Download | Annual [DPC] Report to the Washington Legislature, Dec. 1, 2019

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The OIC (WASH. State) also recommends the Legislature further clarify that employer offerings are unlawful due to the increase in direct practices offering employer plans and marketing to employers.

In 2007, Washington became the first state to define and regulate direct patient primary care practices and to prohibit direct practice providers from billing insurance companies for services provided to patients under direct practice agreements. In 2013, the Washington Legislature passed E2SHB 2319, “An act relating to furthering state implementation of the health benefit exchange and related provisions of the affordable care act.” This is called “The Exchange Bill.” Section 8(3) of the bill, now codified as RCW 43.71.065(3), allows the Exchange Board to permit direct primary care medical home plans, consistent with section 1301 of the ACA, to be offered in the Exchange beginning on January 1, 2015.

At the 2019 Concierge Medicine FORUM hosted by The DPC Journal’s sister publication, Concierge Medicine Today (CMT) in Atlanta, GA USA (Oct. 24-26, 2019)

The OIC also recommends the Legislature further clarify that employer offerings are unlawful due to the increase in direct practices offering employer plans and marketing to employers. It is likely that the language in RCW 48.150.050 that permits employers to pay direct practice fees on behalf of their employees has been misconstrued by direct practices to provide permission to create employer plans. Consumers and employers would be best protected by either removing employer payments or adding further clarification. NOTE: 10 clinics reported they no longer provide direct practice services/or did not submit their annual statement to renew their registration with the OIC.

  • There were 18,268 enrollees in fiscal year 2018 and 14,482 enrollees in 2019, a decrease of 20.72%.
  • Nine clinics reported a total decrease of 887 direct practice patients.
  • 20 clinics reported a total of 1,665 new patients, gaining as few as one patient (Sound Clinical Medicine) to as many as 644 patients (Assurance Healthcare & Counseling Center).

By Mike Kreidler, Insurance Commissioner | http://www.insurance.wa.gov 

Executive Summary

In 2007, the Washington state Legislature enacted engrossed Second Substitute Senate Bill 5958, which is codified as RCW 48.150. This bill created a new primary health care delivery option called direct patient-provider primary care practices or “direct practices.” The bill requires the Office of the Insurance Commissioner (OIC) to report annually to the Legislature on direct health care practices. Under RCW 48.150.100(3), this includes but is not limited to “participation trends, complaints received, voluntary data reported by the direct practices and any necessary modifications to this chapter.” In a direct health care practice, a health care provider charges a patient a set monthly fee for all primary care services provided in the office, regardless of the number of primary care visits used or if the patient received no care during that period. No insurance plan is involved, although patients may have separate insurance coverage for more costly medical services. Direct practices are sometimes called “retainer” or “concierge” practices.

There were 18,268 enrollees in fiscal year 2018 and 14,482 enrollees in 2019, a decrease of 20.72%.

 

The 2019 annual report on direct patient-provider primary care practices analyzes two fiscal years of annual statements:

  • Fiscal year 2019: July 1, 2018 through June 30, 2019.
  • Fiscal year 2018: July 1, 2017 through June 30, 2018. Participation trends in fiscal year 2019
  • There were approximately 14,482 direct practice patients out of 7.5 million Washington state residents1, 0.19 percent of the population.
  • Patient participation decreased by 3,786 patients, or 20.72%, from the 18,268 patients in 2018.
  • The number of practices registered with the OIC decreased to 34 from 41 in 2018.
  • Fees changed in the following ways:
    • Eight direct practices did not change their fees.
    • Four direct practices decreased fees

Complaints Received

The OIC’s consumer advocacy group received two complaints regarding direct patient practices.

At the 2019 Concierge Medicine FORUM hosted by The DPC Journal’s sister publication, Concierge Medicine Today (CMT) in Atlanta, GA USA (Oct. 24-26, 2019)

Necessary Modification to Chapter

The annual statement contains questions that direct practices are required to answer and questions they are not required to answer. Historically, direct practices do not answer the voluntary questions. As a result, it is difficult for the OIC to monitor for compliance with Chapter 48.150 RCW without the relevant information concerning the practices.

For example:

•RCW 48.150.020 prohibits discrimination by direct providers. However, the questions that seek information about the possibility of discrimination in practices are voluntary and are most often left blank.

•Additionally, RCW 48.150.050 prohibits direct practices from establishing a direct practice agreement with employers, but the questions directed at ascertaining compliance with this provision are voluntary.

There is no practical means for the OIC to monitor direct practices for compliance with Chapter 48.150 RCW.  Therefore, the OIC recommends removing the term “voluntary data” from the statute for clarity and requiring direct practices to answer all of the questions on the annual statement.

The OIC also recommends the Legislature further clarify that employer offerings are unlawful due to the increase in direct practices offering employer plans and marketing to employers. It is likely that the language in RCW 48.150.050 that permits employers to pay direct practice fees on behalf of their employees has been misconstrued by direct practices to provide permission to create employer plans. Consumers and employers would be best protected by either removing employer payments or adding further clarification.

More frequently, direct practice agreements are failing to include the information required by law so that patients are fully informed. For example, agreements are failing to inform consumer of costs for services not covered by the agreement, but simply state that some services may involve additional costs. Agreements are frequently failing to include to disclaimer statement to inform consumer that a direct practice agreement is not comprehensive coverage, so that the consumer understands that emergency and specialty care must be paid out of pocket or that consumers should purchase a supplemental health plan. Rarely, do direct practice agreements contain the contact information for the OIC as required by RCW 48.150.100 to inform of consumer of their ability to call us if they have any concerns or questions. Ensuring Washington consumers are protected from unlawful practices has involved an increasing amount of time for the OIC to conduct these reviews. Of greater concern is the number of statements the OIC has received that indicate that the practice has been operating for some or a significant amount of time without ever submitting a statement to the OIC. This practice exposes consumers to potential harm from unlawful agreements and business practices that may not comply with Chapter 48.150 RCW, such as the large number of agreements that we have seen recently. Additionally, the OIC has noticed an increase in direct practices marketing to employers and offering what appear to be employer plans. The OIC is in the process of investigating these practices to determine if they are in compliance with Chapter 48.150, but there are strong indications that raise significant concerns that direct practices are moving beyond direct-patient primary care to employer-based offerings.

Monthly fees at direct practices vary from $32 to over $1,541. Enrollees at eight practices pay between $100 and $200 per month. In contrast, enrollees at 21 direct practices pay $100 or less, and enrollees at five direct practices pay more than $200 per month. The OIC does not collect data regarding the affordability of the fees for direct practice patients.

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Recommendations for Legislative Modifications (WA. State; Dec. 2019)

Washington is at the forefront of national regulation of direct primary care practices. Although direct primary care practices have not gained significant market share, they are present in 12 counties in Washington. The annual statement contains questions that direct practices are required to answer and questions they are not required to answer. Historically, direct practices do not answer the voluntary questions. As a result, it is difficult for the OIC to monitor for compliance with Chapter 48.150 RCW without the relevant information concerning the practices.

For example:

•RCW 48.150.020 prohibits discrimination by direct providers. However, the questions that seek information about the possibility of discrimination in practices are voluntary and are most often left blank.

•Additionally, RCW 48.150.050 prohibits direct practices from establishing a direct practice agreement with employers, but the questions directed at ascertaining compliance with this provision are voluntary.

There is no practical means for the OIC to monitor direct practices for compliance with Chapter 48.150 RCW. Therefore, the OIC recommends removing the term “voluntary data” from the statute for clarity and requiring direct practices to answer all of the questions on the annual statement.

The OIC also recommends the Legislature further clarify that employer offerings are unlawful due to the increase in direct practices offering employer plans and marketing to employers. It is likely that the language in RCW 48.150.050 that permits employers to pay direct practice fees on behalf of their employees has been misconstrued by direct practices to provide permission to create employer plans. Consumers and employers would be best protected by either removing employer payments or adding further clarification.

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SOURCE: https://www.insurance.wa.gov/sites/default/files/2019-11/direct-practice-report-2019.pdf

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