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Tuesday May 09, 2017

Patients on High-deductible Plans Need Primary Care Coverage

Our health care system has experienced many changes in the past three decades, including impactful and consequential changes in insurance design.

Insurance reforms enacted during the past 30 years, including those in the Children's Health Insurance Program, the Medicare Modernization Act (MMA), and the Patient Protection and Affordable Care Act (ACA) have increased access to health care coverage for millions. As a result of these laws, the nation's uninsured rate has reached a historic low. In fact, the uninsured rate(www.cdc.gov) decreased from 15.7 percent in 2009 to 9.1 percent in 2015.  

However, despite significant reductions in the number of uninsured, these changes in policy have not adequately relieved the financial pressures on individuals, families and employers. As a result of increasing economic pressures, there has been a proliferation of high-deductible health plans (HDHP). HDHPs are insurance plans with a minimum deductible and maximum out-of-pocket limit as defined by the Internal Revenue Service (IRS). Currently, the deductible threshold is $1,300 for an individual and $2,600 for a family. Under a HDHP, all medical care must be paid for out of pocket until this minimum deductible is met.

Many of the newly insured have secured their health care coverage through a HDHP.  Although the ACA drove higher utilization of HDHPs, the ACA did not create these insurance products. HDHPs were first offered by employers in 2001, but didn't experience large growth until after creation of health savings accounts through the MMA in 2003. During the past decade, the popularity of HDHPs has consistently increased among employers and individuals.  

In 2006, 4 percent of employees enrolled in an employer-sponsored HDHP. By 2015, 24 percent of employees were enrolled in such plans. HDHPs are especially appealing to younger workers. While these plans are gaining popularity in the employer-sponsored insurance market, they also are prevalent in the individual and small group markets. In fact, according to a report in Health Affairs(healthaffairs.org), approximately 90 percent of enrollees in the individual marketplace have a deductible beyond the qualifying threshold for an HDHP.  

HDHPs have been an important component of our efforts to decrease the number of uninsured, but they come with significant challenges -- most notably is the simple fact that HDHPs provide a disincentive for individuals to seek primary and preventive care due to the associated out-of-pocket expenses. Recent academic literature shows that individuals with HDHPs delay or prolong seeking health care services as a result of the out-of-pocket financial obligations that exists with HDHPs.  

Delays in seeking care, lapses in maintenance, or adherence to treatment protocols lead to a worsening of an individual's health. Ultimately, providing needed care will cost the individual, their insurer and the health care system significantly more money. For example, the average cost of a visit to a primary care physician is $160(www.jhsph.edu). By comparison, the median charge for outpatient conditions in the emergency room is $1,233(www.ncbi.nlm.nih.gov) and the average hospital stay is $10,000(www.hcup-us.ahrq.gov).

Based on these indicators, you could see your primary care physician 7.7 times for the cost of a single visit to the emergency room and 62.5 times for a single hospital admission. Furthermore, it is estimated that more than $18 billion could be saved annually(www.debt.org) if patients whose medical problems are considered avoidable or non-urgent took advantage of primary or preventive health care rather than relying on emergency rooms.  

To address this issue, the AAFP has developed a policy proposal that would expand access to primary care physicians for individuals and families who have a HDHP. Our proposal would provide individuals and families with a high-deductible health plan (as defined by the IRS) access to their family physician, or primary care team, without the obligation to meet the cost-sharing requirements (deductibles and co-pays) stipulated by their policy.

The company issuing the HDHP would be required to provide full coverage for designated primary care services for the plan year. Covered services would include Evaluation & Management (E&M) codes for new and existing patients (99201-99215) prevention and wellness codes (99381-99397), chronic care management and transition care management codes. The company issuing the HDHP policy would be responsible for paying the physician according to the contracted rate for these services.  

Patients would be required to designate a primary care physician or a primary care team.  The designated primary care physician or team would be the only site of service eligible for this benefit for the enrollment period. If a patient fails to designate a primary care physician, the insurer would be responsible for assigning a primary care physician to the patient. Our proposal defines primary care as those eligible clinicians enrolled in Medicare via the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and practicing under one or more of the following Physician Specialty Codes: 01 General Practice; 08 Family Medicine; 11 Internal Medicine; 37 Pediatric Medicine; and 38 Geriatric Medicine.

This is an important component of our efforts to promote primary care as foundational to our nation's health care system. We have started to engage members of Congress and will be working to advance this policy as part of the current health care debate.

Wonk Hard    
On May 4, the House of Representatives narrowly approved the American Health Care Act (AHCA) (H.R. 1628) on a vote of 217-213.  The passage of the AHCA brings to a close a brutal four-month effort on the part of House Republicans to fulfill their promise to repeal and replace the ACA. The legislation now moves to the Senate where its fate is unknown. It is clear from Senators' public statements that they will significantly alter the legislation. The AAFP released a statement shortly after House voted.

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.