direct primary care: policy and planning primer (slides) · public and private plans seek...

DIRECT PRIMARY CAREPOLICY AND PLANNING PRIMER

James J Eischen Jr

Why Fee for Covered Service Is Not Working

bull Reimburses for specificinterventionsservices performed

bull Not time spent quality of care patientoutcomes

bull Financially incentivizes over-utilization viahigh reimbursement intervention

bull Financially disincentives preventable careand early patient education not reimbursed

Public and Private Plans Seek Reimbursement Alternatives

The US ranks near last among industrialized nations in several quality measures

ndash While remaining themost expensive system inthe world double theGDP of most nations

Mirror Mirror on the Wall 2014 Update How the US Health Care System Compares Internationally THE COMMONWEALTH FUND

httpwwwcommonwealthfundorgpublicationsfund-reports2014junmirror-mirror

Public and Private Plans Seek Reimbursement Alternatives HospitalProvider Perspective

The push towards value-based reimbursement

httpwwwcmsgovNewsroomMediaReleaseDatabaseFact‐sheets2015‐Fact‐sheets‐items2015‐01‐26‐3html

Public and Private Plans Seek Reimbursement Alternatives Innovator Perspective

Technology outpacing the health care marketplace

But fee-for-service provides little or uncertain reimbursement for wellness solutions

Public and Private Plans Seek Reimbursement Alternatives Patient Improvement

How mHealth Should Help Patients Control Their Healthndash Janis Powers HFMAORGhttpwwwhfmaorgContentaspxid=28498

bull mHealth = Mobile Health

bull Shifting towards patient centered mHealth

Public and Private Plans Seek Reimbursement Alternatives The Wellness Marketplace


There is room for exponential growth and innovation in the US wellnesshealth marketplace


5 Healthcare Trends You Could Cash in onndash Murray Newlands INCCOM

HTTPWWWINCCOMMURRAY-NEWLANDSMEDICAL-HEALTH-TRENDS-AND-STARTUPS-GROWINGHTML

bull Within the next 5 years the health wellness industry is expected togrow to a $737 billion market (hint people might pay for healthhellip)

bull ldquoBig data has already earned its place as one of the top lsquotrends towatchrsquo Among the many industries likely to be heavily reliant onanalytics is healthcarerdquo

Public and Private Plans Seek Reimbursement Alternatives Marketplace Experiments

Early-stage Telehealth Business ExamMed Wants lsquoMedCoinsrsquo to Push Boundaries of Concierge Care

ndash Stephanie Baum MEDCITY NEWS

httpmedcitynewscom201501early-stage-telehealth-business-exammed-wants-med-coins-push-boundaries-concierge-care

ExamMed attempts to induce patient and physician behaviors with alternative currency transparency (intriguing)hellip

But is it ldquomoving the needlerdquo onbull direct physicianpatient connectionbull direct patient investment


Engaging Patients to Decrease Costs and Improve Outcomesndash Alexandra Kimball Kristen Corey and Joseph Kvedar MEDICAL ECONOMICS

HTTPMEDICALECONOMICSMODERNMEDICINECOMMEDICAL-ECONOMICSNEWSENGAGING-PATIENTS-DECREASE-COSTS-AND-IMPROVE-OUTCOMES

bull 79 of surveyed patient respondents said they weremore likely to select a health provider who allowsthem to conduct health care interactions online ona mobile device or at a self-service kiosk

bull One study found that many would even pay forsuch online services


Aetna Claims Yoga Classes Are Worth $3K Per Employee Each Yearndash Heather Caspi MEDICAL HEALTHCAREDIVE

HTTPWWWHEALTHCAREDIVECOMNEWSAETNA-CLAIMS-YOGA-CLASSES-ARE-WORTH-3K-PER-EMPLOYEE-EACH-YEAR370673ndash CITING The Journal of Occupational Health Psychology httppsycnetapaorgpsycinfo2012-04383-001

bull ldquoEmployees report on average a 28 reductionin stress a 20 improvement in sleep qualityand a 19 reduction in painrdquo

bull Reported $3Kyear savings due to both healthcosts and work efficiency


Telemedicine and Employers The New Frontierndash Epstein Becker GreenHTTPWWWLEXOLOGYCOMLIBRARYDETAILASPXG=EE9FC27D-D56C-4FC8-9B17-42B381DB495AampUTM_SOURCE=LEXOLOGY+DAILY+NEWSFEEDampUTM_MEDIUM=HTML+EMAIL+-+BODY+-+FEDERAL+SECTIONampUTM_CAMPAIGN=CALBAR+REAL+PROPERTY+SECTION+SUBSCRIBER+DAILY+FEEDampUTM_CONTENT=LEXOLOGY+DAILY+NEWSFEED+2015-03-04ampUTM_TERM

bull 74 of consumers would use telehealth services if available

bull 76 of patients prioritize access to care over the need for human interactions

bull 70 of patients are comfortable communicating with their health careproviders via text e-mail or video


Telemedicine and Employers The New Frontierndash Epstein Becker GreenHTTPWWWLEXOLOGYCOMLIBRARYDETAILASPXG=EE9FC27D-D56C-4FC8-9B17-42B381DB495AampUTM_SOURCE=LEXOLOGY+DAILY+NEWSFEEDampUTM_MEDIUM=HTML+EMAIL+-+BODY+-+FEDERAL+SECTIONampUTM_CAMPAIGN=CALBAR+REAL+PROPERTY+SECTION+SUBSCRIBER+DAILY+FEEDampUTM_CONTENT=LEXOLOGY+DAILY+NEWSFEED+2015-03-04ampUTM_TERM=

Use of telemedicine is increasingly viewed as efficient and cost-effective becausebull Shift from fee-for-servicebull Increase in sophisticated health technologies

Viable option to avoid employee time-off-work for visits


3 Off-the-Wall Things Insurers are Doing to Increase Engagementndash Heather Caspi HEALTHCAREDIVE

HTTPWWWHEALTHCAREDIVECOMNEWS3-OFF-THE-WALL-THINGS-INSURERS-ARE-DOING-TO-INCREASE-ENGAGEMENT364555

Food Deals

ndash One health plan is using the app NutriSavingsThe app scores their groceries uponcheckout

ndash If their total score is high enough $20 permonth for participating




Workouts ndash Pact Health a health plan which

started as a health app increases and decreases deductibles $5 per workout

ndash ldquoA loss is three times more motivatingthan a gainrdquo




Integrated Technology

ndash Another plan offers a $1 per day incentivefor reaching steps per day goals

ndash The goal is that fitness tracking app userswill be encouraged to utilize other appfeatures like provider cost comparisons


How Mayorsquos ldquoDr Googlerdquo Deal Disrupts Medicinendash Michael Milenson FORBESHTTPWWWFORBESCOMSITESMICHAELMILLENSON20150225HOW-MAYOS-DR-GOOGLE-DEAL-DISRUPTS-MEDICINESS=PHARMA-HEALTHCAREampUTM_SOURCE=SAILTHRUampUTM_MEDIUM=EMAILampUTM_TERM=HEALTHCARE20DIVEampUTM_CAMPAIGN=ISSUE202015-02-2520HEALTHCARE20DIVE

bull ldquoRecommending a Google search lsquoas the first stop forthose needing health informationrsquo in the words of aMayo physician executive represents a true paradigmchangerdquo

bull Information technology is forcing a new doctor-patientrelationship with new rules for new roles

The Silo Effect of Passive Patient Engagement

Patient engagement is great but without physician integration primary care and wellness marketplace remain disconnected silos

Are we creating a sustainable health care economyAre the physicians the ldquomissing treesrdquo of Easter Island

PatientsConsumers

httpwwwunsvcomvoanewsspecialenglishscripts201110230040

Employeesrsquo share of medical expenses (premiums plus deductibles) was almost 10 of the median US income in 2013

Irsquom busyhellipis anyone paying me to do this

Direct Patient Investment amp Direct Physician Integration Toward Achieving Desired Healthcare Reimbursement Reform Outcomes

Why Physicians are Turning to Private Direct Solutions

bull Less red tape less stress and more time for patients

httpimpactnewscomaustin‐metrolake‐travis‐westlakedirect‐primary‐care‐a‐growing‐option


In a Survey of ResidentsIn a Survey of Residents

90Said that they would prefer employment with a salary

rather than an independent practice income



39Said that they were not

ready to handle the business side of medicine



1 in 4 New Doctors Would Change Careers If they Could Start Overndash Bruce Jaspen FORBES HTTPWWWFORBESCOMSITESBRUCEJAPSEN201501111-IN-4-DOCTORS-

WOULD-CHANGE-CAREERS-IF-THEY-COULD-START-OVER


What Are Plan Reforms Missing

bull Direct Patient Investment

bull Direct Physician Financial IncentivesEngagement

bull Financially Induced Desired Behaviors From Both Physiciansand Patients

Private Direct Medicine AKA

httpwwwdisabled‐worldcommedicalrehabilitationconciergephp

Direct Patient Investment Direct Physician Integration

Some Basic Information

Source Cash-Only Practices 8 Issues to Consider Niel Chesanow MEDSCAPE

httpwwwmedscapecomviewarticle824543

80 of retainer medicine market

Average annual fee $1200 ‐ $3000

Typically fees paid annually

Same day appointments

247 care text messaging instant access

Most still bill plans


Average monthly fee $25 ‐ $100

Typically monthly fees not annual

Most donrsquot have same day access

Some added communication access

Many do not bill plans

Concierge Medicine Direct Primary Care


Why Patients Are Turning to Private Direct Solutions

bull Predictable private payments rather than co-pays or deductibles that may look ldquofreemarketrdquo but disincentivizing care events

bull Improved patient communicationappointments after-hours electronic access

bull More coordinated and personalized care

Image httphealthresearchfundingorghigh‐deductible‐health‐plan‐pros‐cons


Copays and Deductibles Deterrents to Seeking Care

One study found 10 decrease in ER visits

among enrollees of highdeductible plans

In the two lowest incomegroups 25 decrease in highseverity first time medicalvisits

Image httphealthresearchfundingorghigh‐deductible‐health‐plan‐pros‐consAnalysis of High Deductible Health Plans RAND CORPORATION httpwwwrandorgpubstechnical_reportsTR562z4analysis-of-high-deductible-health-planshtml

What Does Private Direct Medicine Contribute

Direct Patient

Investment

Potentially Improved Outcomes

Reduced Plan Costs


httpstateofreformcomnewsindustryhealthcare‐providers201501qliance‐study‐shows‐monthly‐fee‐primary‐care‐model‐saves‐20‐percent‐claims

Data Suggests Direct Private Medicine Reduces Plan Utilization and Improves TrackingOutcomes

Direct-Pay Medical Practices Could Diminish Payer Headaches

ndash Lisa ZamoskyMEDICALECONOMICS

HTTPMEDICALECONOMICSMODERNMEDICINECOMMEDICAL-ECONOMICSCONTENTTAGSCONCIERGE-SERVICEDIRECT-PAY-MEDICAL-PRACTICES-COULD-DIMINISH-PAYER-HPAGE=FULL

Direct Physician Delivery for Private Fees

Gain Sharing with Intervention Reimbursement Can We Legislate Small Business Functions

bull Traditional fee-for-service plan reimbursement struggles to align physicianinteraction with patient education amp coordination

bull ACO and other value reimbursement modelsndash Missing direct patient financial involvementndash Missing direct physician incentive (but there are success stories-Palm Beach ACO $20 Million)

bull If the solutions are physician accountability and incentivized patientengagement doesnrsquot small business more naturally achieve both


Direct Patient Subscription

Physician Directly Connected to

bull Care Coordination

bullOutcomes

bull Customer Service


Could the future include something like OneMedical(hint there is room for administrative amp tech solutionshellip)

ldquoFor an annual fee patients have access to a variety of tech-enabled health services including 247 virtual care and same day appointments However One Medical is not concierge medicine mdash the practices still accept insurance to cover a portion of healthcare costsrdquo

Dignity Partnership Brings New Primary Care Model to Arizona Emily Rappleyehttpwwwbeckershospitalreviewcomhospital‐physician‐relationshipsdignity‐partnership‐brings‐new‐primary‐care‐model‐to‐arizonahtmlutm_source=Sailthruamputm_medium=emailamputm_term=Healthcare20Diveamputm_campaign=Issue3A202015‐02‐1120Healthcare20Dive


bull The physician as a connected care ldquocaptainrdquo requires smallbusiness posture this is a natural alignment of profit andpersonal accountability

bull Can reimbursement reform achieve care goals absentincentivized physician connection (ie whytelemedwireless tracking has great technology and limitedphysician adoptionhellip) NO

Private Direct Care Models Projections for Growth and Broader Application

In a survey among physicians more than 10 of respondents planned to switch to private direct practices within three years

httpwwwheritageorgresearchreports201408direct‐primary‐care‐an‐innovative‐alternative‐to‐conventional‐health‐insurance

Medicare Compliance

Why are Medicare compliance requirements strict

US lost between $82 billion and $272 billion in 2011 to medical fraud and abuse

httpwwweconomistcomnewsleaders21603026-how-hand-over-272-billion-year-criminals-thats-where-moneyfrsc=dg7Ca

Medicare Compliance

Main concern with DPC and Medicare Assignment So-Called ldquoDouble Billingrdquo

bull Patients may not be charged for services that Medicare covers andreimbursesndash May not be charged an ldquoAccess feerdquo or ldquoAdministrative feerdquo for

practices accessndash May be privately charged for services not covered by Medicarendash Or physician opts out of Medicare and avoids Medicare Assignment

private fee complexities

Medicare CompliancePhysicians who have opted-out

ndash May charge for ldquoaccessrdquo and ldquocarecoordinationrdquo and other coveredservices

ndash BUT must comply with opt-outcontract rules

ndash Are not ldquofreerdquo of federal or state lawsbut avoid Medicare Assignment issue

Medicare ComplianceA physician from Minneapolis Minnesota agreed to pay $53400 to resolve liability under the Civil Monetary Penalties Law The physician charged under a yearly contract for services that the physician characterized as not covered by Medicare (1) coordination of care with other providers (2) a comprehensive assessment and plan for optimum health and (3) extra time Some services were deemed covered by Medicare

httpsoighhsgovfraudenforcementcmpoverchargingasp

Medicare ComplianceIn 2007 North Carolina physician paid $106600 to resolve Civil Monetary Penalties Law liability The practitioner and patients entered into a membership agreement for a patient care program for an annual fee providing (1) an annual comprehensive physical examination (2) same day or next day appointments (3) support personnel dedicated exclusively to members (4) 24 hours a day and 7 days a week physician availability (5) prescription facilitation (6) coordination of referrals and expedited referrals if medically necessary and (7) other service amenities as determined by the practitioner Some services were deemed covered by Medicare


Medicare Compliance

In 2013 a South Carolina practice $170260 for charging mandatory ldquoadministrative rdquo or ldquoformsrdquo fees to all patients to cover certain unspecified administrative services with explanation that the charge was necessary due to poor plan reimbursement


Medicare Compliance ndash Opt-Out

bull File an affidavit (sect409 )bull Signed private contracts (sect408)bull Complies with billing for urgent care services (sect4028)

bull Retain a copy of each private contract which has been entered into forthe duration of the opt-out period

Opt-Out Requirements


bull All private contractsdeemed null and void

bull Opt-out is nullifiedbull Must submit claims for all

Medicare covered servicesbull Will not receive payment

for those services

Consequences Of Opt-Out Non-Compliance

How to Structure Medicare Participating Private Direct Medicine Models

Medicare billing compliance ldquobuzz wordsrdquo to avoid

ndash Access

ndash Care Coordination

ndash Preventative Care

ndash Membership

ndash 247 Communications

ndash Electronic Records Access


Drafting Recommendations Patient-Physician Contract

bull Easy to read contract

bull Clarity on key issues

bull Avoid state insurance consumer issues

bull FAQs and brochures for amenity details contract for complianceclarity



bull Allocate non-covered amenities allocated to private fees to avoidMedicare compliance issues (Q Does your staff know how to properlyexplain your retainersubscription model)

Or comply with opt-out requirements httpwwwcmshhsgovManualsdownloadsbp102c15pdf

bull Avoid inducementsdiscounting (ie no free toaster ovens)



bull Durationtermination

bull Renewal (automatic renewal vs termination)

bull Disclaim insurance provided

bull Accurate and compliant marketing materials

bull AVOID PROMISES YOU CANrsquoT KEEP

A sustained integrated wellness economy integrating patients physicians and plans

QUESTIONSJames Eischen

eischenjhiggslawcom619-236ndash1551

wwwhiggslawcom

Follow James Eischen at assessandplan for healthcare news articles and more

Why Fee for Covered Service Is Not Working

bull Reimburses for specificinterventionsservices performed

bull Not time spent quality of care patientoutcomes

bull Financially incentivizes over-utilization viahigh reimbursement intervention

bull Financially disincentives preventable careand early patient education not reimbursed

Public and Private Plans Seek Reimbursement Alternatives

The US ranks near last among industrialized nations in several quality measures

ndash While remaining themost expensive system inthe world double theGDP of most nations

Mirror Mirror on the Wall 2014 Update How the US Health Care System Compares Internationally THE COMMONWEALTH FUND

httpwwwcommonwealthfundorgpublicationsfund-reports2014junmirror-mirror















































Food Deals






















PatientsConsumers

























































Direct Patient

Investment


Reduced Plan Costs
















bullOutcomes












Medicare Compliance




Medicare Compliance













Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom
















































Food Deals






















PatientsConsumers

























































Direct Patient

Investment


Reduced Plan Costs
















bullOutcomes












Medicare Compliance




Medicare Compliance













Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom





















PatientsConsumers

























































Direct Patient

Investment


Reduced Plan Costs
















bullOutcomes












Medicare Compliance




Medicare Compliance













Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom

























































Direct Patient

Investment


Reduced Plan Costs
















bullOutcomes












Medicare Compliance




Medicare Compliance













Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom

















bullOutcomes












Medicare Compliance




Medicare Compliance













Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom












Medicare Compliance




Medicare Compliance













Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom


Medicare Compliance













Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom






Medicare Compliance











for those services




ndash Access



ndash Membership
























wwwhiggslawcom






for those services




ndash Access



ndash Membership
























wwwhiggslawcom























wwwhiggslawcom


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