periodic fee for non-covered services, and 2) continues to also bill third parties on a fee for service basis Concierge practices, such as MDVIP or MD 2, continue to bill third parties in the traditional fee for service fashion in addition to the periodic fee 3

7 DPC vs Concierge Cost Differences Price is not a component of the definition Concierge fees are often much higher MD 2 initially charged $20,000 per year for non-covered services DPC groups often charge around $1,000 per year for all services Overhead costs are unchanged in concierge practices Many Groups Support DPC ACOFP DPC Task Force Direct Primary Care Coalition American Academy of Family Physicians DPC Interest Groups, Workshops, public policy endorsement American Academy of Private Physicians Family Medicine Education Consortium Organized multiple DPC National Summits American Association of Physicians & Surgeons DPC United 4

8 DPC Folks Think Differently DPC Research Methods Located as many DPC practices as possible (100), recorded publicly available data from the practice website: Practice Fee Structure Membership ranges (avg of high and low charges for pts > 29 years old) Any per visit fee (average of four visits per year) Any enrollment fee (divided by twelve for a monthly comparison) Practice Design (pure DPC or split) Medicare status (opt out vs accepting) Practice self description (DPC, Direct, Concierge, other) 5

9 Results All Practice average monthly cost = $ (range $35.67 to $562.50) All Practice Median monthly cost = $79.00 Self Described DPC average monthly cost= $80.68 Self Described Concierge average monthly cost= $ Split practice average monthly cost= $89.57 Opted Out practice average monthly cost= $ Enrollment Fee = $82.63 (only 24 of 81) (range $29 to $300) Per Visit Fee = $16.85 (only 17 of 81) (range $5 to $35) 6

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11 What s in the Name? Only 44 of 100 practices located in the study referred to themselves using the term Direct Primary Care 17 did (inaccurately) self describe using the term concierge, which can lead to confusion for both patients and policy makers, although it did correlate with a higher membership price Many other adjectives were used to describe each DPC practice If you have seen one DPC practice, you have seen one DPC practice 8

12 Charging a Per Visit Fee Approach used by only 17 out of 81 practices with price info Average of $16.85, Median of $20 with range of $5 to $35 The fee does not appear to affect the number of in-office visits Qliance and Access Healthcare data suggests an avg of slightly under four inoffice visits per year Other DPC docs report an avg of 1% of patient panel requires services daily, supporting an avg of slightly under four (3.65) office visits per year as well Charging an Enrollment Fee Only used by 24 of 81 practices with price info Average of $82.63, Median $77.50 Range of $29 to $300 9

13 Limitations Complicated pricing structures Lack of price transparency among all websites Scope of practice variance Summary Findings DPC is Affordable Median $80 per month, Average $100 per month Over 90% of practices are small and independent Per visit fees are used by less than 1/4 of DPC practices Enrollment fees are used by less than 1/3 of DPC practices Public price perception is accurate DPC affordable Concierge - expensive Flexible geographic location 36 states, rural or urban 10

14 Medicare Opting Out Must be actively renewed every two years Legally safer option (False Claims Act, Stark, etc.) Ideal for a Pure DPC practice Non-covered Services Terminology game must stay one step ahead of the government Moonlighting is less complicated More common in Hybrid practices Medicaid and Traditional Insurance Do not sign any traditional third party contracts! This would give insurance companies leverage to block your DPC efforts You can go public with denials of coverage (Brian Forrest has an example) Always have each patient sign an individual contract with your practice (even when brought to you by an employer or other group) The ONLY appropriate role of a third party in DPC is payment These agreements should not have any effect on your documentation or price Medicaid managed care pilot (Qliance) Medicare Advantage (Iora) Eventually more patients via state run insurance exchanges 11

15 The Business of Insurance State Insurance Commissioners argue that DPC is too much risk Membership contract amounts to the unlawful sale of insurance No case law directly on point Huff v St. Joseph s Mercy Hospital of Dubuque Corporation IRS definition anticipated related to Health Savings Accounts Would be additional persuasive evidence that DPC is not a health plan Each state may approach this issue independently Six states have passed laws designed to address this concern Wise contract terminology will be your defense minimize risk States with DPC Laws The Good Washington Utah Louisiana Michigan The Bad Oregon The Ugly West Virginia The Irrelevant Arizona Pending Georgia Idaho Mississippi (SB 2687) Missouri (HB 769) New Hampshire (SB 176) Oklahoma (SB 560) Texas (HJR 109) Florida 12

16 State Washington West Virginia Oregon Utah Arizona Louisiana Michigan Date Passed Requirements for Certification as Preventive Care Pilot Retainer Medical Medical Retainer Direct Primary Care Direct Primary Care Medical Retainer Title Program Practice Agreements Provider Practice Agreements Phrases Defined Direct Patient-Provider Primary Health Care Requires that a "direct fee" be charged on a monthly basis, no definition or use of term periodic fee "primary care" poorly defined using terms basic and simple, "Not Insurance" Yes (& HMO) Yes "primary care" = outpatient, nonspecialist, "retainer medical fee" poorly defined "Routine" health care services Poor definition of "DPC Provider Plan", Poor definition of "Primary Care Provider" failed to define periodic fee, vague definition of "direct fee" "Routine" health care services Unclear - the only time the phrase "not insurance" is used is in the mandatory disclosures section Yes Yes Yes Yes Reporting Obligations Yes Yes - Severe Yes None No No No Mandatory Disclosure Yes No Yes (in both contracts and marketing materials) Brief "not insurance" No Yes Brief "not insurance" Discontinue Care Provision Yes No No None No Yes None "Double Dipping" Prohibition No No No Yes No No Yes Marketing Restrictions No Severe No, only via disclosure requirements No No No No Inadvertent Pilot/Exchange Ban Potentially No Likely Potentially No Potentially Potentially Promotion of DPCMH in exchange No No No No No No No Scope Mild restrict, primary care is broadly defined Narow Narrow Broadly defined Broad Mild restrict, primary care is broadly defined Broadly defined Policing Authority Must submit annual statements to the insurance commissioner HCA & Ins Commish Dept of Ins - may investigate and subpoena, broad authority to adopt new rules None None LA St Med Bd None Separate License needed No Yes Yes No No No No Discontinuing Care Provisions (WA, LA) Patient participates in fraudulent activity Patient fails to pay for services Patient is abusive and is an emotional/physical danger to DPC Patient repeatedly fails to comply with the recommended txt plan DPC discontinues operations as a DPC 13

17 Required Disclaimer (Louisiana) This agreement does not provide comprehensive health insurance coverage. It Provides only the health care services specifically described. (WA, LA) Inform the patient of his financial rights & responsibilities to DPC Encourage patient to maintain insurance for non DPC services State that DPC will not bill a health insurance issues for DPC services Include contact information for the state medical board West Virginia Preventive Care Pilot Program Initially limited to six sites Program expires (again) on June 30, 2016 (grandfathering available) Health Care Authority full control of provider selection (Cert of Need) All fees, marketing materials, and forms are subject to prior approval from the insurance commissioner No marketing (except for known uninsured or known HDHP = $3,000) Mandatory 6 month wait for employer to purchase DPC conversion Must submit income tax returns to HCA Primary Care defined using terms basic and simple 14

18 State by State Summary Terminology problems continue Only 3 of the 6 states with legislation even use the term DPC Any DPC definition (if provided) is poor Only Washington, Louisiana, and Arizona offer some type of definition A broad definition is contained in the Affordable Care Act States where DPC could be more difficult Vermont West Virginia Oregon State Model Legislation Recommendations Define DPC using 3 part definition Should contain a clear NOT Insurance provision This is consistent with the not a health plan language in the ACA Mandatory contract and advertisement not insurance disclaimers No separate state registration should be necessary Require an individual contract with each patient List recommended discontinuation of care contract language Broadly define primary care scope of practice Promote formation of wrap around insurance policies 15

19 Affordable Care Act Sec HHS shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary Qualified Health Plan Essential Health Benefits Ambulatory patient services Emergency services (reduced) Hospitalization (reduced) Maternity and newborn care Mental health / substance abuse / behavioral health Prescription drugs (reduced) Rehabilitative and habilitative services and devices Laboratory services (reduced) Preventive and wellness services and chronic disease management Pediatric services including oral and vision care 16

20 Federal Register HHS Rules Direct primary care medical home plan = an arrangement where a fee is paid by an individual, or on behalf of an individual, directly to a medical home for primary care services, consistent with the program in Washington Primary care services = routine health care services, including screening, assessment, diagnosis, and treatment for the purpose of promotion of health, and detection and management of disease or injury Federal Register HHS Rules We considered allowing an individual to purchase a direct primary care medical home plan and separately acquire wrap-around coverage. However DPCMHs are providers, not insurance companies allowing a separate offering would require consumers to make two payments for full medical coverage, adding complexity 17

21 Federal Register HHS Rules While we recognize the importance of accreditation and quality assurance, we are not establishing that direct PCMHs be accredited in order to participate in QHP networks. We encourage QHP issuers to consider the accreditation, licensure, or performance of all network providers. We do not interpret that phrase as including providers of nonprimary care services, such as specialists. We are not directing exchanges to create incentives for contracting with direct PCMHs. We encourage exchanges to promote, and QHP issues to explore, innovative models of delivery along the care spectrum. Top 3 Legal Advisements If you decide to start a DPC practice: Consider the Business of Insurance Opt out of Medicare (and avoid signing standard Private Insurance and Medicaid contracts) Go all in Hybrid practices are legally riskier Hybrid practices have higher overhead 18

22 Broad Predictions DPC will grow exponentially over the next five to ten years IRS will change Health Savings Account interpretation Wrap-around catastrophic insurance plans will be offered Will likely represent over half of the primary care market in 10 years Increased interest in primary care, physician ratio will improve Litigated victories against initial insurance commissioner challenges Second series of suits will later be filed based upon scope Triple aim actually achieved! Any Questions? 19

23 Direct Primary Care in the Trenches: Meeting the Quadruple Aim Brian R. Forrest, MD Copyright 2014 Access Healthcare Direct all rights reserved What Keeps Family Physicians up at Night? Concern about Medicare RAC Audits Confusion about ACO implications Wondering if they will be able to be independent Uncertainty about viability of their practice ICD-10 and other bureaucratic changes? costs? SGR, RUC not working, workforce problems 1

24 Physician Trends and Attitudes Survey of 1311 physicians nationwide by Physicians Practice 9/14 53% considering or already in Direct Primary Care 35% considering or already working in Concierge Model Only 20% in process or have achieved PCMH recognition 4.4% plan on entering ACO 3.9% plan to become PCMH 4% plan to become hospital employed DPC-Direct Primary Care Pro Significantly lower out of pocket costs for most Quality improved due to more time (value- based instead of volume-based care) Complete price transparency Lowers overhead/helps practices financially Improved access for underinsured and poor Con Major transition/disruptive Recruiting patient panel (copay culture) Adapted from Forrest, B.R. Physician s Practice Pearl 12/7/11 New Primary Care Models Can Change the Way You Practice Medicine 2

25 Concierge and DPC-Similar and Different Both improve quality of care for patients Both improve physician experience/pay Concierge severely shrinks panel size DPC improves access for low income/uninsured whereas concierge worsens Workforce improved instead of compromised with DPC What is the Difference Between Concierge and DPC? DPC generally affordable for the average person (Honda vs. Ferrari) DPC can be successful in rural and poor communities DPC can lower out of pocket costs and downstream costs DPC panel size is optimal 3

26 Vision Realized-My Favorite Moment How Access Healthcare Model Created: The Hypothesis: 1999My Study Different Models(15 years ago) -Data on 42 providers If You: Decrease Overhead (micropractice) and Have patients pay in full at time of service, monthly, or yearly (direct payment) Then you can: Reduce Fees, Increase Collections, And Focus on patient care-improve Quality 4

27 What People Said About This Idea You re Crazy! That will never work. You won t be able to afford to stay in practice. Primary Care Math Traditional Our Model $1.00 $1.00 x.65 collected (avg in US) x % overhead (avg in US) - 18% left.81 left 5

28 Overhead Dramatically Reduced 65% 18% 6

29 Genius of the GYM $5 $3 Access Healthcare: a D-PCMH Micropractice Model Charge low per member per month directly to patient or their employer or their insurer* nominal per visit fee to cover overhead costs Net profit double to triple per patient per year A La Carte Non-Member transparent pricing at 80% off typical rates for service 4 FTE equivalents in overhead costs saved per physician-mostly due to no insurance related staffing 7

30 Affordable Care Medical Home Member subscription/membership model : patients charged affordable fee per month and a nominal fee per office contact- no extra charge for common labs, EKGs, U/As, etc. Patients who come in rarely only for acute complaints are not forced to be members and can have services from an a la carte menu posted in waiting room- typically 80% off most services A La Carte Model: patients who opt not to be members (usually young patients with occasional acute problems like UTIs) add up bill on a discounted price transparent menu with 80% discount This makes out of pocket costs average less than a the least expensive individual cell phone plan per year (even the chronically ill multisystem patientincluding labs, in office procedures, the entire basket of services in our office ) Summary of DPC Model for AH Lower patient charges-80% less (improves access for underinsured) Higher collections (99% for 12+ years) with overhead 15-22% More time with patients/less patient volume(even with similar panel) Not bound to insurance contracts - no insurance filed Less stress/lower risk exposure/decreases medical mistakes 1 Allows better familiarity and firmer patient relationships thus decreasing risk 1,2 Allows time to coordinate all aspects of patient s medical care to truly be the patient s medical home 1-O Hare, Dennis C. et al. FPM.2/2004 Vol 11. No.2 The Outcomes of Open Access Scheduling. 2-Linzer, Mark et al. Advances in Patient Safety Vol 1. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study. 8

31 Kick the Payer out of the Exam Room - Make the Physician-Patient Relationship a 2 Party affair The 5/50 Paradox Medicaid patients? Insured Patients (52%)? 9

32 QCAP-The Quadruple AIM Increased Quality Improved Cost Access Patient/Physician SBP LDL HDL Traditional/PCMH Hybrid DPC Practice COSEHC DATA

33 Patients attaining target goals who were not at control at baseline All Practices SBP LDL 100 LDL 130 A1c DPC Practice COSEHC DATA Physician Income Expectations For a family physician with patient panel capacity of 1200 and a visit volume of 16 patients maximum per day incomes can be similar to specialists like cardiology or GI and better than general surgery and most of the other internal medicine subspecialties If you want to do packages for the extremely economically challenged and create a lower fee schedule or sliding scale that is reduced by another 50%(as compared to average DPC practice fee), this can still net 50% more in salary for a family physician even if their entire panel was in this demographic.(works for rural communities or low median income areas) 11

34 ACCESS HEALTHCARE, PA Chronic Disease Management and Valuing Trust Does Trust Matter? How much trust is built in a 35-minute visit versus an 8-minute visit? Research shows the cost of litigations when the patient and doctor spend more time together and have more trust is significantly lower 1,3 The average primary care doctor pays $11,000/yr. in malpractice premiums. Two physicians at Access Healthcare together pay less than $4000 per year 2. Also the decreased volume of 30 patients vs. 12 patients, means that you are 2.5 times less likely to be sued just based on volume. 1 A study of sued and non-sued obstetricians found that patients who saw obstetricians with the most frequent number of prior lawsuits were significantly more likely to report spending less than 10 minutes with their physician during each visit; 2 Dr. Brian Forrest, Access Healthcare 3Kristin E. Schleiter, JD; Difficult Patient-Physician Relationships and the Risk of Medical Malpractice Litigation AMA Journal of Ethics. March 2009, Volume 11, Number 3: ACCESS HEALTHCARE, PA Management of Chronic Disease in a DPC Model Only 50% of patients nationally with high BP who are seeing a doctor and are being treated for high BP have their BP under control 1 80% of patients at goal in a review of 3 DPC physicians 2 1 NHANES data 2 Access Healthcare Direct patient data

35 Number of patients 2/27/ Access Healthcare Direct Diastolic Blood Pressure 82% ATGOAL 8% 90% ATGOAL Baseline ATGOAL NOT ATGOAL Follow-up JNC 7 Goal Attainment: < 90 mm Hg; < 80 mm Hg diabetic ACCESS HEALTHCARE, PA US vs. World vs. Access Healthcare Direct Practices All Patient Out-of-Pocket costs per year including insurance premiums in DPC Model with High Deductible Plan The Organization for Economic Co-operation and Development (OECD) OECD. All rights reserved 13

36 ACCESS HEALTHCARE, PA Two DPC physicians, One Quarter 2Q2013 Results reflect a traditional profile Access Healthcare 1 : In a full quarter, doctors provide about 600 diagnoses. This equates to about 200 a month or 50 a week. Most patients have more than one ailment. Patient population is demographically and diagnosis code c/w NC averages-except higher portion of uninsured 1 Access Healthcare Review of patient visit data Access Healthcare LLC, All rights reserved ACCESS HEALTHCARE, PA Doctor and Patient Experience Compared: Total Doctor-Patient Minutes/Year Doctor minutes for patient Traditional Care 140 Access Healthcare Traditional Care 35 Access Healthcare In the AHC model, patients get more minutes, and are charged less leading to more favorable outcomes. 14

37 ACCESS HEALTHCARE, PA Patient Experience Compared: Observation Traditional DPCMH Patients per day Doctor minutes available Doctor minutes for non-patientfacing work Doctor min. average for patient interface Typical Per Patient Insurance out of pocket costs for premiums $2500 Employee Plan 1 $ 33% less 2 Typical Visits per Year Total Doctor time Hospitalizations per 1000 pt/yr Doctor minutes for patient 35 8 Traditional Care Access Healthcare In the DPC model, patients get more minutes, and are charged less leading to more favorable outcomes. 1 Various leading plans were reviewed including BCBS and UHC, this figure represents the approximate employee-based outof-pocket from those plans, per person covered. 2 Review of a 2013 BCBS plan with high deductible and catastrophic health coverage Interesting Tid Bits Primary-care physicians with rising overhead, more paperwork, and packed waiting rooms are propelling ever-greater numbers to shed insurance and charge a retainer- up to 33% by 2016 according to Accenture Survey In 2011 the average American medical practice spent $82,975 per doctor just dealing with insurers, according to the Commonwealth Fund. In 2010, patients in this model visited emergency rooms 65 percent less than similar patients. Thirtyfive percent fewer of them needed to be hospitalized. They required 66 percent fewer specialist visits. In 2012 the average premium for an employer-provided insurance policy for a family of four climbed to a record high of $20,728, according to Milliman, a health-care consultancy. 15

38 Key Problems the Model Solves: Financial viability of independent practices (overhead can be <20%) Physician burnout- med students often say it seems like we are on vacation Work force recruitment-med students see hope in this modelbeing able to make as much as other specialists helps GME bottleneck-private residency programs can be self funding Access to primary care for most Practice determines reimbursement/payment rates Malpractice risk decreased Non-clinical bureaucracy/paperwork decreased Quality metrics and value based care are built in with measured practices exhibiting top tier chronic disease management One Medical Student s Thoughts- Why Medical Students Should Be Excited About Direct Primary Care(excerpt from blog published on DPCMH.org, KevinMD and Primary Care Progress)-By Brian Lanier Direct primary care makes me incredibly optimistic about the future. I will avoid the hamster wheel and provide the kind of care I envisioned, while building deep, rich connections with my patients. I will be offering a level of care previously only available to the rich that almost anyone can afford. I will be taking meaningful steps towards true, primary-care driven and patient-centered health reform, and I won t have to wait for the system to figure it out. I will be able to provide the majority of care my patients require instead of having time only for refills and referrals. In short, I will be part of the solution, both for my patients and for the system as a whole. Brian Lanier is a fourth-year medical student at the University of North Carolina and a future family physician. Follow him on Twitter 16

39 AAFP Response:DPC The AAFP recently created a document with frequently asked questions(4 page PDF) to accompany the Academy's newly created policy on direct primary care (DPC), a model in which practices charge patients a flat monthly or annual fee in exchange for access to a broad range of primary care services. "The AAFP supports the physician and patient choice to, respectively, provide and receive health care in any ethical health care delivery system mode, including the DPC practice setting," says the policy. It notes that the model is structured to "emphasize and prioritize" the physician/patient relationship to improve health outcomes and lower costs and is consistent with the AAFP's advocacy of both the patient-centered medical home and a blended payment model. According Glen Stream, M.D., M.B.I., of Spokane, Wash., "There is more than one way to build a patient-centered medical home (PCMH)." He noted that the number of AAFP members developing DPC practices was increasing. "The model eliminates the insurance middleman and provides revenue directly to the practice to innovate in both customer service and quality of care for the patients they serve," said Stream. Significance of Direct Primary Care in Employers-low cost option for employers, ACA has a section discussing that this qualifies as insurance with HBE qualified plan as approved by HHS-section 1301 A 3 -Patients-higher satisfaction and better outcomes at lower out of pocket costs with complete price transparency -Medscape article reports explosive growth of this model and in conjunction with Concierge practices represents currently 12% of primary care- expected to be 30-40% of market by Summit in St. Louis last October Washington D.C., New Orleans, Miami, AZ- AAFP to hold 3 regional workshops at the end of the year and Annual Assembly -Insurers-products launching now to integrate into HBE eligible plans-including Medicaid and Medicare Advantage -Large Companies like Expedia.com, Freelancers Union, Whole Foods, Grove Park Inn, Huntington Bank, McDonalds, and Taco Bell/Long John Silver s already looking to or currently contracting with DPC practices. 17

40 Medicaid and DPC looks promising -In Washington State, Coordinated Care has partnered with 5 DPC practices to provide primary care for Medicaid Patients -With the initial 40,000+ enrollees: ER visits are down 60%, hospitalization and readmission down 65%, and overall costs for this Medicaid population is 30% less for 2013 than the non-dpc pilot practices -Opportunity exists to do this in any state (like NC). It would make Medicaid a preferred payer by many family physicians- double the net revenue per patient of fee for service is possible (and payment is upfront every month-no waiting on delayed reimbursements) -In Washington State, participating physicians getting $50+ per member per month -This can really make practicing in rural and low income communities sustainable and recruit needed workforce into those areas Last updated 6/14 Access Healthcare Direct Network Practice Practices Using our model/software including hybrid practices 18

41 Where to Learn More Sprey, E. Physicians Practice New Practice Models are Gaining Acceptance 9/14 Forrest, B.R. Physicians Practice Pearl New Primary Care Models Can Change the Way You Practice Medicine 12/11 Forrest, B.R. Medical Economics Cover Story Cutting Edge 5/25/11 Mescia, Tony. Weekly Standard Cash for Doctors Revisited 4/11 Mescia, Tony. Weekly Standard Cover Story Cash for Doctors 5/23/10 Morgan, Lewis. Medical Economics Cover Story Keeping it Simple 1/22/10 Forrest, B.R. Physicians Practice. July Cash and Carry Healthcare Still Works. Forrest, B.R. Family Practice Management. June Breaking Even on 4 Patients per Day. Forrest, B.R. Physicians Practice. June Cash and Carry Health Care. Forrest, BR. NC Medical Journal May Innovations in Primary Care. The Access Healthcare Model Backer, Leigh Ann. Family Practice Management. February Cash Paying Patients and Growing (just starting to use this but giving regular DPC updates now) (link to first article above) source of compilation of 20+ articles on the DPC model website for DPC network practices. Undergoing renovation and updates free membership for students and residents- website for members only 19