Insurance Companies and DPC


(Robin Dickinson) #1

Continuing the discussion from Questions for Hint Summit Employer Panel:

@HadenMD We just had a law passed in Colorado and while insurance companies were involved, they didn’t seem to be our most difficult stakeholder, though I wasn’t the one who tackled them. @drcflanagan @lisainden @appalenia Do you have any insists into this?

Questions for Hint Summit Employer Panel
(Appalenia Udell, Esq.) #2

DPC laws that seek exemption from regulation without installing patient protections are a red flag for lawmakers, and also for insurance companies who invest significantly in regulatory compliance. Is this part of the problem in your situation? If not, likely there was a miscommunication somewhere and the value and opportunity of a DPC pairing hasn’t been effectively expressed. In drafting the CO law, we had to come up with numerous ways of saying the same thing in order to effectively address the concerns of the various stakeholders. Stick with it! Let us know if we can help!

(Matthew Haden) #3

Thanks to @jpkeese and others, we recently got a DPC bill passed in Virginia, but it was over the objections of insurance lobby. I haven’t caught up with Jay yet to hear how we got past the governor’s veto this go-around.

It would be helpful to know the oppositions specific objections as we continue to work on bills across the country to exclude DPC from insurance regulations.

(Robin Dickinson) #4

I think this was key to getting this passed here in Colorado. We had to tailor our message to our audience and meet with different interests separately to explain DPC in the way that suited them best. On a basic level I think we all know that it would have been foolish to approach HHS with a promise to decrease regulation and increase physician autonomy and expect them to fall all over themselves supporting it. But they like things like explaining that by defining DPC, we make it possible to do a Medicaid pilot. Doesn’t matter whether​ or not any particular doctor will. The point is HHS feels included.

(Melissa Mc Atee) #5

North Carolina is trying hard to get legislation passed too. It’s amazing to me that we can’t find some more intelligent ground when it’s clear that patients that belong to a DPC practice are statistically less expensive than their peers. They see specialists less, visit urgent cares less and the ED less. It’s not rocket science.

(Christopher Habig) #6

I thought Gov. McAuliffe vetoed this?

(Robin Dickinson) #7

@philsq would you mind starting a separate thread and update us where we are now? There have been a lot of changes!


(Dr Phil Eskew, DO, JD, MBA) #8

Hey Robin,

Things are fairly quiet at the state level right now. McAuliffe changed his mind in Virginia. We have 23 states that have passed DPC laws. See here To my knowledge the only state with active legislation is Pennsylvania. Their fall session just started today and their well written DPC bill already passed it’s house committee today. At the federal level the new Cassidy Graham bill (HR 1628) Sec 113 contains the HSA correction language that we originally proffered in the Primary Care Enhancement Act.


(Robin Dickinson) #9

Thanks @philsq!

(Dr Phil Eskew, DO, JD, MBA) #10

Anytime! @Robin_Dickinson

(cjs56) #11

I understand that Blue Cross in South Carolina has a chokehold on any D.P.C. law in that state. S.C. had to back out of a D.P.C. law apparently for the reason that the insurer Blue Cross has too powerful a marketing and lobbying force. But, I also understand that it is possible to practice D.P.C. there and not have to worry about not having a law. Just need to speak with the D.P.C. physicians and briefly consult with an attorney.
What would happen if you partnered with an insurance company, and later, they backed out of the contract? What would happen to your D.P.C. patient panel? Like several years ago, Greater San Diego H.M.O. went bankrupt and the physicians had to see the patients for free for several months.
Watch your contract with the insurance company. You probably will never get a fair contract. Their attorneys are too smart.
Iora partners with Humana. What would happen to them if Humana backed out? Or, if Humana broke the contract and went to another D.P.C. practice with a new contract?
From what I’ve learned, some insurers are targeting a high risk patient population which is good from a family medicine clinical and challenging perspective.
But, what if you partnered with an insurance company and they sent you patients that were already on opioids and you (the D.P.C. physician) thought that the opioids were not indicated.
What would you do then? Would you be facing some battles? Would the patients get angry? Would the insurer get angry? Would you lose patients? Would the opioids hinder further improvement of other medical problems? Is the insurer targeting this patient population because no other physicians in the market like that style of practice? Would the insurer, in turn, break your contract?

(Dan Stock MD) #12

I think you have to understand what health insurance has become to understand why insurers are always going to be against DPC. Insurance is there to cover unforeseen expenses, but when a company can get money to cover both unforeseen and foreseen aspects of an economic arena such as “healthcare costs” from patients or from governments in patient’s behalf, it becomes a pre-payment scheme. Since pre-payment schemes make a percentage of what is consumed, the greater the volume sold and the cost of the good/service sold the more the scheme administrator makes. US healthcare is now a prepayment scheme, the two most important rules to make money are 1) make patients buy their goods/services through the pre-payment scheme, not directly, and 2) don’t get them healthy or they buy less goods/services. We in DPC should expect nothing but resistance from insurers and the governments, and will have to be forceful and resourceful in making this successful.

(Christopher Habig) #13

When we helped write and pass the Indiana DPC law, which said that DPC is not nor ever will be regulated as insurance, the only opposition insurance had was a worry that some unscrupulous doctors would try to double-bill customers. This means that doctors would make customers pay a monthly fee, then try to submit bills to insurers. The legislature viewed this as unnecessary since DPC wouldn’t have contracts with insurers, anyways. Anthem’s HQ is right down the street and Indiana has a sizable insurance/pharma presence in the statehouse lobby groups. The DPC legislation passed without a single Nay vote.

I truly don’t think that insurance is the enemy to hold up DPC, I believe that opposition will come from pharma and device manufacturers as DPC populations get healthier and need fewer meds, tests, etc…

(Robin Dickinson) #14

@Christopher_Habig we had a very similar experience in Colorado. My own expectation is that it will be the for-profit hospitals who will be our biggest enemy. As we get to be a big enough force to scare people, we’ll find out for sure. Only time will tell…

(Rudi Kauffman) #15

I’m a bit skittish about the long-term prospects of DPC engaging in the existing system - in short, I believe that any efforts to secure a piece of the existing funding stream makes DPC subject to significant regulatory oversight that can kill the very creativity and efficiency that makes it work.
We have had significant success focusing directly on insurance providers who have pure self-insurance products (we bypass brokers altogether). We’ve used this with local banks and municipalities with significant success. The result is that we usually can enter a direct contract with the employer (who functions as the sole gatekeeper on their self-insurance plan) and this, in turn allows us to shape the nature of obligations, pricing, and documentation in a variety of settings and independently of each other. Ultimately, this means that we are not beholden to any single regulatory framework and are consequently less susceptible to any single shift in preference or pricing. The downside is that we must individually prove our worth to each employer; however, we have found that DPC is such a robust model that the financial savings are obvious and significant within 9 months…