HRA-Employer Conversation Resources, Vermont at it Again, Delayed "Cadillac Tax"

If you live in Vermont and are DPC oriented, you likely breathed a sign of relief when the state abandoned law it had passed to establish a single payor system as of 2017 (which would have made DPC in the state all but impossible).  Look out, because they are at it again!   One of these options is an all-payer model. Act 54 of 2015 directs the Agency of Administration and the Green Mountain Care Board to “jointly explore an all-payer model, which may be achieved through a waiver from the Centers for Medicare and Medicaid Services” (CMS).  Details can be found in this Vermont Legal Aid Guide and this Vermont Biz article by Erin Mansfield also offers some helpful info.  

The Consolidated Appropriations Act of 2016 was signed last week by President Obama.  Highlights include:
- The absence of any language making DPC membership fees a deductible HSA expense
- Delay the "Cadillac Tax" by two years (it now starts Jan 1, 2020) and for those that choose to pay it, the tax is now considered a deductible business expense
- Eliminates the medical device tax for 2016 and 2017
- Reduces federal revenue by $34 Billion

Health Reimbursement Accounts - I am routinely asked whether employer DPC offerings fall within this space.  Fellow physicians want a black and white answer, but unfortunately this clear cut answer does not exist.  I'm attempting to find the time to author a comprehensive piece discussing these issues, but in the likely event that does not happen, the simplest way I can refer to this situation is as follows: The HRA "issue" is mainly a hurdle for business owners that are both subject to the ACA requirement (i.e. have 50 or more employees) and want to pay for all or a portion of their employees DPC periodic fee WITHOUT offering those same employees any type of qualifying coverage.  Recent IRS notices do offer some guidance:
- IRS Notice 2015-87
- IRS Notice 2013-54
- IRS Notice 2015-17

Highlighting Excellent Blogs - I plan to do this more often.  For those out there looking for a greater understanding of the ACA's impact on employers - more specifically the health insurance mandate and how that might weigh on their decision to purchase DPC for their employees, please consider the following posts from the Employment Matters Blog, which did a 24 part series : I would recommend DPC oriented readers start with the following entries:
- Part 1
- Part 3 (The Basics)
- Part 5 (Reporting of Health Reimbursement Arrangements under Code § 6055)
- Part 6 (Reporting Group Health Plan Opt-Out Arrangements under Code § 6055)
- Part 8 ( Reporting Offers of Coverage “On Behalf of Another Entity”)
- Part 16 (Reporting for, and Clearing Up Confusion Over, Post-65 Retiree Health Reimbursement Arrangements)
- Part 20 (Reporting Affordability on Form 1095-C, Part II, Line 16 Using 2-Series Codes 2F, 2G, and 2H)

That's all for now.  Merry Christmas to all!  (Click the title of the post if you wish to comment, ask a question, or propose a future blog topic.)

Phil Eskew

Four Updates Worth Sharing

1) State Policy Update - Remember we already have 14 states that have passed DPC Legislation, and 10/14 are helpful.  (For details about any below see the states pages.)

1) West Virginia 2006 (Bad law - makes DPC more difficult)
2) Washington    2007
3) Oregon            2011 (Bad law - makes DPC more difficult)
4) Utah                 2012
5) Arizona           2014 (Irrelevant law - offers no true "not insurance" protection)
6) Louisiana        2014
7) Michigan         Jan 10, 2015
8) Arkansas         Feb 19, 2015 (Bad law - vague definitions focused on "concierge")
9) Mississippi      Mar 18, 2015
10) Idaho               Apr 9, 2015
11) Oklahoma     Apr 21, 2015
12) Kansas            May 7, 2015
13) Texas              May 28, 2015
14) Missouri         July 2, 2015

Legislation has been proffered in Wyoming, Nebraska, and Virginia.  Prior Florida legislation that nearly passed may be reintroduced.  Discussions about potential DPC legislation are also taking place in Massachusetts, and North Carolina.  If you are aware of any states that I am missing please let me know.

2) Another Ignorant Commentary About DPC

This time it comes from an expected opponent with an obvious bias.  Since passing their legislation earlier this year many legislators in Michigan have continued to promote the benefits of DPC.  Well, Mr. Rick Murdock, the Executive Director of the Michigan Association of Health Plans wants everyone to pipe down.  In this letter Mr. Murdock calls DPC a "bad public policy idea" resembling "swiss cheese" with many "holes."  His arguments are based largely out of his own misunderstanding and/or attempts at deception - after all he does work for a "nonprofit" organization serving insurance companies that stand to lose a lot of money as the DPC movement continues to empower more patients.  
- He seems annoyed that the comprehensive primary care promised by DPC practices does not also have the ability to cover all emergency situations and guarantee that patients will never need to enter the hospital.  (Well - we are NOT selling insurance - after all.)
- He confounds Medicaid ideas in an absurd manner and insinuates that DPC worsens these problems.  
- He then argues that without the insurance company in place to (deny) review claims, no one will be able to detect fraud.  Why don't we rely on the patient?  The same patient that has now been empowered through price transparency to police his own care.  As Josh Umbehr would say "he who holds the purse strings holds the power."

3) Upcoming DPC Events

 Things typically quiet down during the holidays, but I will be speaking at two DPC winter conferences:  (See the events tab for direct links)

Jan 29, 2016 AAPS - Thrive, Not Just Survive XXIII - Orlando, FL
Feb 26-27, 2016 AAPP - Spring Summit on Private Medicine - San Diego, CA

If you will be attending either event and want to catch up in person, just drop me a note (phil@dpcfrontier.com) and we can plan a time to chat.

4) Washington Insurance Commissioner's 2015 Report

When Washington passed DPC legislation in 2007 the Insurance Commissioner fought against it, and one of his "wins" in the legislative debate resulted in a requirement that practices regularly submit data to the insurance commissioner.  The commissioner was excited that he would get to tally the complaints and failures of DPC practices... or so he thought.  Year after year the report simply highlights how well DPC is doing in the state, and the commissioner's office has to reluctantly gather the data and file the report each year.  So what are this year's highlights?

"Overall patient participation increased from 8,658 participants in 2014 to 11,504 in 2015; this is a 32 percent increase, a total of 2,846 patients."

"Complaints received: The OIC did not receive formal or informal complaints regarding direct patient practices in the past year."

"At this time, the highest monthly fee is $909 per month at MD² Bellevue; the lowest is $25 per
month at Roth Medical Clinic in Spokane."

I find it fun to point out that the skeptical Office of the Insurance Commissioner has zero patient complaints to report after eight years of DPC in the state!

Phil Eskew

The Mapper has Been Updated - Over 400 DPC Locations!

The DPC Mapper has now been updated.  Around twenty new locations were added and I am pleased to report that we are now north of 400 practice locations!  Colorado is in first place in the race for the most practices with 33 locations, now including DPC at the University of Colorado as well.  Hawaii, Iowa, Nebraska, North Dakota, and South Dakota are still lacking their first DPC practice.  As always, if your practice is missing from the mapper please let us know!