Bill could allow health saving account use for DPC

Monthly subscriptions are not just for Netflix and gym membership any more. For some people, getting in to see the doctor right away is worth paying a monthly retainer. And if a bill introduced in Congress passes into law, paying directly for primary care will be a lot easier to do.

The Primary Care Enhancement Act of 2016  proposes to amend the tax code so consumers can use their health savings accounts (HSAs) to pay physicians in direct primary care (DPC), bypassing insurance. H.R. 6015 would also enable Medicare enrollees to pay for direct primary care using Medicare funds, rather than pay out of pocket.

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Whether H.R. 6015, proposed by Rep. Erik Paulsen, R-Minnesota, and Rep. Earl Blumenauer, D-Oregon, will spur expansion of direct primary care is uncertain.

The American Academy of Family Physicians (AAFP) estimates that 2% of its members are DPC providers.

“A tremendous number have expressed an interest, and the number is growing,” says AAFP President John Meigs, Jr., MD. “The AAFP supports this bill, as well as an identical bill proposed in the Senate last year. Congress moves at glacial speed sometimes, and with the election coming up, not a whole lot of work is getting done right now.”

The bill is currently sitting in the House Ways and Means Committee and was referred to the Subcommittee on Health.  

Further reading: The rise of direct primary care

Direct primary care physicians charge patients a monthly fee for care and access to a package of services rather than by fee-for-service or insurance. The subscription model can grant patients increased access to doctors, discounted drugs and laboratory services. 

According to Meigs, the proposed law will allow people with high deductible plans to use their HSA to pay for primary care, given that people with high deductible insurance plans can use their insurance for catastrophic coverage and hospitalizations, and cost-effectively tap their HSAs for primary care.  

Next: There are some caveats about DPC

“Direct primary care is sort of a niche market,” says Meigs. “It is not going to have mass-market appeal. Practices can provide discounted services by getting rid of insurance overhead. [DPC] is a great way to get back to doing what we like to do-treating patients without insurance interfering with the physician-patient relationship.”

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Nevertheless, more people gravitating to direct primary care could also lower the number of physicians available to serve traditionally insured patients.

“If you are giving them greater access, and you are going to have more time with your patients, then you can’t book as many,” says Meigs.

A 2015 American College of Physicians (ACP) position paper noted average DPC practices have between 600 to 800 patients compared to fee-for-service practices panels that typically exceed 2,500 patients.  

Ryan Neuhofel, DO, a Lawrence, Kansas, primary care physician, says that aside from the benefit of physician access as needed, direct primary care’s value proposition can be worthwhile for patients with high deductible health plans particularly because he can offer discounted lab services and generic medicines. “If I save people a single visit to the emergency room, it is four to five years of subscription [monthly fee],” says Neuhofel. 

In turn, his DPC practice allows him more time with patients, and the flexibility to answer patient questions over the phone, when requested.    

But some have caveats about DPC

But the ACP decided to not endorse this bill or promote DPCs, calling for more unbiased research on the impact of wide variations in monthly fees, lack of accessibility and affordability to all patients, including Medicare patients.  

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Recognizing physician frustration with paperwork, low reimbursement and frustration with restricted time with patients, the ACP characterized DPC as “potentially a reasonable option as authorized by the Affordable Care Act in insurance exchanges paired with a wraparound insurance policy covering everything outside of primary care-as long as consumer protections are not weakened.”

The ACP supports physician and patient choice of practices that are “accessible, viable and ethical,” particularly for poor and underserved populations. 

“Making it clear that HSA use is appropriate for DPC would allow patients with a high deductible health plan with a HSA to use their HSA funds in our practice,” says Emilie Scott, MD, who has a DPC practice in Irvine, California. “A concern that is often voiced is that those with high deductible medical plans will not access medical care unless they are very ill, out of concern for costs. 

“DPC is the perfect fix for this as the services are unlimited for a low price,” Scott continued. “The direct benefit for our practice is that this will help our patients with HSA accounts, and it will help us offer our services to those with HSAs who really would benefit the most from our services.”