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    Obamacare is severely holding DPC back from succeeding

    Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Anish Koka, a cardiologist in private practice in Philadelphia. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

     

     

    Dr. KokaIn a world created by nonphysician administrators where 15 minutes per patient, 30 patients per day, little ancillary support and the constant threat of litigation is mixed with declining reimbursements and high debt loads, it comes as little surprise that primary care physician burnout and suicide rates are among the highest of any occupation.

     

    Related: Is Obamacare actually making America healthier?

     

    The answer to this lament helpfully provided by health policy analysts who have spent little or no time in actual practice is to reimagine the physician as a population health master who leads a team with healthcare coaches, personal trainers and masseurs connected to patients via some high-tech wearable device providing data no one has the inclination or time to look at.

    As the physician-patient relationship has been eroded by employment that turns physicians into shift workers, patients are increasingly forced to single-handedly navigate a healthcare system that becomes increasingly complex.

    A much better solution to this problem would be a model that allows more time for patients and liberates physicians from a reimbursement climate and overhead costs that minimizes physician-patient interactions and incentivizes patient throughput. 

    It is within this space of unhappy patients and physicians that Direct Primary Care (DPC) has risen to prominence. DPC typically involves a direct payment between patients and physicians, usually in the form of a subscription service that may range from $50 to $100 per month.

    Physicians in this arrangement do not bill insurance and offer same day/next day access, and frequently include the cost of other medical services, such as labs and immunizations, as part of the monthly fee.

     

    Further reading: As insurers leave Obamacare exchanges, doctors pay the price

     

    The math isn’t complicated: 600 patients paying $100/month would translate to $720,000/year of gross revenue, with no need for the overhead normally related to collecting payments from insurance companies. A panel of 600 patients also returns the gift of precious time stolen from physicians and patients.

    Unfortunately, this reasonable model is opposed by a phalanx of current policy makers for a very good reason: A successful DPC model makes the current version of the Affordable Care Act (ACA) even more unworkable than it already is. In defense of the designers of the ACA, there are 20 million people now covered that did not and mostly could not get health insurance in the past.

    Next: "The ACA fails at most everything"

    Anish Koka
    Anish Koka is a cardiologist in private practice in Philadelphia trying not to read the writing on the wall. Follow him on twitter ...

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    • drkimcorba@------.com
      Dr. Koka--Thank you for taking the time to write this article. I am a DPC physician. The more that gets published about DPC, the better for free market medicine. You make some salient points but there are a few that require comment: 1. "..600 patients paying $100/month woud translate to $720,000 of gross revenue..." is inaccurate. The average per patient monthly fee in DPC is $60.00 which equals $432,000 gross revenue. The $100.00 price point is usually for patients nearing or of Medicare age and no DPC practice I am aware of has a full panel of patients that age, unless they were operating in a nursing home, skilled care or personal care facility--which may not be a bad idea! The revenue and pricing needs to be clear so not to mislead any doctors considering converting an existing practice or starting one from scratch. 2. "Yet another problem with the ACA-DPC relationship-relates to the minimum health care benefits mandated. DPC is not an end-to-end solution bc is only provides ambulatory services while visits to specialists....are not covered." I have pricing from independent specialists such as Cardiology, GI, Colorectal Surgery, Gyn, Podiatry, Physical Therapy, soon to add more. I even got DPC pricing for facility fees from an ambulatory surgery center for any procedures done at that site. Patients have HDHP's that meet the minimum requirements and choose to use the DPC pricing I have procured and submit these specialist fees to their HSA, or out-of-network deductible. They are using up their HSA less quickly with these lower fees and saving it for a potential catastrophic illness. 3. "Payments in DPC are not considered a 'qualified medical expense and....ineligible to use with an HSA.." Agree with above comment referencing Roy Ranthum who has written extensively about this issue. There are bills awaiting consideration on Capital Hill regarding allowing HSA to pay Direct Primary Care fees; they are bills H.R. 5324 and S. 2980, the Health Savings Account Expansion Act of 2016, Additionally any medications (wholesale dispensed from my office), discounted labs or imaging (which I have for my DPC patients for a small fraction of normal costs, ie. Z-pack for $1.95, MRI L/S spine for $440.00) can be submitted for reimbursement through HSA legally. Again, more money STAYS in their HSA. 4. "ACA mandates minimum essential benefits like prescription plans and lab benefits that HDHP don't provide.." My personal HDHP (family deductible of $4,000) covers all of the above and I have patients who have higher deductibles that provide just what you are saying isn't covered. So this blanket statement is misleading. I am glad to be able to have dialogue and read articles such as yours, the more publicity and education that occurs about Direct PRimary Care, the better. Legislation has passed successfully in 17 states, and has met some resistance in the 2 you mentioned above. But overall, it is growing rapidly, more states will pass legislation, and the ones that haven't will have it reintroduced. We are saving patients thousands, will save health care thousands as well and give excellent and comprehensive care (which should be mentioned in any article about DPC). Thank you- Kimberly Legg Corba, D.O.
    • drkimcorba@------.com
      Dr. Koka--Thank you for taking the time to write this article. I am a DPC physician. The more that gets published about DPC, the better for free market medicine. You make some salient points but there are a few that require comment: 1. "..600 patients paying $100/month woud translate to $720,000 of gross revenue..." is inaccurate. The average per patient monthly fee in DPC is $60.00 which equals $432,000 gross revenue. The $100.00 price point is usually for patients nearing or of Medicare age and no DPC practice I am aware of has a full panel of patients that age, unless they were operating in a nursing home, skilled care or personal care facility--which may not be a bad idea! The revenue and pricing needs to be clear so not to mislead any doctors considering converting an existing practice or starting one from scratch. 2. "Yet another problem with the ACA-DPC relationship-relates to the minimum health care benefits mandated. DPC is not an end-to-end solution bc is only provides ambulatory services while visits to specialists....are not covered." I have pricing from independent specialists such as Cardiology, GI, Colorectal Surgery, Gyn, Podiatry, Physical Therapy, soon to add more. I even got DPC pricing for facility fees from an ambulatory surgery center for any procedures done at that site. Patients have HDHP's that meet the minimum requirements and choose to use the DPC pricing I have procured and submit these specialist fees to their HSA, or out-of-network deductible. They are using up their HSA less quickly with these lower fees and saving it for a potential catastrophic illness. 3. "Payments in DPC are not considered a 'qualified medical expense and....ineligible to use with an HSA.." Agree with above comment referencing Roy Ranthum who has written extensively about this issue. There are bills awaiting consideration on Capital Hill regarding allowing HSA to pay Direct Primary Care fees; they are bills H.R. 5324 and S. 2980, the Health Savings Account Expansion Act of 2016, Additionally any medications (wholesale dispensed from my office), discounted labs or imaging (which I have for my DPC patients for a small fraction of normal costs, ie. Z-pack for $1.95, MRI L/S spine for $440.00) can be submitted for reimbursement through HSA legally. Again, more money STAYS in their HSA. 4. "ACA mandates minimum essential benefits like prescription plans and lab benefits that HDHP don't provide.." My personal HDHP (family deductible of $4,000) covers all of the above and I have patients who have higher deductibles that provide just what you are saying isn't covered. So this blanket statement is misleading. I am glad to be able to have dialogue and read articles such as yours, the more publicity and education that occurs about Direct PRimary Care, the better. Legislation has passed successfully in 17 states, and has met some resistance in the 2 you mentioned above. But overall, it is growing rapidly, more states will pass legislation, and the ones that haven't will have it reintroduced. We are saving patients thousands, will save health care thousands as well and give excellent and comprehensive care (which should be mentioned in any article about DPC). Thank you- Kimberly Legg Corba, D.O.
    • UBM User
      Can you provide an IRS citation (or other authoritative cite) supportng your claim that DPC payments can not be paid by a HSA? Kevin Greig Eugene, Oregon
    • UBM User
      It's true it won't pay monthly fee, but proabably will pay generated bill for actual services: This is from an article on the site directprimarycarejournal: Roy Ramthun of HSA Consulting Services based in Washington, DC, says “The IRS does not generally consider the monthly payment a ‘qualified medical expense.’ However, we do believe that they will accept reimbursements from an HSA for actual services provided by your practice physicians if you can produce something for the patient that they can use to document the services they received (including any procedure/treatment codes), the date they were provided (and by whom), and the amount you would charge the patient for the services provided. I know your practice is not set up that way, but the patient needs something that tells them the fair market value of the services they received for tax-free reimbursement from their HSA.”

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