1. Robert Hall Director, Government Relations 6/12/2018
PCPCC Policy and Advocacy Call The Primary Care Patient Protection Act of 2018 (HR 5858)
Robert Hall
Director, Government Relations
6/12/2018

2. Standard Primary Care Benefit
Primary Care Patient Protection Act of 2018 (HR 5858)
Elise Stefanik (R-NY) and Brad Schneider (D-IL)
STANDARD PRIMARY CARE BENEFIT IN HIGH DEDUCTIBLE HEALTH PLANS
RECOMMENDATION
The American Academy of Family Physicians (AAFP) urges House members to cosponsor the Primary Care Patient Protection Act of 2018 (HR 5858), a bill sponsored by Reps. Elise Stefanik (R-NY) and Brad Schneider (D-IL). The bill will make it more affordable for patients with high deductible health plans to access primary care.
Background
One insurance option now available, high-deductible health plans (HDHPs), offer health care coverage with a minimum deductible and maximum out-of-pocket limit set by the Internal Revenue Service (IRS). HDHPs are growing. In 2017, almost 22 million Americans had enrolled in an HDHP, up from only one million in However, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family. This out-of-pocket cost can cause patients to delay seeking care, lapse in maintenance, or adherence to medication and treatment protocols.
Family physicians are in the business of preventing sickness and managing chronic conditions, but cannot provide care if patients will not access it due to cost concerns. Unfortunately, the current trajectory of HCHP insurance coverage exacerbates this growing problem. While they are innovative structures that the AAFP supports, HDHPs can compound the cost problem, especially for low-income Americans. Among low-income individuals with diabetes, for instance, the “skin in the game” created by the HDHP structure appears to discourage appropriate use of health services. HDHPs should provide more value for the premiums families pay.
Family physicians hear about cost concerns from patients every day. Even if they have health insurance, patients are skipping care because they simply can’t afford it, and perhaps more troubling, patients are more worried about paying for care than getting sick.
About 40% of Americans report skipping a recommended medical test or treatment and 44% say they did not go to a doctor when they were sick or injured in the last year because of cost.
More people fear the bills that come with a serious illness than the illness itself (40% vs. 33%).
The Solution
Under the Stefanik-Schneider bill, individuals with a HDHP would have access to their primary care physician, or their primary care team, without cost-sharing. The company issuing the HDHP to the individual or family would be responsible for providing full coverage of primary care services for the plan year. Primary care is focused on comprehensive, continuous and coordinated care. Primary care services include primary care, prevention and wellness, and care management services (defined by a specific set of billing codes in the legislation).
Primary care, for the purposes of the legislation, is defined broadly to include the following physician specialties: General Practice; Family Medicine; Internal Medicine; Pediatric Medicine; and Geriatric Medicine. Nurse practitioners are also eligible.
Patients will designate their primary care clinician and that physician or nurse would be the site of service for this benefit for the enrollment period.
If a patient has not designated a primary care physician, the insurer issuing the HDHP would be responsible for assigning a primary care physician or nurse to the patient.
The California health care marketplace has instituted a similar structure and documented that there was no negative impact on premiums.
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3. Uninsured Rates Rise Steadily
Sources: Sara Collins, Munira Gunja, Michelle Doty & Herman Bhupal, “First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse,” The Commonwealth Fund, May 1, 2018.

4. Health Care Coverage by Type
157.4 million covered lives in employer-based plans
Sources: “Health Insurance Coverage of the Total Population,” Kaiser Family Foundation, March 2017.
Medicaid- 19%: Includes those covered by Medicaid, the Children’s Health Insurance Program (CHIP), and those who have both Medicaid and another type of coverage, such as dual eligible who are also covered by Medicare.
Medicare- 13%: Includes those covered by Medicare, Medicare Advantage, and those who have Medicare and another type of non-Medicaid coverage where Medicare is the primary payer. Excludes those with Medicare Part A coverage only and those covered by Medicare and Medicaid
Employer 48%: Includes those covered by employer-sponsored coverage either through their own job or as a dependent in the same household
Non-Group-7%: Includes individuals and families that purchased or are covered as a dependent by non-group insurance
Military- 4%
Uninsured- 9%

5. High Deductible Health Plans (HDHPs)
HDHP/HSA enrollment increasing
In 2017 ~ 22 million enrolled
2005, only 1 million enrolled
Definition of HDHP
Deductible at least $1,350 individual, $2,700 family
Include preventive services with no copay
STANDARD PRIMARY CARE BENEFIT IN HIGH DEDUCTIBLE HEALTH PLANS – through 99215
RECOMMENDATION
The American Academy of Family Physicians (AAFP) urges House members to cosponsor the Primary Care Patient Protection Act of 2018 (HR 5858), a bill sponsored by Reps. Elise Stefanik (R-NY) and Brad Schneider (D-IL). The bill will make it more affordable for patients with high deductible health plans to access primary care.
Background
One insurance option now available, high-deductible health plans (HDHPs), offer health care coverage with a minimum deductible and maximum out-of-pocket limit set by the Internal Revenue Service (IRS). HDHPs are growing. In 2017, almost 22 million Americans had enrolled in an HDHP, up from only one million in However, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family. This out-of-pocket cost can cause patients to delay seeking care, lapse in maintenance, or adherence to medication and treatment protocols.
Family physicians are in the business of preventing sickness and managing chronic conditions, but cannot provide care if patients will not access it due to cost concerns. Unfortunately, the current trajectory of HCHP insurance coverage exacerbates this growing problem. While they are innovative structures that the AAFP supports, HDHPs can compound the cost problem, especially for low-income Americans. Among low-income individuals with diabetes, for instance, the “skin in the game” created by the HDHP structure appears to discourage appropriate use of health services. HDHPs should provide more value for the premiums families pay.
Family physicians hear about cost concerns from patients every day. Even if they have health insurance, patients are skipping care because they simply can’t afford it, and perhaps more troubling, patients are more worried about paying for care than getting sick.
About 40% of Americans report skipping a recommended medical test or treatment and 44% say they did not go to a doctor when they were sick or injured in the last year because of cost.
More people fear the bills that come with a serious illness than the illness itself (40% vs. 33%).
The Solution
Under the Stefanik-Schneider bill, individuals with a HDHP would have access to their primary care physician, or their primary care team, without cost-sharing. The company issuing the HDHP to the individual or family would be responsible for providing full coverage of primary care services for the plan year. Primary care is focused on comprehensive, continuous and coordinated care. Primary care services include primary care, prevention and wellness, and care management services (defined by a specific set of billing codes in the legislation).
Primary care, for the purposes of the legislation, is defined broadly to include the following physician specialties: General Practice; Family Medicine; Internal Medicine; Pediatric Medicine; and Geriatric Medicine. Nurse practitioners are also eligible.
Patients will designate their primary care clinician and that physician or nurse would be the site of service for this benefit for the enrollment period.
If a patient has not designated a primary care physician, the insurer issuing the HDHP would be responsible for assigning a primary care physician or nurse to the patient.
The California health care marketplace has instituted a similar structure and documented that there was no negative impact on premiums.
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6. Consumers Fear Health Costs
About 40% of Americans report skipping a recommended medical test or treatment and 44% say they did not go to a doctor when they were sick or injured in the last year because of cost.
More people fear the bills that come with a serious illness than the illness itself (40% vs. 33%).
STANDARD PRIMARY CARE BENEFIT IN HIGH DEDUCTIBLE HEALTH PLANS – through 99215
RECOMMENDATION
The American Academy of Family Physicians (AAFP) urges House members to cosponsor the Primary Care Patient Protection Act of 2018 (HR 5858), a bill sponsored by Reps. Elise Stefanik (R-NY) and Brad Schneider (D-IL). The bill will make it more affordable for patients with high deductible health plans to access primary care.
Background
One insurance option now available, high-deductible health plans (HDHPs), offer health care coverage with a minimum deductible and maximum out-of-pocket limit set by the Internal Revenue Service (IRS). HDHPs are growing. In 2017, almost 22 million Americans had enrolled in an HDHP, up from only one million in However, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family. This out-of-pocket cost can cause patients to delay seeking care, lapse in maintenance, or adherence to medication and treatment protocols.
Family physicians are in the business of preventing sickness and managing chronic conditions, but cannot provide care if patients will not access it due to cost concerns. Unfortunately, the current trajectory of HCHP insurance coverage exacerbates this growing problem. While they are innovative structures that the AAFP supports, HDHPs can compound the cost problem, especially for low-income Americans. Among low-income individuals with diabetes, for instance, the “skin in the game” created by the HDHP structure appears to discourage appropriate use of health services. HDHPs should provide more value for the premiums families pay.
Family physicians hear about cost concerns from patients every day. Even if they have health insurance, patients are skipping care because they simply can’t afford it, and perhaps more troubling, patients are more worried about paying for care than getting sick.
About 40% of Americans report skipping a recommended medical test or treatment and 44% say they did not go to a doctor when they were sick or injured in the last year because of cost.
More people fear the bills that come with a serious illness than the illness itself (40% vs. 33%).
The Solution
Under the Stefanik-Schneider bill, individuals with a HDHP would have access to their primary care physician, or their primary care team, without cost-sharing. The company issuing the HDHP to the individual or family would be responsible for providing full coverage of primary care services for the plan year. Primary care is focused on comprehensive, continuous and coordinated care. Primary care services include primary care, prevention and wellness, and care management services (defined by a specific set of billing codes in the legislation).
Primary care, for the purposes of the legislation, is defined broadly to include the following physician specialties: General Practice; Family Medicine; Internal Medicine; Pediatric Medicine; and Geriatric Medicine. Nurse practitioners are also eligible.
Patients will designate their primary care clinician and that physician or nurse would be the site of service for this benefit for the enrollment period.
If a patient has not designated a primary care physician, the insurer issuing the HDHP would be responsible for assigning a primary care physician or nurse to the patient.
The California health care marketplace has instituted a similar structure and documented that there was no negative impact on premiums.
(See
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7. Consumers and HDHPs Lower income have higher price sensitivity
Diabetes example
Overall HDHPs tend to over-correct for off-target utilization
“Among privately insured adults aged 18–64 with employment-based coverage, those enrolled in an HDHP were more likely than those enrolled in a traditional plan to forgo or delay medical care and to be in a family having problems paying medical bills.” CDC: Financial Barriers to Care: Early Release of Estimates From the National Health Interview Survey, 2016
STANDARD PRIMARY CARE BENEFIT IN HIGH DEDUCTIBLE HEALTH PLANS – through 99215
RECOMMENDATION
The American Academy of Family Physicians (AAFP) urges House members to cosponsor the Primary Care Patient Protection Act of 2018 (HR 5858), a bill sponsored by Reps. Elise Stefanik (R-NY) and Brad Schneider (D-IL). The bill will make it more affordable for patients with high deductible health plans to access primary care.
Background
One insurance option now available, high-deductible health plans (HDHPs), offer health care coverage with a minimum deductible and maximum out-of-pocket limit set by the Internal Revenue Service (IRS). HDHPs are growing. In 2017, almost 22 million Americans had enrolled in an HDHP, up from only one million in However, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family. This out-of-pocket cost can cause patients to delay seeking care, lapse in maintenance, or adherence to medication and treatment protocols.
Family physicians are in the business of preventing sickness and managing chronic conditions, but cannot provide care if patients will not access it due to cost concerns. Unfortunately, the current trajectory of HCHP insurance coverage exacerbates this growing problem. While they are innovative structures that the AAFP supports, HDHPs can compound the cost problem, especially for low-income Americans. Among low-income individuals with diabetes, for instance, the “skin in the game” created by the HDHP structure appears to discourage appropriate use of health services. HDHPs should provide more value for the premiums families pay.
Family physicians hear about cost concerns from patients every day. Even if they have health insurance, patients are skipping care because they simply can’t afford it, and perhaps more troubling, patients are more worried about paying for care than getting sick.
About 40% of Americans report skipping a recommended medical test or treatment and 44% say they did not go to a doctor when they were sick or injured in the last year because of cost.
More people fear the bills that come with a serious illness than the illness itself (40% vs. 33%).
The Solution
Under the Stefanik-Schneider bill, individuals with a HDHP would have access to their primary care physician, or their primary care team, without cost-sharing. The company issuing the HDHP to the individual or family would be responsible for providing full coverage of primary care services for the plan year. Primary care is focused on comprehensive, continuous and coordinated care. Primary care services include primary care, prevention and wellness, and care management services (defined by a specific set of billing codes in the legislation).
Primary care, for the purposes of the legislation, is defined broadly to include the following physician specialties: General Practice; Family Medicine; Internal Medicine; Pediatric Medicine; and Geriatric Medicine. Nurse practitioners are also eligible.
Patients will designate their primary care clinician and that physician or nurse would be the site of service for this benefit for the enrollment period.
If a patient has not designated a primary care physician, the insurer issuing the HDHP would be responsible for assigning a primary care physician or nurse to the patient.
The California health care marketplace has instituted a similar structure and documented that there was no negative impact on premiums.
(See
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8. Solution: HDHPs cover prevention and primary care
HR 5858 allows patients 2 primary care visits paid for through the premium (no deductible required)
Tested in Covered California (CA’s Exchange)
“…for most tiers, neither primary care nor specialty ambulatory care visits are subject to the deductible, and copayments for primary care visits are lower than those for specialty or emergency department care… These priorities align benefit design with the goal of supporting patients in getting the right care at the right time.”
STANDARD PRIMARY CARE BENEFIT IN HIGH DEDUCTIBLE HEALTH PLANS – through 99215
RECOMMENDATION
The American Academy of Family Physicians (AAFP) urges House members to cosponsor the Primary Care Patient Protection Act of 2018 (HR 5858), a bill sponsored by Reps. Elise Stefanik (R-NY) and Brad Schneider (D-IL). The bill will make it more affordable for patients with high deductible health plans to access primary care.
Background
One insurance option now available, high-deductible health plans (HDHPs), offer health care coverage with a minimum deductible and maximum out-of-pocket limit set by the Internal Revenue Service (IRS). HDHPs are growing. In 2017, almost 22 million Americans had enrolled in an HDHP, up from only one million in However, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family. This out-of-pocket cost can cause patients to delay seeking care, lapse in maintenance, or adherence to medication and treatment protocols.
Family physicians are in the business of preventing sickness and managing chronic conditions, but cannot provide care if patients will not access it due to cost concerns. Unfortunately, the current trajectory of HCHP insurance coverage exacerbates this growing problem. While they are innovative structures that the AAFP supports, HDHPs can compound the cost problem, especially for low-income Americans. Among low-income individuals with diabetes, for instance, the “skin in the game” created by the HDHP structure appears to discourage appropriate use of health services. HDHPs should provide more value for the premiums families pay.
Family physicians hear about cost concerns from patients every day. Even if they have health insurance, patients are skipping care because they simply can’t afford it, and perhaps more troubling, patients are more worried about paying for care than getting sick.
About 40% of Americans report skipping a recommended medical test or treatment and 44% say they did not go to a doctor when they were sick or injured in the last year because of cost.
More people fear the bills that come with a serious illness than the illness itself (40% vs. 33%).
The Solution
Under the Stefanik-Schneider bill, individuals with a HDHP would have access to their primary care physician, or their primary care team, without cost-sharing. The company issuing the HDHP to the individual or family would be responsible for providing full coverage of primary care services for the plan year. Primary care is focused on comprehensive, continuous and coordinated care. Primary care services include primary care, prevention and wellness, and care management services (defined by a specific set of billing codes in the legislation).
Primary care, for the purposes of the legislation, is defined broadly to include the following physician specialties: General Practice; Family Medicine; Internal Medicine; Pediatric Medicine; and Geriatric Medicine. Nurse practitioners are also eligible.
Patients will designate their primary care clinician and that physician or nurse would be the site of service for this benefit for the enrollment period.
If a patient has not designated a primary care physician, the insurer issuing the HDHP would be responsible for assigning a primary care physician or nurse to the patient.
The California health care marketplace has instituted a similar structure and documented that there was no negative impact on premiums.
(See
(See
(See
(See
(See

9. HDHPs evolved
Primary care services include CPT codes through for new and established patient office or other outpatient evaluation and management.
Primary care, for the purposes of the legislation, is defined broadly to include the following physician specialties: General Practice; Family Medicine; Internal Medicine; Pediatric Medicine; and Geriatric Medicine.
Nurse practitioners are also eligible if allowed by state law.
STANDARD PRIMARY CARE BENEFIT IN HIGH DEDUCTIBLE HEALTH PLANS – through 99215
RECOMMENDATION
The American Academy of Family Physicians (AAFP) urges House members to cosponsor the Primary Care Patient Protection Act of 2018 (HR 5858), a bill sponsored by Reps. Elise Stefanik (R-NY) and Brad Schneider (D-IL). The bill will make it more affordable for patients with high deductible health plans to access primary care.
Background
One insurance option now available, high-deductible health plans (HDHPs), offer health care coverage with a minimum deductible and maximum out-of-pocket limit set by the Internal Revenue Service (IRS). HDHPs are growing. In 2017, almost 22 million Americans had enrolled in an HDHP, up from only one million in However, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,350 for an individual or $2,700 for a family. This out-of-pocket cost can cause patients to delay seeking care, lapse in maintenance, or adherence to medication and treatment protocols.
Family physicians are in the business of preventing sickness and managing chronic conditions, but cannot provide care if patients will not access it due to cost concerns. Unfortunately, the current trajectory of HCHP insurance coverage exacerbates this growing problem. While they are innovative structures that the AAFP supports, HDHPs can compound the cost problem, especially for low-income Americans. Among low-income individuals with diabetes, for instance, the “skin in the game” created by the HDHP structure appears to discourage appropriate use of health services. HDHPs should provide more value for the premiums families pay.
Family physicians hear about cost concerns from patients every day. Even if they have health insurance, patients are skipping care because they simply can’t afford it, and perhaps more troubling, patients are more worried about paying for care than getting sick.
About 40% of Americans report skipping a recommended medical test or treatment and 44% say they did not go to a doctor when they were sick or injured in the last year because of cost.
More people fear the bills that come with a serious illness than the illness itself (40% vs. 33%).
The Solution
Under the Stefanik-Schneider bill, individuals with a HDHP would have access to their primary care physician, or their primary care team, without cost-sharing. The company issuing the HDHP to the individual or family would be responsible for providing full coverage of primary care services for the plan year. Primary care is focused on comprehensive, continuous and coordinated care. Primary care services include primary care, prevention and wellness, and care management services (defined by a specific set of billing codes in the legislation).
Primary care, for the purposes of the legislation, is defined broadly to include the following physician specialties: General Practice; Family Medicine; Internal Medicine; Pediatric Medicine; and Geriatric Medicine. Nurse practitioners are also eligible.
Patients will designate their primary care clinician and that physician or nurse would be the site of service for this benefit for the enrollment period.
If a patient has not designated a primary care physician, the insurer issuing the HDHP would be responsible for assigning a primary care physician or nurse to the patient.
The California health care marketplace has instituted a similar structure and documented that there was no negative impact on premiums.
(See
(See
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