Bipartisan Support to Address Primary Care, Telehealth, Drug Costs

• February 11, 2019
• Jennifer Boese

The U.S. Senate Health, Education, Labor and Pensions Committee (HELP) continues its look into health care costs. The committee held multiple hearings last year and is off to a rapid start for 2019 with two hearings over the past week.

Senate HELP Committee Chair Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) work well together and are continuing that bipartisanship specifically related to health care cost. To that end, the Committee’s recent hearing on the role of primary care in improving cost and outcomes coupled with past hearings reveal key areas of potential agreement.

Direct Primary Care (DPC)  

DPC continues to gain interest from legislators, and testifiers at the recent Senate HELP hearing included another DPC provider, Dr. Josh Umbehr of Atlas MD. Dr. Umbehr’s practice takes no insurance and uses a sliding scale fee of up to $100/month. When asked by the Committee how his costs can be so low, Umberh stated two key things: since he doesn’t take insurance, roughly 60% of his time if freed from unnecessary paperwork; and, he purchases drugs wholesale. Senators were very intrigued by Umbehr’s DPC model, particularly related to drug costs and whether DPC could be used in rural communities.

Umbehr said that most physicians do not know that in 44 states they can directly purchase drugs from a wholesaler. Further, he can get medications for up to 95 percent less this way. Dr. Umbehr felt DPC was particularly suited for rural areas. He indicated, on average, a physician would need a panel size of 2,000-3,000 patients to be viable. This would require 5-7 support staff along with a good payer mix of insurers. Umbehr testified that under a DPC model, it would be viable with 600 patients and take 1-2 full-time employees for each physician. He has helped over 600 physicians move to DPC and it has worked in very small communities. When combined with telemedicine, DPC can extend the reach of primary care even further.

Chair Alexander asked what barriers exist to expanding DPC and how Congress could help. Umbehr referred to the current rules surrounding how DPCs are treated under Health Savings Accounts (HSA).

Onsite Clinics, Telehealth, Drug Costs

Another testifier, Ms. Tracy Watts, also cited HSA laws as a barrier, but her comments related to employers using onsite or near-site primary care clinics.

All four testifiers discussed the role of telehealth in health care. Ms. Watts discussed it as the “new front door” to health care. Dr. Sapna Kripalani highlighted the need to support telehealth in order to allow more innovative care delivery, including in the home, and in care coordination. Another testifier, a geriatrician, discussed how Project ECHO was successfully deployed to care for the elderly. What stands in the way of advancing these telehealth more rapidly? Responses included a lack of broadband, “originating site” requirements, and, of course, lack of reimbursement.  

In just about any health care hearing, the price of pharmaceuticals comes up. One testifier, Ms. Watts, indicated that for the employers she works with, branded drugs account for 35% of drug costs, and will likely go about 50% in the next couple of years. In addition, many orphan drugs are coming online and these are particularly expensive. Employers are keenly looking to keep these costs under control, including a focus on the site of care for where drugs are administered.  

Bipartisan Agreement on Policies?

As I think through the above hearing and the series of hearings over the past year coupled with statements by key Members of Congress and the priorities that seem to be percolating to the top, I think the following are a few of the areas where Congress begins its work on health care:

• Direct Primary Care. Sen. Bill Cassidy (R-LA), also on this committee, has had bipartisan proposals previously and will likely introduce again, especially to address HSA issues with DPC.
• Telehealth. There is a growing recognition that virtual care will be part of the future of care delivery, and that outdated statutes must be updated to expand its use. Statutes that require rural locations (originating sites) and other updates would significantly improve the outlook for telehealth; however, I expect a more targeted approach. That approach will likely focus on allowing/reimbursing for telehealth under specific innovations or for specific disease (ex: diabetes) or populations (substance use, behavioral health) since Congress may not have the appetite for large-scale reimbursement changes.
• Drug Costs. There is a strong desire in Congress to address drug costs. There are multiple areas of potential agreement, and I will elaborate on those in subsequent blogs or articles. Stay tuned!
• Balance Billing/Surprise bills. See my earlier blog post.
• Transparency. Transparency. Transparency throughout all aspects of health care.

Agree? Disagree? Let’s hear your thoughts.

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