1. Direct Primary Care
An Innovative Alternative Payment Model
April, 2017
Jay Keese
Executive Director
Direct Primary Care Coalition
www.dpcare.org

2. Direct Primary Care
in the Trump Era
• ACA Repeal effort
• American Health Care
Act
• Tax Reform
• Executive Actions
• Executive Order 1
• Sec. 1332Waivers
• Treasury/IRS Guidance
• State Innovations
• Letters To Govs
• 20 State Laws and
counting
• Budget crunch
• Medicaid/State
Employees

3. What Is Direct Primary Care?
• High-functioning primary care
and prevention services: A
Medical Home
• Direct agreement between
doctor and patient
• Monthly retainer or periodic fee
paid by individual, employer,
health plan, or other payer
• No third party, fee for service
billing
Significantly reduced administrative
costs
• Medical services: Not insurance
or health plan
• Defined in ACA - §1301 (A) (3)... and
• 20 State Laws (e.g. WA 48.150 RCW)
DPC State of Play: 2017
• DPC Practices in 47 States + DC *
• Median fee about $70 per month *
• Better outcomes, patient satisfaction
• Savings of +/- 20%; employers, exchanges
and Medicaid
* Journal American Board of Family Medicine , Nov. 2015

4. DPC is working with…
Self-Insured Employers
Medicare Advantage
Medicaid Health Plans
State and Local Government
Health Plans
Integrated Health Systems

5. DPC Policy Issues:
• State Legislation
• Insurance definitions in 20 states: More needed to prevent future regulation
• Legislation may be needed to bring DPC to Medicaid – 1332 Waivers
• State Legislatures must weigh in with Congress on HSA issues
• Fix DPC issues in the Tax Code: Health Savings Accounts
• DPC not a qualified medical expense {IRC 213 (d)}
• IRS considers DPC a “health plan” {IRC 223 (c)}: DPC disqualifies HSAs
• Primary Care Enhancement Act S. 1989; H.R. 6015 clarifies tax code on both points
• Bring DPC to Medicare/Medicaid
– the nation’s highest utilizers of care
• DPC offered in Medicaid Managed Care and Medicare Advantage
• No Regular FFS Medicare/Medicaid payment methodology for DPC
• S. 1989 – defines DPC as “Alternative Payment Model” (APM)
• MACRA payment reforms may lead to path as APM

6. 1. Washington – 48-150 RCW
2. Utah – UT 31A-4-106.5
3. Oregon – ORS 735.500
4. West Virginia – WV-16-2J-1
5. Arizona – AZ 20-123
6. Louisiana – LA Act 867
7. Michigan – PA-0522-14
8. Mississippi – SB 2687
9. Idaho – SB 1062
10. Oklahoma – SB 560
11. Missouri – HB 769
12. Kansas – HB 2225
13. Texas – HB 1945
14. Nebraska – Legislative Bill 817
15. Tennessee – SB 2443
16. Wyoming – SF0049
17. Arkansas – HB 1161
18. Kentucky – SB 79
19. Colorado – HB 17-1115
20. Indiana – SB 303
• Laws generally define DPC as a medical service outside of
state insurance regulation, offer varying levels of consumer
protection
• Restrictive WV and AR laws modified in 2017
• Arizona law fails to define DPC and provide full protection
from Insurance regulation.
• Two governors vetoed DPC legislation last year, VA and MT
DPC Legislation in 20 States
X
X
X

7. 2017 State Legislation
13+ Additional states considering legislation:
• Alabama– Passed Senate
• Arkansas– Revision Signed by Governor
• Colorado– Signed by Governor
• Florida – Passed House
• Georgia– Passed Senate
• Indiana – Signed by Governor
• Kentucky – Signed by Governor
• Montana– Passed Both Houses Veto Threat
• Michigan – HSA Resolution Introduced
• New York
• Pennsylvania
• South Carolina– Introduced
• Virginia – Passed Both Houses Veto Threat
• West Virginia – Revision Signed by Governor

8. The Primary Care Enhancement Act
• H.R. 365 - Bipartisan Bill - Reps Erik Paulsen (R-MN) and Earl
Blumenauer (D-OR) Sens. Bill Cassidy, MD (R-LA) and Maria
Cantwell (D-WA)
• Clarifies HSA Provisions re: DPC in the Tax Code
• DPC is not a health plan under IRC §223 (c)
• DPC is a qualified health expense under the IRC §213 (d)
• Allows individuals with HSAs to pay for DPC services with HSAs.
• Please contact Senators and Representatives today
and ask them to Co-Sponsor the Primary Care
Enhancement Act
• www.dpcare.org to send email or for more information

9. Direct Primary Care Coalition
www.dpcare.org
For further information contact:
Jay Keese
Executive Director,
(202) 669-4061
jpkeese@cagdc.com