Executive Director of DPC Coalition
Jay Keese is the CEO of Capitol Advocates, a prominent policy and advocacy firm headquartered in Washington D.C., specializing in healthcare issues. With a career spanning decades, Jay's journey began in government relations at the American Medical Association, where he passionately represented physicians' interests.
Throughout his illustrious career, Jay has achieved remarkable success in winning legislative and regulatory battles that have shaped healthcare delivery and payment reforms. His expertise extends to advocating for doctors, employers, payers, states, health technologists, hospitals, and medical device and pharmaceutical manufacturers. Notably, during the COVID-19 pandemic, Jay played a pivotal role in securing critical waivers to state and federal laws, enabling healthcare practices to fully harness digital health services like telehealth and remote patient monitoring to enhance care during public health emergencies.
In addition to his role at Capitol Advocates, Jay leads several national healthcare stakeholder coalitions. As the Executive Director of the Direct Primary Care Coalition, he spearheaded the definition of Direct Primary Care (DPC) as a medical service offered outside of insurance within the Affordable Care Act (ACA), subsequently influencing over 30 state laws and regulations clarifying the treatment of DPC services. His advocacy work extends to the Partnership to Fight Chronic Disease (PFCD), where he collaborates with a diverse coalition to improve health outcomes and control costs through value-based payment and delivery reforms.
Jay's influence reaches far and wide, as he contributed to shaping innovative reforms in the ACA and played a key role in implementing programs such as physician direct contracting with the Centers for Medicare and Medicaid Services (CMS) and the CMS Innovation Center (CMMI).
Beyond policy advocacy, Jay has been a driving force behind the adoption of health information technology and patient care applications. He played a central role in developing a risk-based regulatory framework for smartphone apps adopted by the Food and Drug Administration, a crucial component of the Food and Drug Administration Safety and Innovation Act (FDASIA). These principles were later integrated into the 21st Century Cures Act.
Jay's journey began as an aide to the late Senator John Heinz (R-PA), where he gained invaluable experience in healthcare policy. He has also shared his knowledge as a guest lecturer at the Georgetown University School of Medicine and as an Adjunct Professor of Health Benefit Design at the University of Lynchburg, where he teaches a master's degree class on the history of health policy.
Outside of his professional life, Jay is an avid cyclist and skier. He and his wife Sara reside in Alexandria, Virginia, and have three grown children: Katie, Caroline, and William.
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Direct primary care is an innovative, alternative path to insurance driven healthcare. Typically, a patient pays their doctor a low monthly membership and, in return, builds a lasting relationship with their doctor and has their doctor available at the time. their fingertips. Welcome to the My DPC Story podcast, where each week you will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the direct primary care model.
I'm your host, Marielle Concepcion, family physician, DPC owner, and former fee for service doctor. I hope you enjoy today's episode and come away feeling inspired about the future of patient care. Direct. Primary care.
Jay Keese is CEO of Capital Advocates, a Washington, D. C. based policy and advocacy firm specializing in healthcare issues. Jay has represented physicians for decades, starting with a career in government relations at the American Medical Association. Over the years, he has won important legislative and regulatory battles for doctors, employers, payers, states, health technologists, hospitals, device and pharmaceutical manufacturers on critical health care delivery and payment reforms.
During the COVID 19 pandemic, Jay worked closely with physician groups. Congress and both administrations on critical waivers to state and federal laws that allow practices to fully utilize digital health services, such as telehealth and remote patient monitoring to provide better care in a public health emergency.
Jay currently runs several national healthcare stakeholder coalitions. He serves as executive director of the direct primary care coalition. He was instrumental in drafting a provision in the affordable care act or ACA, which defines direct primary care as a medical service offered outside of insurance.
which meets A. C. A. Essential health benefits criteria. He then played a major role in the passage of over 30 related state laws and regulations, clarifying the treatment of DPC medical services, and bringing value based primary care arrangements to Medicaid and state employees, health programs. He also leads advocacy work for the Partnership to Fight Chronic Disease, or PFCD, a coalition of patients, providers, community leaders, businesses, unions, and health policy experts committed to improving health outcomes and controlling costs by slowing the spread of preventable chronic disease by implementing more value based...
Payment and delivery reforms. He played a role in shaping many of these innovative reforms in the a c A and has helped implement programs like Physician Direct Contracting with the Centers for Medicare and Medicaid Services, or C M S and the C M S Innovation Center, or C M M I. Jay has worked with doctors, health technologists and software manufacturers for decades to support the adoption of health information tech.
Technology and patient care applications. He worked with a broad bipartisan group of stakeholders on the creation of a risk-based regulatory framework for smartphone apps adopted by the Food and Drug Administration, part of the Food and Drug Administration Safety and Innovation Act. He helped expand and implement many of these principles and provisions included in the 21st Century Cures Act.
He began his career as an aide to the late Senator John Hines, Republican from Pennsylvania. A member of the Senate Finance Committee and chairman of the Senate Aging Committee. Jay has been a guest lecturer at the Georgetown University School of Medicine and serves as an adjunct professor of health benefit design at the University of Lynchburg, teaching a master's degree class on the history of health policy.
Jay is an avid cyclist and skier. He and his wife Sarah live in Alexandria, Virginia and have three grown children, Katie, Caroline, and William.
Good morning, Jay.
Good morning, Mariel.
I know it's a technically afternoon over where you are because you're in Washington, DC and I'm in California. But for those listeners who don't know who Jay Keese is, can you please go ahead and give us a little bit about your history, the background that you have on Capitol Hill, especially, and how you started advocating for DPC?
Yeah, happy to. Uh, and, and thanks for having me on today. It's exciting. I'm, I'm really happy to be. Reaching out, particularly on this day when we have some good news to talk about with regard to DPC and, and, and Washington. So I started out in 1984 as a, as a legislative aid and a driver for United States Senator John Heinz, uh, who was back then was, would be today a mythical unicorn.
Called a moderate Republican, you know, and that was those were Republicans who could get along a lot with Democrats. And in fact, my boss did great things and he was the, uh, 1 of the only guys ever to get an 80, 85 or 90 percent rating with the AFL CIO and 85, 90 percent rating with the Chamber of Commerce in the same year.
So, you know, it was sort of all about making consensus and. Heinz was the chairman of the Senate aging committee and a member of the Senate finance committee and was very deeply involved in health care issues. So after I left the Hill, I worked for about a decade for the American Medical Association as an in house lobbyist and really dug deep into physician issues there.
I have represented over the years, you know, a wide range of stakeholders in the healthcare industry. Um, everything from pharmaceutical interests to, uh, healthcare technology, EHR vendors, I represented coalitions. Of patients and doctors, I've worked on intellectual property issues and tax issues and lots of different issues around health care.
But I'd say, you know, 80 percent of the work that I've done has really revolved around physicians, physician issues, antitrust, med mal, malpractice reforms, in addition to the work that I'm doing with the DPC community, I'm working with a group of some of the largest OBGYN practices. In the country, helping them navigate the challenges under the Dobbs decision and Roe v.
Wade and things. So we've been deeply involved, my firm and me, we've been deeply involved in, in healthcare issues on the physician side for more years than I really care to count. So, uh, it's fun to be here and talking about DBC. On the DPC background, specifically, Garrison Bliss, who was then the chief medical officer, I guess, because there was also a CEO of QLiants, which was the first large scale DPC practice in the country, contacted me, uh, actually through his CEO, in 2009, as the Affordable Care Act was really just about to be voted on, and it was a little bit of a panicked call.
It was, uh, You know, Garrison called and said, Hey, you got to do something to help us stop this Affordable Care Act thing, because it's kind of, we have this great DBC experiment going on in Washington state. It's working really well. It's saving businesses a lot of money and getting patients better care.
And it's really exciting. But, you know, the Affordable Care Act bargain is that, you know, everybody in the country is going to get health insurance. And that all primary care is going to be delivered through health insurance. And so while that was a train rolling pretty fast down the tracks that we couldn't stop, we told Garrison at the time that, you know, I thought we could get an amendment to the ACA.
That said that a direct primary care medical hall, which was a term of art that was we used back then about basically a DPC practice working in conjunction with a qualified health health plan that the 2 of those could independently offer a benefit to an employee or somebody on the exchange. And the DPC would be separate from the qualified health plans, but when you wrap the 2 together, that they would meet the Obamacare requirements for essential health benefits.
So. The very same essential health benefits that a qualified health plan would have to meet alone would have to be met by this combined use of the qualified health plan and the DPC together. And we were successful, and we put it in the ACA. And then we spent almost 10 years passing state laws to harmonize that provision and tell state insurance commissioners what the ACA said, which was...
That direct primary care is not an insurance plan, even though it charges a monthly fee that is, in fact, a medical service that is more appropriately regulated by the existing state medical boards, rather than the state insurance commission. And, and, you know, we've been going strong ever since. Obviously, I think if you look at the growth curve of DPC over the years.
It hasn't been a hockey stick. It's been a steady, steady growth curve. And you can look at that growth curve over the places where we passed the ACA. There were a bunch of States that passed a bunch of laws. And as the States passed the laws, lo and behold, DBC grows because it's free from, you know, regulatory constraints that are otherwise, you know, uh, keeping people from moving into the practice model.
And it's been really exciting. I love working for doctors. I always have, I could never be a doctor, so I'm really glad that I. Have a doctor and I have people that I can count on for the best possible, you know, advice on the medical side. And I'm honored that people seem to count on me for the best possible advice they can get on the policy and the legislative side.
So it's been a great, it's been a great ride. And here we are over 10 years later, and we're still going strong.
Amazing. And like you said, you know, this is, we're recording on pretty big day in terms of those 10 years, what we've worked towards, what you guys have worked towards, especially on the Hill to get DPC, you know, even more accessible to everyday Americans.
So let's talk about the amazing things that are happening in the DPC space when it comes to DPC on the Hill. There are three bills, the Primary Care Enhancement Act, the Medicaid Primary Care Improvement Act, as well as the Veterans Access to Direct Primary Care Act. Now, these are incredible, incredible bills because, again, we are all fighting to push this rock uphill in our own communities, with you, you know, in, in D.C., with states changing laws to protect D. P. C. All of these things are with the goal of helping, again, everyday Americans access D. P. C. So let's start talking about this first Primary Care Enhancement Act. What is it and where is it as of today? Yeah, so there's been a lot of versions of this bill. You know, I actually drafted the first version of the bill that I think a lot of people think is the clean, the be all end all of it, which, which basically just says, you know, look, DPC is a qualified medical expense and it's not.
Considered insurance under 2. 3c of the Internal Revenue Code. Let's take a step back about and I'm like, why do we have to have this bill? I think one piece of advice I always offer doctors knowing that I am not their lawyer. I am not even a lawyer. I'm a lobbyist and a legislative specialist. I write laws, but I don't force them and I don't protect people from them.
So when it comes to, you know, like HSA and tax advice. You know, unless you are a doctor and a tax lawyer, you probably shouldn't be offering your patients tax advice about what they can and can't do with their HSAs and HRAs and stuff, but common knowledge is out there that the HSA statute that was written in 2003, a part of the Medicare Modernization Act has some very specific criteria that make an individual eligible for an HSA and the one that most people know that in order to be eligible to have an HSA and tax preferred dollars Really triple tax preferred dollars.
In other words, dollars that are exempt from taxes as they go into the HSA. So that's a tax exemption there. While they're sitting in an HSA bearing interest, they're exempt from taxes. And then if you take them out and you use them. On a qualified health expense, they are also taxes exempt. So these are triple tax preferred dollars, which are like, if you ask your tax accountant, this is like, these are the best tax.
Some people would call 'em loopholes. I call them tax shelters or laws, you know, whatever. But these are the best tax conditions you can get in a, in an account. So I obviously the I R S and the Congress felt that there ought to be some constraints put around, you know, what this can be used for. And there's a list of two 13 D qualified.
Medical expenses that you can use, that the I r Ss, you can use your h s A for primary care is on that list. And a rulemaking in the, uh, uh, previous administration defined sort of definitively, you know, yeah. That DP fees can be used as qualified medical expenses with an F Ss, a flexible spending account or a H R A health reimbursement arrangement.
So there, there's no question that the pri, if they're used for primary care, The DPC fees are are qualified medical expenses. Then there's another set of rules again around what makes an individual taxpayer eligible to have an HSA. It says if you have an HSA it has to be paired with a high deductible health plan and you may not have another form of health plan or another set of services or another contract for services that covers things that are part of The high deductible health plan.
So if you think about it in their minds, it's like no double dipping, right? You can't have the tax preferred payment and have a plan that's going to pay for other services outside of that. And we all know that an HDHP has to primer cover primary care, but it doesn't cover anything like primary care services that you get from, uh, you know, my doctor, Matt Hayden, or, or, or from you or from Glenn Flanagan or any of other members that are providing these amazing services through DPC.
The I r s just doesn't see it that way. So their interpretation of this is pretty black letter law. So you have a D P C contract to them, it looks like a second health plan that is not a high deductible health plan that it, that makes you ineligible to fund your H S A. So it isn't that you can't have D P C and have an H S A, it's just that you can't have D P C and put any money into your H S A, so you might as well not have an H S A.
So the laws are confusing. They were written in 20, 2003. They haven't been updated since, and for about 10 years, we've been trying to change this. And the biggest problem that we have had in changing it is that every time a bill goes through Congress, they give it a score. And the score is basically how much is this bill going to cost?
And the primary thing that that a tax bill looks at is how much is this going to cost in terms of lost revenue to the Treasury? So if you start thinking about that triple tax preferred status, people putting more money into an HSA to spend on DPC, which we think will happen, you know, like if you can use your HSA for DPC, we think people think it's a great bargain and they're going to do it.
And then taking that money out and spending it on DPC, that's money that's never going to go into the treasury. So the last go around, they scored our bill, the Primary Care Enhancement Act as costing Over 10 years, about 1. 8 billion to the treasury. That's lost revenue that the treasury won't get, hooray, that you're going to get to keep and use on your doctor.
So what a novel concept, uh, uh, you know, like you get to, you get to do whatever you want with your own money and spend it on the doctor of your choice. And there have been these confusing regulations. They really haven't been enforced by the IRS ever. And like, you know, maybe this is one of the more wildly non complied with laws in the country.
But, you know, because there's confusion around what you can use your HSA for. But, you know, again, it's really up to you and your tax account and your tax attorney about about about those things. It's also important to note that. This isn't a provision that will get doctors in trouble because, you know, unless you have an HSA, you know, potentially the only person to get in trouble here is your patient, you know, so the burden would be on the patient.
And the IRS has said if a patient is found with a DBC agreement, they should defund their HSA and stop using it. There's no penalty. There's no remedy. You know, that's it. You can't have the money in there. So it's very confusing. It's ridiculous. It's an anachronism. It's something that is outdated. The, you know, 33 different states, state laws, the Affordable Care Act, and virtually every other regulatory body in the country says the DBC is not insurance.
But unfortunately, the way the law is written, it looks like insurance to the IRS until we change the law. And that's what we're trying to do. So we had a great day in the Ways and Means Committee yesterday, despite Probably heard the government's probably going to shut down and there's a lot of partisan rancor.
But the 1 thing that members of that panel on the ways and means committee, which is a tax rating body could agree on it was that, you know, DPC is a valuable service. And, uh, whether you like HSAs or not, and in fact, if HSAs actually went away. We wouldn't have this problem because you couldn't be ineligible to fund your HSA if there isn't an HSA.
So the reform that we're asking for in the Primary Care Enhancement Act really isn't about the HSA as much as it's about getting people primary care in any setting they want. Whether it's an HSA, we want them to have it in Medicaid, which we're going to talk about, Medicare, private pay plans, everybody ought to be able to have access to DPC and that's our goal.
Um, so yesterday was a good day. We got, we got a bunch of Democrats and all the Republicans to vote out of the Ways and Means Committee. It's going to the House floor when we get through this, you know, crisis of the shutdown and agree on a budget. Well, I'm sure we will be voting on packages. There's, there's actually 2 bills pending.
Uh, we'll talk about the Medicaid bill in a minute, but there's 2 bills pending at the desk waiting for full consideration in the House floor. 1 of them could get passed almost unanimously under a suspension of the rules. This 1 will probably have a vote. It'll be more partisan because there's just simply a lot of members of Congress, particularly on the Democratic side that think that the HSA vehicle is kind of for wealthy people and not the common man.
Although we would. Disagree with that a little bit and might, might not vote, vote for it. But, but we think it'll certainly pass the house. And, um, and so that's great. We did this once before in 2019, we passed a version of this bill and, uh, we'll do it again and keep pushing the rock up in the hill that we'll get it.
We have a companion in the Senate. I met today with Senator Bill Cassidy, who's a doctor from Louisiana, and, and, and talked with his staff about moving this bill in the Senate when it passes the House and they're gung ho and ready to do it. So here we are, we're working really hard to push this rock up a hill and get it, you put it, and, and, and get this old definition of DPC and the tax code changed.
It would definitely be very welcome for a lot of people and a lot of people who are, you know, getting into DPC, hearing different things, thinking, can you use your HSA? Can you not use your HSA? Can patients use your HSA or not? When it comes to what happened in 2003, can you also touch on the cap, the 150 cap?
What does that cap mean and who is it for? It's really not a cap if you think about it, you can charge anything you want. Nobody's telling you what you can charge the more proper way to look at this. And again, this has to do with this score. And I said, uh, that the bill in 2019 scored at 1. 8 billion dollars because of inflation and more people have HSAs.
That score has actually gone up to 2. 03 billion over 10 years. And they did a little gimmick with it and pushed the enactment date back to 2026 to make it, you know, the first couple of years are always more expensive. So it trims that off to bring it down a little bit, but that's a big number. And typically when Congress passes a bill that spends, again, think about this.
This isn't really like spending, like government spending your money. This is money the government's not going to get. Right, so, you know, the 150 was put in there to mitigate that. That's what that spend would be. So, because the IRS looked at it and and the joint committee on tax, we sat down with years ago and and they said, well, you know, you could this could be for concierge plans.
You could spend 5000 dollars a month. And then that makes that number go way up. So, you know, like if you were going to max out an IRA, an HSA at 6, 000 and keep that in there for 30 years, I mean, these are the kinds of numbers they're adding up billions and billions of dollars worth of costs. And it was simply not be able to pass what the 150 cap as it's called says, it's a limitation on the amount of the fee that can be paid for using these pretax.
And basically, you know, it doesn't actually say, oh, well, you can charge more imbalanced bill. It says, if you have a DPC arrangement. That is more than 150 dollars, which, by the way, today, according to the Millman study is double the national average is also indexed for inflation. So it'll go up every year.
But let's say you charge 150. We note that the one medical group, uh, DPC plans that are still out there are, some of them are priced at 149. So people are on to this. If it's above 150, it simply does not meet the qualification for this exception. And it's, it's as it is today, you know, so, so that was done for these two reasons.
One is the score. And two was to make sure that people understood this is for affordable DPC, not for concierge. And, you know, people probably wouldn't be doing this if it was for concierge, for the wealthy. And let's face facts, most of these HSA plans are tied to employer plans, and there's no employer out there paying that much money for a DPC arrangement.
And if it's indexed for inflation, I think that will take care of, you know, the growth. I believe strongly, I don't want to tell any doctor what he or she can charge. But I believe strongly that DPC is also about being affordable primary care that everybody has access to. And, you know, 150 a month, you know, you're getting up into the price of a cell phone bill.
You know, like the, the DPC is lower than the price of the average cell phone bill right now. And, you know, like, what do you want a doctor or a cell phone? You can talk to on your doctor. It seems eminently reasonable to me. We don't love it in a pure world. The way I initially drafted the bill, there wasn't any kind of limitation in it.
But it's not realistic, realistic to expect Congress or the IRS to agree to, you know, allowing unlimited dollars to be put into a triple tax preferred, you know, shelter. That's what it's about. Yeah. And
thank you for touching on that because there are a lot of people who are coming into the DPC space who aren't even aware that that exists.
And again, when we talk about DPC going into the future, as we talk about, you know, expanding DPC being protected by law in other states beyond those 33 people need to be aware of this. So I appreciate you mentioning that or I appreciate 1 more limitation that's in there too. I wanted to mention that's caused a lot of confusion and particularly since another thing we're trying to work really hard on is to.
Lower prescription drug costs for patients by allowing them to, to, you know, access, uh, cash pay meds through their DPC doctor for pennies on the dollar of what they pay out of their copay using the PBM and the insurance. There is a provision in there that would restrict DPC to primary care only and would would not allow DPC doctors to sort of, like, create a plan that included.
A formulary of prescription drugs in it. So it doesn't mean you couldn't sell them separately the way the language is drafted. It simply means you couldn't roll them up into the plan. And I know there's a few DPC docs that are doing that. Another thing done to keep the score down, as you can imagine, you know, if you wanted to include drugs and you had a Cadillac plan list of drugs that included, you know, uh, Eloquist and all the expensive brand drugs in it, then yeah, the sky would be the limit on how much money could go into those things and run up the price.
The Senate version of the bill does not have that prescription prohibition. The House bill does, and we're trying to figure out whether or not we can mitigate that one. So we allow you to include that. But it doesn't say you can't dispense. That's not what it says. And some people have said that's what it says.
It's not. And again, mind you, this is all voluntary. Like, this is for your patients that have HSAs for you to offer a plan. And that plan, you know, might wind up because of these regulations. Not a perfect world. Looking a little different than the plan that the patients that don't have HSAs have. So that's another option too, you know.
So I, I think it's important to look at the facts of the bill, read the bill. Uh, HR 3029 is where the main text is. And it is very clear, you know, like, this is an occasion where we do not want to let the perfect be the enemy of the good. Because... Right now the cap is zero.
Definitely. And like you mentioned earlier, when employers were looking at DPC in the early days of DPC and finding out that this is not concierge medicine and employees were able to put, you know, dollars into their HSA with the hopes that they could, you know, spend it on something that was quality primary care.
This is a move towards, you know, really making that happen. And I also want to touch here on. The, the growth of DPC amongst employer groups. So can you talk about how DPC is being adopted into different communities, especially because of employers building DPC into self funded plans?
Well, I would tell you the employer groups have lobbied just as hard for this bill as we have the American Benefits Council, the ERISA industry committee, the U S chamber of commerce.
You know, all the major employer groups are our allies on this Boeing, Amazon, not just as the owner of one medical now, but as one of the world's largest employers wants to provide this benefit. And in fact, people may know that Jeff Bezos was one of the initial investors in QLiants and, and loves the idea of having DPC.
There used to be a DPC worksite clinic in, in the Amazon office. So. All of these large employers and small employers, the gas station owner, the brewer, the, and unions, you know, firefighters, unions use DPC, the New Jersey state employees unions have a DPC option. The Nebraska state employees, uh, have a, have a DPC option.
Like the unions love this because it's first dollar coverage. For all the care, you're almost all the care you're ever going to need in your, in your life. And then when the company hands you a crappy, uh, high deductible health plan, Oh, well I have my DPC. So, you know, that's a recipe that might work for me, you know, like I might be able to, to, to make this work.
So it's a great, great option. And, uh, we want. The employers are our best allies. We've worked really hard at the DPC coalition to build the bridges to these employers that are market share for DPC practices. And we love that work. It's exciting. And the employers love it. When we put the provision in the Affordable Care Act, I can't tell you how many employers came out of the woodwork just saying, this is amazing because now we can offer a high deductible plan.
And look at our patients with a straight face and saying, we're giving you this amazing value, this benefit with a connection to the DPC practice and, you know, dramatically reduce the cost of providing a health care benefit. We worked really closely with Milliman a couple of years ago in 2020 to do the study that looked at that.
We're doing another 1 that's that's in the field right now. Milliman. And if you don't believe us, believe the society of actuaries and they say the actuaries themselves. say that DPC when being used as a part of an employee health benefit can reduce the downstream expenses to the employer by as much as 20 percent, 19.
8 or some something percent. Reduce, uh, you know, hospital visits and ER visits, 40 percent, numbers like that. They're not found in any other health reform.
Amazing. Now let's talk about the Medicaid Primary Care Improvement Act because that went through committee in June and it passed unanimously. Can you tell us what the Medicaid Primary Care Enhancement Act is and how it could potentially affect people who, you know, right now with Medicaid, Medi Cal type plans are getting You know, arguably some of the worst care that we have out there because there's less and less people each year who are accepting Medicaid and Medi Cal plans.
Yeah, it's true. Um, and in fact, Medicaid, generally speaking, is different in every state. Medicaid is pretty good insurance for, from the patient's perspective. From the doctor's perspective, not so good, right? Because the rates are insane. So, the problem becomes access, and particularly in rural states that have a sizable agricultural workforce that's seasonal, uh, for instance, you see a lot of employees that go into Medicaid when they're not working during the winter months, or, you know, again, back to Amazon, you have all these people that do seasonal work in the Amazon warehouses that have really good health benefits from November through January, but then, then they're kind of back in Medicaid.
This actually was an interesting conversation that we had years ago between a doctor who was the dean of the Houston School of Medicine, University of Houston, Tom Banning at the Texas Academy of Family Physicians, and Dan Crenshaw, who's a Republican member of Congress from Texas. We're all trying to figure out like, what, how would DPC be able to help, particularly in a red state that hasn't adopted the expansion of Medicaid beyond the poverty level, you know, would DPC be able to help?
We all sort of thought, wouldn't it be a neat idea if the money that's flowing to the FQHC, the federally qualified Medicaid. Health centers for to take care of primary care for individual patients. What if that money flowed into the and then out of the to a doctor that would really be able to be a patient's doctor and rather than going to the hospital or the clinic.
Uh, you know, the urgent care clinic, every time there's a problem, that individual would have the doctor's cell phone number and be able to talk to the doctor on a regular basis. We actually did this experiment, uh, with QLiants, with DPC and Medicaid and found, you can talk to Erica Bliss about this. She has all the data.
Of course, the Medicaid managed care company didn't want to share it, but compared to the regular Medicaid managed care. They were saving the state like 60%, not just 20 percent of the cost of a patient because they are, these patients would be crying. This is the first time they've ever had a doctor that's, that's their doctor.
They have somebody that will actually talk to them rather than, you know, probably some nurse that flashes between their eyes, you know, in an emergency room when they're there for the sniffles. You know, and, and so we think there's, there's really room for that. We know it's complicated and we know it's not going to be for everybody.
And we'll never be for a, for something that would mandate that, you know, like you take Medicaid patients, but you know, if it were offered, um, and it was, it was a reasonable price. What if Medicaid through the state could pay for the patients that can't afford your fees?
Well, believe it or not, there's some states you can't even do that. Like Colorado, that's, that's against the law. I think Kentucky. So this bill does a couple of things. It doesn't mandate a program at all. So the program that I just talked about is aspirational. It's something like, we might want to see it work that way.
There's other people that would like to see, Seema Verma, who is the last CMS director under President Trump, wanted to see a program where the Medicaid beneficiary got a voucher and they could use that to buy services from a DPC doctor. A lot of people that think Medicaid patients couldn't handle that.
I don't believe that. I think some could, but I think some can't. The vast majority of these folks might not even have a bank account. So, you know, this would be one of those programs, more than likely, where the money would flow not from the patient to you, but from the state to you. And what the bill says is that the CMS, the agency that runs Medicaid and Medicare in D.C., would have to sit down with a stakeholder group, including DPC doctors. The managed care companies that run the Medicare, uh, Medicaid programs in the states, the state Medicaid directors, and come up with some guidance about what this would be. And then if states want to do this, as long as it kind of fits within that guidance, you know, states would be able to do this without coming to CMS to beg for a waiver.
And it would also, I think, clarify to those states that say, well, you know, you can't have DPC because it's not doing the Medicaid mandated fee schedule in the state. That would clarify that, hey, states shouldn't be doing that either. So it would set us on the road to figuring out how to take the poorest of our patients and care for them in a way where they're going to get a government benefit.
We know that. How can we figure that out short of doing a food stamp program or a voucher? Program, which a lot of people like that idea. And I like that idea. At the end of the day, that's not always going to be for everybody. But what, what, what could be the best possible thing? So, this isn't a short term thing.
It did pass as you mentioned, unanimously out of the house energy and commerce committee. It's at the desk awaiting a. Consideration we expect once the resolution gets put forth on the, on the shutdown, we do expect this will be passed under a condition. They called suspension of the rules, which is when Congress just votes up or down no amendments on something that's got bipartisan agreement.
And usually they're almost unanimous, or, you know, out of the 435 members of Congress on the house. You know, 400 of them will vote for it. There's a bunch of people who just vote no and everything, right? So, uh, we won't get everybody, but, but everybody loves this idea. Like, how can DPC help get better care to the poorest and neediest and sickest people in the country?
And I think it's a great idea. Again, we're at this great juncture where. Members of Congress are thinking about things they can do to help DPC along and, you know, we might not have come up with this one, but it's something we love. And Dan Crenshaw and Kim Schreier, who's a pediatrician from Washington State, a member of Congress from Seattle are our champions.
They're really passionate about this bill and, uh. We're going to see where we can go with it. Uh, we had a conversation today with Cassidy and others about a Senate companion to this thing. There's no score on this one. So we do think that, you know, we're keeping our fingers crossed. This is something maybe we get across the finish line this year or next before the session ends at the end of 2024.
No, it's so interesting because you're this interview is coming out on the heels of Dr. Stephanie Phillips, who is in the poorest region of Georgia. There are many patients of her practice that are uninsured and able to still pay her 75 on average per member per month that speaks to the value of DPC that people as patients really take to heart.
They, you know, when patients know that they can save themselves a ton of money because they. Didn't have to go to the emergency room for the sniffles. Like you mentioned, you know, that's a huge savings for them potentially. So, and also I love that. We have the experience of QLiants to build off of versus if we had not had the lessons learned from QLiants for this bill made it out of the
Well, people might not know the story there and I mentioned that 60 percent figure and again, you'd have to talk to Erica Bliss about what those numbers were. That's what I remember from my feeble old brain, you know, from from way back then. But the reality is. Look, I mean, that Q Alliance was obliterated because the managed care company that they worked with on that plan saw that huge savings and had the state clawed that money back.
It's money that managed care company never got. So they shut that thing down. We did. There were some major learnings and we've incorporated all of those into those bill into that bill. One is the data needs to be shared. The managed care companies share the data about how the DPC is doing. With the DPC, with the state, with, with the patient, with everybody, there needs to be a three way communication.
There's a three way contract here. There's a contract between the managed care provider and the DPC, the DPC and the patient and the combined unit with the state. So all three of those parties need to be at the table to figure out what's going on, or it's an uneven floor to have your dance on, you're going to, you're going to crash the dance floor, which is exactly what happened.
This bill would establish a mechanism for that conversation to have happen. For the states for CMS to for everybody to agree on a reasonable set of principles that you could do DPC in the states with Medicaid on and doctors in the states are going to have to come to the table and agree on that to be able to move forward.
And are you going to be able to do it at 10 or 20 bucks a month? No. But are you going to be able to do it at 50 when you usually charge in private pay, maybe 75? Maybe. Let's, let's talk realistic, you know, Turkey about what the fee will be, for instance. That's an important part of the conversation. You guys don't have to work for free, you know, and what's the value of that?
Where's the data coming from? All of these things would be worked out in this construct. And I like it. I like where it's going. It's not saying, Hey, we're going to jump into something headlong. Medicaid is going to be hard. But I think we've anticipated that and learned from those lessons. Uh, where we went before and we're learning from the state employees programs, too, that have similar aspects of government payer involved.
It's great to be able to, you know, like, after all these years working on this stuff to be able to really take the learnings that you guys have given us in the field and the state legislators who are thinking about this stuff. And definitely if you haven't heard before, both Dr. Erica Bliss and Dr. Garrison Bliss have been on the podcast. So definitely listen to their episodes and we'll also include, um, I believe it was a 2018, uh, DPC summit where Dr. Erica Bliss last spoke about the QLions experience. So definitely check that out in the blog accompanying Jay's podcast. Now let's talk about Veterans Access to Direct Primary Care Act.
Yeah, absolutely. I'm the son of a veteran. My father was a naval aviator. He flew torpedo bombers with George Bush in World War II. So it was so fun being out in San Diego with all the aircraft carriers. Uh, felt like an old home week, you know, for me, but I really enjoyed that. And we want to do, obviously, everything we possibly can for our veterans.
The Veterans Administration is made up of, I think, 21 different, uh, V. A. districts, VISNs they call them, that run V. A. hospitals and it's a hospital service territory. And a couple of years ago, you might know that because of all the wait times at the V. A. s, they created a program called Community Care. And the idea behind Community Care was that a veteran, if they can't get in to see the V.A. doctor, may go to an individual doctor, and the doctor can charge V. A. a fee for service. What he would charge, you know, like, I think it's a Medicare, Medicare plus payment rate kind of thing. But we have had a couple of conversations with the VA and we said, what if, what if you paid the monthly fee? So the VA has this thing, just like CMS has a center for innovation, they have a center for innovation.
And, and the VA thought, you know, that'd be a good thing for the center of innovation. Congressman Chip Roy from Texas, who's also a big fan of HSAs. Proffered a bill. Again, we didn't really work on this bill, the drafting of this bill, but you know, we like, directionally we like, and it has two parts. One, it says they're going to establish an HSA for veterans, and the veterans would be able to use the money out of the HSA to pay a TPC doc.
And so we view those as sort of two separate things. They're part of this bill because it's got an HSA component, and there's a lot of Democrats, as we said before, they don't love HSAs. There aren't any Democratic co sponsors on this bill, but we sort of feel if it were kind Maybe split apart into two different bills.
One was the HSA bill and one was the DPC bill. And we'd be happy to support both. But if the DPC bill moved independently, we think just like we saw yesterday and the committee where there was a lot of partisan rancor about the government shutdown and HSAs are for the rich. A lot of Democrats said, well, we love the DPC, but you know, we can't vote for this other stuff over here.
So if the DPC, you know, it would be similar to what we're talking about with Medicaid, VA would have to create a rubric under which DPC doctors would work, and I think that the idea would be that the VA would pay the DPC doc directly a monthly fee to take care of the veteran. I love this idea. Who needs more care than our veterans today?
They're in very complicated behavioral health situations with. Post traumatic stress disorders and head trauma, you know, obviously care for major wounds like amputations and blindness and things that that are going to require very complicated care coordination through a primary care doctor. In addition to all the specialists.
That VA might work with, I think it's a great idea to allow these folks to have a doctor, a personal doctor that they can take care of their needs and, uh, you know, look beyond the prosthetics and the, and the problems that the veterans might have on behavioral health to their just general health needs and, and the behavioral health needs also being another monitor for, you know.
This, this crisis that we're having with so many veterans committing suicide every, every day, you all can be, you know, first line of defense for these men and women who've given all to serve our country. And I, uh, it would warm my heart to be able to bring this to veterans. And, you know, I think we can, but it's a longer process.
You know, we've been at the DVC HSA thing for a long time, and Washington moves at a glacial pace. So I don't necessarily expect this bill to be flying off to the President's desk to be signed this year, but we're going to work really hard to perfect it and to make sure. That it's a reasonable policy choice and, uh, work with VA committees, the VA and all of you to make sure that something gets done right here.
And, you know, there's definitely VA patients who can testify to the power of DPC. Like, for instance, I have a Vietnam veteran in my practice and that veteran, you know, needed Significant follow up and so I was able to contact people in within the V. A. As well as outside of the V. A. Through personal tax through a faxes to their clinic personally that gave exactly why I needed my patient to have a more detailed follow up and because of that advocacy, my patient got care much sooner.
And they didn't only have to go to the VA for that care because if they had, it would have been much more delayed, um, unfortunately in this case. And so there are definitely veterans out there who are saying like, right now, if the VA is not paying for it, that's okay, I'm still going to invest in my own private doctor.
And it has made a huge difference, especially for my particular patient.
The VA doctors are heroes too. Don't, don't get me wrong. They're great people. But I think if you've ever interacted with doctors at the VA. either primary care doctors or specialists. They're so appreciative when they have uh, follow ups from the private sector and if nothing else, particularly if they're going to be a complicated condition that involves a stay at a VA hospital, to have a consulting physician from the outside be a part of that care team is super important and that veteran is going to get better care for it, always.
And definitely is deserved by veterans, but definitely deserved by all patients because, you know, when, when we have, I love when we have, um, experiences, my husband and I, when we talk to specialists and they're like, Hey, this is my cell phone. Give me a call because we got to talk about a little bit more.
We got to talk about this patient a little bit more. It's. Fantastic. And I really appreciate doctors like Dr. Nicole Harkin, who owns Whole Heart Cardiology. She's a direct care cardiologist, and she makes it a point as part of her workflow to send the referring doctor her summary. So there is a communication and not just like, Oh, well, I have to have my nurse request records and pray to everything that they actually get received.
The doctor is, is making that, is having the time to make. The communication happened between the specialist and the referring doctor. So definitely, we'd love to see, you know, where this goes in the future. Now, with that, you know, like you said, DPC is not protected by law in all states. It's not protected in California at the date of this interview.
So when it comes to what people can do who are listening to this episode, and they're talking about talking amongst themselves about how, how can I make change in my community? What can I do to help this DPC rock move uphill? What advice do you have for them? Well, the first thing piece of advice would be you got to join the DPC coalition.
We need everybody we possibly can. dpcare. org is our website. There's a join button. You can click it. And we tried to structure the coalition, just like you structure your fees. We, we asked for your first patient, the general membership and DPC coalition is 50 a month. So it's an ongoing thing that supports all the lobbying activities that we're talking about, all the outreach to the employers, the program we're working with lineal health and ASM on medications on, so.
The number one thing you can do to get involved is to join the DPC coalition. We have not had an opportunity to have a DC fly in since the pandemic. Candidly, we were hopeful to have one this spring in conjunction with the AAFP meeting, but things got moving so fast on the legislation and we weren't able to really pull it off together.
Uh, but we will be, we, we, we will have fly ins. You'll have an opportunity to come to DC and lobby. We work as a resource to any either State Academy of Family Physicians, State Medical Society, or even DPC state chapter coalitions. We were talking about building 1, 1 of these in California. We have 1 in Montana.
We have 1 in Massachusetts. There's state state chapters that we work with. And we actually, on the states, we don't do a lot of on the ground lobbying, but we provide all the resources, the testimony, we do the drafting. The bill that has passed in over 33 state legislatures is a model bill that is available for free for anybody to look at on our website.
So, that's 1 way that we've been able to really impact almost all of the state laws that are out there right now are based on that law. And it's just very simply says. DPC is not insurance. The business of insurance is not subject to the regulation of the State Insurance Commission. It is regulated like any other medical service by the State Board of Medicine.
And so, as I said, there's 33, I think, states that have passed laws and there's another three states. that have very good BPC regulations that the insurance commissioner has put forth. And we worked hard with those insurance commissioners, Massachusetts is one of those. There are a number of other states where we don't really need a DPC law because there's nothing prohibitive in the state insurance code out there.
California is one of those where there's a lot of ambiguities. There's a whole different set of laws called Knox Keene in California that guide HMOs. And HMOs are designed are defined in Knox Keene basically as medical services that are paid for with a monthly fee. And, you know, by a strict read, you know, DPC practices fall into that.
There's never to my knowledge, been any enforcement and I'll remind you all again, I'm not your lawyer. And so I can't really give you legal advice about whether or not you're violating Knox Keene, but there's that there's the state insurance code. Then there's the state medical code that has various different reporting requirements and things that can get complicated the best.
Form of advice. You know, we have Phil Eskew who is our general counsel and everybody knows Phil from the mapper and DPC frontier. Phil will give you a lot of free legal advice, which is on behalf of the coalition as a part of what he does, does for us, you can call him up anytime and contact him through the website, but he won't, he's not going to be your lawyer.
So you really do need somebody to look at your contract to make sure. That you're crossing the T's and dotting the eyes and making sure that the contract is good. And these are the primary worries. I think you have, you know, with DPC and state law, I think would be pretty well known in certain states and big ones like California.
If there was a lot of enforcement going on. We'd figure it out. We have issues in Washington state where the state insurance commissioner actually does publish a report under under the state law there on DPC every year. And there's been varying degrees of people not wanting to do that or whatever. And the reality is, you know, we've never had there's a hotline.
To call and, you know, nark on your DPC doctor for doing things that are, that are violating state insurance law. To my knowledge, it's only ever had one call from a doctor who tried to nark on a nurse practitioner's office. So, uh, it's a hotline that goes unanswered every day because there are no problems.
You know, there really is a need for a hotline because, you know, so I guess what I'm saying is these state laws where these states where we haven't passed a law, it does create, I think, a higher bar under which you're going to require you to go lawyer up and get an attorney. That's going to make sure as you're as you're getting your practice established.
That you're doing everything by the book in terms of state law, and you're complying with everything on both the state and the federal law. I don't know of a single state where there's a out and out prohibition. Alaska has a law. I know we've been trying to pass a bill up there. That's pretty prohibitive, but there's again, there's a couple of DPC practices up there.
There's never been any enforcement. So, it's just be careful, work with your attorney. To make sure that you're following as much as possible the state laws and could wind up being that some of these test cases come from some enforcement action where, where you, you know, DPCs, if you're going to go to court and have to defend what you do, I feel really good that you're going to win because no reasonable human being looks at a DPC agreement and says, Oh, well, that's health insurance, you know?
So whether that's in the letter of the state law or not. I feel like we've probably done 90 percent of the work we're going to do at the state level. The states again, Alaska, Pennsylvania, Wisconsin have all tried to pass laws and not not gotten across the finish line yet. We'll continue to work on those.
With the people in the states as much as possible, but, but I think that activity is going to slow down quite a bit. The big ones would be California, New York, maybe Illinois, Illinois, where you're going to poke the bear and really go at it. And those are going to require major efforts. And as things happen, we'll have to formulate a really strong coalition in those states and lobby hard at the state level with somebody on the ground.
It's capable of doing that to get those things done, but we haven't been there yet. We're not ready to go. I think in California yet. I mean, you tell me you're, you're really involved in these conversations, but I think that's where we've been.
Well, I will say, you know, a couple of things, not necessarily about California, but in terms of if you are not sure, you know, Who do I talk to?
Who could be my lawyer? You know, talk to other DPC doctors in your state to see, you know, who is knowledgeable about DPC. Because a person who practices health law, like Dr. Felescu said in his episode of my DPC story, health law is an elective. And so, when people are really learning more and more about DPC, it sets them apart from someone who's doing health law in general.
And the other thing that I wanted to mention was just last March, the California Academy of Family Practice had an all advocacy member meeting. I don't know if this is present in all states. But it definitely was a very, very good experience for me in terms of specifically the CFP had a two particular bills, one about a residency funding and one about having insurances pay for preventative care.
But we were really exposed as. you know, just everyday family doctors to what it feels like and what it is to lobby. And it was very, very interesting because, you know, in my, my representatives, when I spoke to one of the staffers for my area, my geographic area in Northern California, you know, they were just blown away by the stories that I was sharing with them.
And so, you know, as this is my DPC story, your DPC story matters. And, you know, don't ever forget that and definitely, you know, say, Hey, could I use this to harness other people's ears and, you know, make a change in my community? And then, you know, that change, somebody will most likely tell another person about it.
And then the word continues to spread just like, you know, the word of mouth continues to spread for our practices. So I just want to put that in there when it comes to California, we're working on it, definitely working on it. But I'm so glad that we have a nice core of people and that core is growing who are very committed to making sure that our patients have access to direct primary care in California.
So you mentioned, uh, the, uh, the academies of family physicians, AFP, by the way, is a member of the DBC coalition. They're on our steering committee. They're very committed to the DPC movement as one of the, you know, leading, you know, advanced practice models. For primary care and the state AFP chapters are usually great places to go.
And I would encourage everybody listening to this podcast to get involved. If you are a family doc, to get involved in your, in your state AFP. Now, internal medicine hasn't been as supportive as, as I think people know, but it doesn't mean that the state chapters aren't as supportive and almost all the state medical societies that I know.
The state, state chapters of the AMA are very supportive of DPC. So get involved in that vehicle. They're great. They're great people. They have professional lobbyists. They're usually among the best lobbyists in any state capital, you know, so you definitely get involved. And the more that you can get involved in the academy lobbying, the more they're going to bring a, uh, DPC issues up to the fold.
And let me do one other plug really importantly. We've been working really closely with Texas and the Texas Academy of Family Physicians in addition to AFP as a member of the coalition as well because for the last couple of years we've been trying to get a bill to allow dispensing in Texas, which is the only place that really completely prohibits it at a physician's office.
And we got really, really close this year. We had a bill where there was a deal on the table. In Texas, typically, you know, vaccinations for pediatrics for kids are not allowed to be administered in the pharmacies. They waived that during COVID and the experience was good. People found, you know, they like going to their pharmacy to get a vaccination, maybe not going into their doctor's office where, yeah, there might be a lot more sick people or whatever, you know, to do that.
And so, although the pediatricians don't love this idea, because that's a big income stream for them, The trade was, hey, well, if we let pediatric vaccinations happen down to 3 at the pharmacy, why don't we let doctors in DPC practices and primary care practices dispense regular meds? And I think we can get that deal done across the table.
So that's an example of the kind of thing beyond just. The DPC laws again, we worked really closely in Nebraska to pass a bill to allow the state employees to do direct primary care strata health runs that program for the state employees now. And it's really exciting. So there's tons of stuff that we can work out at the state level.
You can just always call me, call the direct primary care coalition, call me and reach out via the website or feel free to give out my info. Marry all with us. JP Keys said CAGDC. org. Shoot me an email. We will always want to fly and get involved on, on behalf of an issue, uh, provide advice for you to get involved.
But my favorite way this happens isn't when I come in and testify, which is when I get you to go in and testify and we can work together on what. What the policy provisions are, what's said and how to navigate the swamps that are all there. And, you know, these state capitals, right? It's, um, you wouldn't walk into a courtroom without a lawyer.
You probably shouldn't walk into a state legislative body without a lobbyist, uh, helping you out. But with that, thank you so much, Jay, for joining us today.
Thanks, Marielle. It was really exciting to talk to you on, uh, on the eve of this great vote that we had. Awesome.
Hopefully we'll get an update soon from you on the next episode of My DVC Stories Legislative
Will do. I'll come back anytime.
Next week, look forward to hearing from Dr. Matthew Hayden of Modern Mobile Medicine in Virginia and Washington, D. C. If you've enjoyed the podcast and you haven't yet done so, subscribe today and share the episode with a physician you may know who needs to hear about DPC. Leave a five star review on Apple Podcasts now as well, as it helps others to find all these DPC stories.
Lastly, be sure to follow us on social media. And if you're wanting to continue learning more about DPC in the YouTube channel. time, check out dpcnews. com. Until next week, this is Mariel Concepcion.
*Transcript generated by AI so please forgive errors.