Today’s episode is one of the most important conversations we’ve had on My DPC Story. As of July 4th, we are standing at a true inflection point for Direct Primary Care—and for every physician, employer, broker, advocate and patient who believes primary care should be personal, accessible, and free from insurance middlemen.
In this special session, I’m joined by Jay Keese, Executive Director of the Direct Primary Care Coalition, who has spent more than a decade at the front lines in Washington, DC. Together, we break down what HR 1—the major tax bill signed into law this year—actually means for DPC. This includes:
- The historic win: HSAs are now fully compatible with Direct Primary Care for the first time ever.
- What patients can do starting January 1: Use tax-free HSA dollars to pay for DPC memberships without losing HSA eligibility.
- How this changes the landscape: New opportunities with employers, brokers, high-deductible plans, and even ACA bronze/catastrophic plans.
- What stays the same, what’s evolving, and what rulemaking from the IRS will finalize.
- What’s coming next: How DPC can scale responsibly and sustainably as demand accelerates.
If you’ve ever wondered how policy actually becomes reality—or what the future of DPC looks like on a national scale—you’ll want to listen closely. This episode is equal parts celebration, clarification, and a roadmap for what comes next.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Today's episode is a veryimportant conversation.
As of July 4th, we are standingat a true inflection point for
direct primary care, and everyphysician, employer, broker,
patient and advocate whobelieves primary care should be
personal, accessible, and freefrom insurance, middlemen is
gonna wanna tune in.
In this special session, I'mjoined by Jay Keese, executive
director of the Direct PrimaryCare Coalition, who has spent
(00:22):
more than a decade at the frontlines in Washington DC fighting
specifically for DPC together webreak down what HR one, the
major tax bill signed into lawthis year actually means for
DPC.
This includes the historic winwhere HSAs are now fully
compatible with direct primarycare for the first time ever,
what patients can do startingJanuary 1st, specifically using
(00:43):
tax-free HSA dollars to pay forDPC memberships without losing
HSA eligibility.
We talk about how this changesthe landscape and how new
opportunities can be formed withemployers, brokers, high
deductible plans, and even a CAbronze catastrophic plans.
We talk about what stays thesame, what's evolving and what
rulemaking from the IRS willfinalize.
And finally, we talk aboutwhat's coming next, how DPC can
(01:05):
scale responsibly andsustainably as demand
accelerates If you've everwondered how policy actually
becomes reality or what thefuture of DPC looks like on a
national scale, you'll want tolisten closely.
This episode is equal partscelebration, clarification, and
a roadmap for what comes next.
So with that, let's dive in.
(01:28):
Direct Primary care is aninnovative alternative path to
insurance-driven healthcare.
Typically, a patient pays theirdoctor a low monthly membership
and in return builds a lastingrelationship with their doctor
and has their doctor availableat their fingertips.
Welcome to the my DPC storypodcast, where each week.
(01:50):
You will hear the ever sorelatable stories shared by
physicians who have chosen topractice medicine in their
individual communities throughthe direct primary care model.
I'm your host, Marielleconception family physician,
DPC, owner, and former fee forService.
Doctor, I hope you enjoy today'sepisode and come away feeling
inspired about the future ofpatient care direct Primary
(02:13):
care.
I'm Mariel Conception.
I'm a family doctor.
I just came from clinic and alsohost the podcast, my DPC story.
And I am super excited to bejoined by Jay Keese of the DPC
coalition who arm in arm.
We've been going to DC andtalking to policymakers to make
inroads.
And we truly have as of thisJuly 4th.
(02:35):
So I will turn the mic over toJay, and then I'm going to share
screen so that we can go throughour slide deck.
Tha thank you everybody forshowing up.
I appreciate this coming to youlive from the nation's capital.
As you can see behind me, thatis a fake background, but you
know, we're, I'm, I'm, I'mpretty close anyway it's been
it's been an interesting year.
(02:55):
It's been a while since we'vegotten together and part of the
reason is that since thebeginning of the year, obviously
I think we've been, we've beenvery busy trying to make sure
that pieces of the DPC agendaare, are, are covered and and,
and are gonna be part of thecongressional agenda.
I think we've done a fairlydecent job at that this year,
because I think you can, I thinkit's suffice to say one of the
(03:18):
top pieces of our agenda for thelast 10 years making HSAs
compatible with direct primarycare has been mission completed.
So we'll get into that in aminute.
A a little bit of housekeeping.
I don't anticipate given thebrevity of the rest of the
session that we'll be doinganything, anything else in DC
this year.
We will more than likely beforeApril have a, a virtual meeting
(03:41):
to begin to set the tone for thenext session.
But with that we can go to thenext slide and, and and, and
jump into jump into our timelinehere.
I think as everybody is aware Iworked pretty closely with this
guy on my right here namedGarrison Bliss to make sure that
we got as a part of the DPCcoalition's first body of work,
to be sure that we got adefinition of direct primary
(04:03):
care into the Affordable CareAct.
We, we were, we were successfulin that and then, then worked to
pass 34, 35 almost state lawsthat.
Sort of harmonized with the a CAprovision.
But, but, but one of the thingsthat was clear from that
definition is that the thedepartment of Health and Human
Services did accept the, the,the definition that was in the
(04:28):
state law in Washington and isin all.
The other 35 state laws as DPCbeing a medical service offered
outside of an, of, of, ofinsurance regulation.
And treated it as such the onearea of federal regulations that
did not, however, was the taxcode.
And, and as Marielle pointed outin HR one which has been
(04:50):
referred to by a, a lot of, lotof titles the big beautiful Bill
was the official name of thebill.
But it was a series of majorhealth tax incentives.
And I wanna go over not only theprovision that addresses DPC,
but two other provisions thatcould work in combination with
DPC.
And we'll have some time to,talk a little bit about how
(05:13):
these three provisions, two ofthem in particular, are gonna
work together and, andpotentially maybe um, in a
position to change the way weget our health benefits in the
long run for the better.
And I do wanna make sure that weleave at least half of our
allotted hour open forquestions.
So, we will take q and a afterthis is over.
(05:34):
I'm think Muriel, we can do thatas live q and a.
And I think there's also a chatoption as well.
I see Muriel nodding, so, thatshould be good.
But I really wanna have an opendialogue and make sure we answer
all of your questions.
So I guess we'll start with therationale behind the primary
Care Enhancement Act, which was,you know, this bipartisan bill
that we was this rock.
(05:54):
We've been pushing up the hillfor well over a decade with
very, very bipartisan support.
We had Bill Cassidy, who is thea, a Republican physician from
Louisiana.
As our primary sponsor of thebill, he's chairman of the
Senate Health Committee that hada lot to say about what was
going into the legislation thatwent into hr, HR one, the, the
(06:15):
tax bill.
And we had, you know, EarlBlumenau, who missed that
deadline by a few months, wasretired before the end of the
year, but was one of the mostsort of liberal democrats.
So we had a conservativeRepublican, a liberal democrat
who worked hard on thislegislation.
Representative Jason Smith fromMissouri, who chaired the house
(06:37):
Ways and means committeerepresentative, lloyd Smucker,
who's a subcommittee chair onthat committee as well, backed
this so did Kim Schreyer fromWashington State democratic
physician, but we had, weliterally had support from all
over the place and took us awhile to get it.
But the, the, the IRSdefinitions of, of who is
(06:57):
eligible to fund an HSA sort ofdid not include DPC because
those, those rules that were setback in 2003 in the Medicare
Modernization Act said that ifyou had a health savings
account, that it had to bepaired with a high deductible
health plan, and that you couldnot have another health plan or.
(07:18):
Other coverage which which,which, which provided things
that were, even if they wereonly marginally covered things
that were covered in the highdeductible health plan.
Since high deductible, healthplans have to, to some degree
cover, cover using an air quotesprimary care direct primary care
agreements, even though they hadbeen been defined by the
(07:40):
Affordable Care Act and 35 Statelaws was considered by the IRS,
some form of other coverage thatcomes in between an individual
and that high deductible healthplan when funding that HSA.
What HR one did it is adoptedthe language from the Primary
(08:01):
Care Enhancement Act that saysas long as you have a direct
primary care agreement that'saffordable and less than$150 per
month, per individual per month,with a maximum of$300 per month
that these, these funds can beused first and foremost to, to
(08:22):
take out of your HSA and bespent on a direct primary care
agreement.
And it also, perhaps even moreimportantly says that if you
have a direct, primary careagreement, you are no longer.
As you were before January oneof this year, as of January one
of this year, you will no longerbe ineligible to fund the HSA
(08:46):
because of the simple act of youhaving that agreement with the,
with the primary care doctor.
So these are two reallybreakthrough concepts.
Number one, that, you know,simply having a DPC agreement
does not make you ineligible tofund your HSA and number two,
that you can take money outtathat HSA, it's triple tax
(09:08):
preferred money.
You can, you can, it, it, it isnot, tax is not collected on
that money when it goes into theHSA.
It is not collected on thatmoney while it is sitting in the
HHSA.
And then when you take it outand use it on direct primary
care, it will not be taxed andyou will also not be prohibited
by IRS law from having an HSA.
(09:31):
So obviously this is a major,major breakthrough for us to be
able to work with highdeductible health plans with
HSAs, which now represent morethan two thirds of all
employer-based health plans thatare offered.
So imagine you going intobusiness and direct primary
care, looking at the privatemarket and insurance and saying,
(09:51):
well, two thirds of the peoplethat are covered by employer
based coverage, which is morethan half of all the coverage
that's offered in America,you're not gonna be eligible to
work with DPC so that thatceiling has been taken care of.
And now if you have an HSA,you're able to safely use your
your, your HSA funds to spendthat on the monthly fees for
(10:12):
DPC.
You're also able to continue tocontribute to that HSA year in
and year out, the maximum levelof contributions every year
while you have a DPCarrangement.
There were two other provisionsin the act in hr, one that were
added as well.
In addition to the primary CareEnhancement Act, one treated
telehealth arrangements in asimilar way that number one
(10:37):
wouldn't be, wouldn't be treatedas something that prohibits you
from.
From funding an HSA, and then ofcourse, dollars could be taken
out to pay for telehealtharrangements.
Most of these are offered byemployers.
So all of these things, andpresumably DPC agreements too,
by virtue of where they're putin the tax code, would also
potentially in a plan that isbundled together with DPC or
(11:00):
with telehealth these would comebefore the deductible.
So potentially in a highdeductible health plan depending
on the way the rules come out,not only is the DPC agreement
and the telehealth agreementable to be used with the HSA if
it's, if it's bundled in with anHSA agreement and a, and a
health and a high deductiblehealth plan it would, it would
(11:21):
naturally, as primary careexpenditures come before that
deductible.
So a$6,000 deductible if youspend a thousand dollars over
the course of the year onprimary care basically becomes a
$5,000 deductible.
In addition to that, anotherprovision that I want to talk
about, which, you know, reallycould be groundbreaking,
particularly as we're in thedialogue that we are in right
(11:42):
now in Washington aboutextending the a CA premium tax
credits for another year or twoand potentially making some
changes in there.
I'll get to those in a minute.
The, the HR one also had aprovision that says that.
HSAs would now be compatiblewith high deductible health
plans offered in bronze levelplans and catastrophic plans in
(12:05):
the exchanges.
So imagine a world in whichthere was a bronze level or a
catastrophic plan offered in ana CA Obamacare exchange that
worked together with a DPCagreement where you could take
your dp, your, your, your HSAmoney that you know whatever the
employer or you are putting intothe HSA and spend it on DPC.
(12:26):
Another potential new growtharea for DPC is working with
both the payers and theindividuals who own these bronze
level plans.
So, you know, really it's kindof on the DPC movement now to
get out there and execute andand to begin to work with these
individuals that are in theAffordable Care Act.
(12:46):
Exchanges.
I am one of those individuals.
So it's gonna be interesting tosee how this plays out for
years, truly.
And me and my wife, at least forthe next few months before I get
into Medicare.
And you can see with my, my, my,my, my Medicare credentials
right here.
You know, I think it's gonna bevery interesting to see how this
plays out.
But suffice to say between theemployer markets, two thirds of
(13:07):
which now offer HSA highdeductible plans and the bronze
and catastrophic level exchangeplans, there is a big new market
out there for HSA, highdeductible plans and DBC.
So I am gonna stop talking.
I've given you sort of myoverarching view of, of where we
are at this minute.
I do wanna talk about the IRSand the rulemaking process,
(13:31):
which we are undergoing rightnow.
But I'd be happy to answer anyquestions'cause I'm sure there's
lots of questions about how dothese work timelines.
Whatever, whatever you have outthere you wanna know more about
the story about how we got here,I'm happy to talk about that as
well.
But let's let's open the let'sopen the field up Mariel for
some questions.
Yep.
So, just as a reminder, Jayalready mentioned he's going to
(13:53):
be speaking at Hint Summit.
It's gonna happen April 8th inNashville, Tennessee.
You can go to summit.hint.com toregister for that.
And Go ahead.
Jeff Turner.
Jeffrey Turner.
Yep, go ahead.
First of all, I just want to saythank you for the, the hard work
that you guys have put in and inmoving this forward.
I know that it, it's taken a lotof effort, time, and just, you
(14:16):
know, people in general.
So I am actually not aphysician.
I am a health insurance broker.
And I'm in Northern California,which is predominantly an HMO
market.
And we have very few DPC doctorsin this area as of right now.
But I have connected with acouple of'em and we've been
(14:37):
discussing how we can bring thisto the masses here, if you will.
So I'm very excited about thisbecause I think it's gonna give
those of us that are in myindustry that truly are
interested in making changes andimpacting the healthcare system,
that this is gonna really giveus another arrow in the quiver,
if you will, to, to pro to movethat forward.
(15:00):
So my question to you, Jay, iskind of twofold in terms of, of
my industry as a whole and thenthe carriers.
Where do you see that this goingin, in, in that regard?
And let maybe the carriers, arethey gonna kind of get on board
with this?
Yeah, good question.
Well, I was just recently inAustin, Texas.
I was invited there by the TexasAssociation of Health Plans to
(15:23):
come and sit on a panel to talkabout this.
And I will tell you, I thinkbecause there is a large market
of DPC in Texas unlike sort ofNorthern California where there,
you know, mariel's up there, butmaybe not too many other
practices.
But I think if you look at themap Phil SKU's mapper Texas has
a lot of dots on it.
(15:43):
So they are already familiarwith this.
Employers in Texas are reallyclamoring to do this, so there's
a lot of attention around it.
And I would say the and by theway, the American Association of
Health Plans ahip did supportthis bill.
So writ large, the NationalGroup of Health insurers
supported the concept of DPCbeing compatible with H dps, of
(16:08):
which they sell a lot.
And and, and so I, I, I don'treally look at insurers as the
adversary, sort of the way wesaw them in the state
legislatures when we were tryingto get the state laws to define
direct primary care as a medicalservice outside of insurance
regulation.
(16:29):
Because, you know, in thatcircumstance, the insurers were
very comfortable with theirstate regulators, most of whom
used to work for them.
And, and it was a, it was a, abrave new world.
DPC has been around a while.
It's a known quantity.
Insurers in Medicare Advantageare trying to do DPC or DPC,
like things and I don't expectthe pushback that we got over
(16:54):
the course of the last decadefrom big insurance the way we
have had it.
Now, I don't have a greatcrystal ball about what things
are gonna look like here in ayear.
Obviously, this ruling, sincethe rules are not out yet, has
come too late for this comingplan year.
But I would say this brokers orDPC practices that want to be
(17:19):
either a part of a, a privateinsurance arrangement with
employers, whether that's a.
Being bundled into A DPC, youknow, PPO or, or, or HDHP plan,
or it's just makingrelationships with the payers so
they know they're out there forthese HSA plans to be able to
(17:41):
use those.
I think it's a good time tostart exploring those
relationships, thosepossibilities.
And please just, you know, docsgo look at this as a new market
and not as the adversary asyou've looked at the insurance
industry in years gone by.
They're gonna, Jeff, I think youprobably more than anybody can
(18:03):
tell them they're gonna try to,you know, screw you.
No question about it.
They're gonna try to nail you tothe wall on price and things.
If you're deal, if you'redancing with the devil, know who
you're dancing with.
But the reality is.
These insurers are looking forthings to create more value and
there is nothing out there rightnow in the health plan market
(18:27):
that I believe can create morevalue than bolting on DPC in
some fashion.
Now, this law allows us to lookat two different perspective
models.
We've talked about bundling intoa plan, and you know, Jeff, for
you that might be like the idealsituation'cause you can use your
services to get involved and andhelp create some of those.
(18:51):
But it also envisions a world inwhich an employer can put.
$60 a month into your HSA andallow you to go out there and
pick whoever your DPC doctor is,which I think you know, let me
see.
Just in the visual show ofhands, who would like that idea
here?
Right?
Who among our docs here wouldlike that idea?
Can I see hands raising?
(19:11):
I would like that idea.
I think there's going to be alot of excitement around, around
that concept.
But to be honest with you, Ithink that employers are
probably looking for people to.
Join into their ecosystem asthey know it.
So I would urge everybody tolook at both of these kind of
(19:31):
options.
And I would say both.
There's gonna be a thousandflowers sort of blooming from
this, but look at the optionsthat are gonna be on the table.
It's gonna require a dialogue.
It's gonna require you know, we,we do not have a unified
national health system.
So this is gonna be state bystate, locality by locality,
employer by employer.
That's the way it works.
But you know, folks like theHealth Rosetta Group and, and
(19:55):
you know, the, the brokers likeJeff, who are interested in DPC,
have been good allies in this.
The National Association of LifeUnderwriters, which is now
called nabi, was a major ally insupporter of this bill.
They joined Boeing and theemployers, people like the
Chamber of Commerce, theNational Association of
Manufacturers, the ERISAIndustry Committee.
You know, we had employers,Boeing, Amazon, major employers
(20:18):
down to small employers, NFIB,and the local gas stations and
flower shops.
Everybody supported getting thison board to give more options
into what, what is anincreasingly you know, skinny
environment in in, in, in thehealth plan world.
So, long-winded answer, but I, Ithink there's a great
opportunity here for both DPCand, and insurers to offer
(20:40):
individuals a benefit thatreally brings a lot of value.
Fantastic.
We have another question fromDr.
Duffy, but I will say before weget to that question this is an,
an important time also for ifyou are wanting to get involved
and make sure that we mold thefuture of where Direct Primary
Care is going.
The the best way is to go to DCand talk with your policymakers.
And dp care.org is where you goto sign up for becoming a, a
(21:04):
part of the DPC coalition.
It's not just physicians, it'salso policymakers patients,
people who are advocates forDPC.
So, Dr.
Duffy is asking, how do weconvince the patient that HSA is
okay to use and that the fundscount towards their deductible?
Is there a form that is needed?
How do they submit the expensereceipt to have it count
annually?
So a couple of weeks ago we tooka group of, of our allies in the
(21:28):
employer world and the bankersand others into a meeting with
the IRS.
The IRS is going to the IRS isgoing to do a, a guidance on
this.
So if you, if you, if you go tothe Internal Revenue
Commission's the, the internalRevenue Services website, you
will see pages and pages andpages of guidance on, on, on on
(21:48):
tax issues.
This is going to be issued morethan likely, not as a, as a, as
an administrative, a fulladministrative rulemaking, but
as a guidance.
So the IRS will on someday inthe near future, hopefully
nearer sooner rather than later.
Publish.
Exactly their guidance on howthis works.
So I think it's gonna be verysimple.
(22:09):
You will, will have a, a link orperhaps even a something can
print out and put at, at yourclinic that will show people
exactly you know, the, the, thefacts that the IRS approves of
this now.
And you'll have a good sourcethere that's not just you, you
know, you or the coalition, butit, it'll be the IRS.
We had a good meeting with theIRS.
(22:30):
I don't think there's going tobe many surprises in this.
There's one, there's actuallytwo areas that we're working
with them on, and we we're alittle uncertain about exactly
how they're gonna rule.
But I have no doubt that as ofJanuary one there, there will be
some kind of guidance from IRSbefore then that will say, you
know, how, and, and the factthat it is you are eligible with
(22:53):
an HSA now to have a DPCagreement and that you can use
those funds towards your, your,your, your DPC there, there are
some conditions, again, thesehave to be affordable
agreements, less than$150.
PMPM.
They can't bundle.
Pharmaceuticals or labs thataren't traditionally covered in
a, in a primary care setting ininto the agreement.
(23:16):
And, and the, the servicesbasically have to be for primary
care only.
So, you know, you can't offerprimary care and you know, hey,
we're gonna get you we'll dogeneral surgery too.
Things that would requireanesthesia.
You know, there's certain rulesaround it that the IRS is going
to be, I think, pretty p prettyspecific in their guidance that
will say, these are the thingsthat count, these are the things
(23:37):
that don't.
But we have no doubt that mostpeople's agreements would be
able to fall into this.
I see.
Phil Escu is on the line too.
He may wanna comment on this alittle bit, but.
My, my, you know, we mightanticipate that some people
might have to make some discretechanges in their, in their
agreements potentially, but,but, but more than likely not.
(23:59):
So, so Phil, I don't knowwhether you had any comment,
commentary on that or anythingelse.
I've, I've said before we go toanother question, but I, I think
that this, this comes in theenforcement and legal side and,
and, and Phil's a great sourcefor that.
So I, I agree with yourinterpretation, Jay.
There, there you can make somesmall changes to try to fit in
there, but ultimately theydidn't have, they really didn't
(24:19):
say what had to be in orexcluded from the monthly fee.
You're still allowed, you know,most people don't charge for an
EKG, we include that, butthere's nothing that says you
couldn't itemize certain things.
And in fact, they're encouragingyou to itemize some labs and
meds, which was already done bymany state insurance
commissioners anyway, thatdidn't like you bundling those
in and subjecting yourself toprice risk that that would
(24:40):
change.
(25:16):
Yeah, the legislation doesactually for a definition of
primary care.
It doesn't look to a range ofCPT codes or, or, or, or any,
any site in the law.
It actually looks to I believeit's 1833 x of the Social
Security Act that describes forthe purposes of Medicare, what a
(25:37):
primary care doctor does.
So basically it says if you areoffering the services that an
offer, that a primary caredoctor who follows Medicare
offers, then you're good.
Our next question is from Dr.
Tipton, can you review some ofthe main decisions slash
strategies that will be in therulemaking process for the HSA
eligible funds to DPC?
(25:57):
So, it's dovetailing off of whatyou just spoke of, but don't
know if you have anything moreto add.
I don't work for the IRS, so Ican't probably reveal any of
that'cause I don't know.
I will say that we had a veryfruitful and polite and good
meeting.
They asked questions that seemedlogical to ask, like.
What is it that you all do, youknow, for a monthly fee?
(26:20):
And they, they asked a lot ofquestions around
pharmaceuticals, around theprice of pharmaceuticals and
what did you charge?
Did you charge anything special?
You know, and we, we, we toldthem, you know, that as far as
pharmaceuticals are concernedabout.
Three quarters of DPC docsdispense pharmaceuticals, but
they're sold separately on acash pay basis is the normal
(26:41):
course of action.
So they didn't seem to see, Imean, that's not all that
different than Mark Cuban orcost Plus or any of that stuff.
So the, there were not a ton ofquestions.
We had been talking to the IRSfor a decade and a half about
this.
The team that we've been talkingto all of these years perhaps
(27:01):
surprisingly or unsurprisingly,is still there.
So, the, the lead, the leadperson on this is the first
person we talked about this,this, this inequity back in
2011.
So we're, we feel good aboutwhere we are, we'll see exactly
what the IRS says in a matterof, I would suspect a matter of
days.
So next, Dr.
Canarium has a question.
(27:22):
Will FSA be treated the same wayas HSA and then Dr.
Chaco, I'll call on you next?
No, FSAs are treated differentlyin the tax code than, than than,
than HSAs and FSA at the end ofthe year has to be turned back
into the gu, into the, into the,into the, into the employer.
So, but there was never arestriction on using you know,
(27:44):
on, on having an a, an HSA,excuse me, an FSA with DPC.
And you know, I think that thethe, the.
2019 ruling out of thetransparency executive order in
the last Trump administration,if it hadn't been clear before,
made it pretty clear that DPCservices, as long as they were
(28:06):
all primary care services, werequalified medical expenses.
So no hangup using an FSA or anHRA health reimbursement
arrangement with your DPC beforethis or after a no change,
basically.
Okay.
Go ahead, Dr.
Chaco.
Regarding pricing and how therule is written, the 150 a
month.
I know there's several questionsin the chat.
What do you do if your pricingis above one 50?
(28:28):
That is not my question.
My question is let's assume themembership is gonna show up on
the invoice.
Primary care, direct primarycare, one 50 a month.
Can you still bill it annually?
Can you bill it?
Is it okay to bill that one 50per month upfront?
Annually?
Because we do that for year one.
Patients are good with that.
We're good with that.
We are aligned with the one 50 amonth.
But I just, I, we looked at therule.
I talked to people at Hint, theysaid there's nothing in there to
(28:50):
say otherwise.
I just wanna get your opinion onthat.
It's a good question.
We have not we did not bringthat up with the IRS that I'm
not, if not, I'm not mistaken.
That's a, that's an unusualpractice.
It's a practice that's much moreakin to a concierge fee for
non-covered service practice.
The I think the language saysperiodic fee and, you know, I, I
(29:12):
think a year is a period.
Yeah, I know there are statesthat are different.
Like Washington State has adifferent rule.
I'm in Florida.
We don't have that rule.
We do it that way just becauseclinically we believe it's most
aligned.
Like, I want you the whole firstyear before, you know, but
anyway, so, so we're just gonnalabel it like one 50 per month,
direct primary care membershipand bill it.
But like, that's a question thatI would love to like, I don't
(29:34):
know, hopefully not get screwedon.
Well, here's, here's the goodthing about guidance.
Guidance is sort of like, livinglaw, right?
So when the IRS publishes aguidance, it's never final.
It isn't a notice of final rule.
It isn't, it isn't, you know,we've made, we've proclaimed
from on high.
It's like this is the IRS's viewof this in a snapshot in time.
(29:55):
So if there is pushback to that,which I, I think there's lots of
ways that you could do yourbilling where there wouldn't be
any pushback.
Then, right.
Then the worst thing thathappens in that situation, is
that you would ask the IRSAquestion of whether or not this
is okay.
And they will get you an answerand I would rather not ask.
Right.
But, and I was about to say,never ask the IRS or anything,
(30:18):
you don't know what the answerto the question's gonna be.
So, and, and also just toclarify, given all the great
data on virtual primary carebeing still sort of acceptable,
this will apply to a directprimary care virtual
relationship.
Correct.
It applies to a, a, a telehealthagreement, whether it's direct,
primary care or not.
So, but it certainly applies totelehealth in a virtual
agreement for direct primarycare services.
(30:40):
As long as those services areall primary care.
Excellent.
Thank you so much.
And if anyone ever hearsotherwise, somehow I'll
hopefully find out.
No, I think, I think you'regonna be okay.
Again, Phil, unless you have anydifference of opinion.
I, I think the, the legislativelanguage cer certainly allows
for it.
And if we did get into a, ashoving match with IRS about it,
(31:01):
we could certainly have membersof Congress who wrote the bill
do some oversight and tell theIRS Hey, that's not, that wasn't
our understanding of the, of thelegislative history of the
language.
So I, I got it.
I don't put this on a DEFCONfour scale right now.
I think you're gonna, I thinkyou're gonna be fine.
I'll be fine.
And I know, and last thing I'llsay, I know that there is a
difference between the DPC worldand the concierge world, but
(31:22):
this is very much based upon aone 50 a month membership fee
fee.
Yeah.
And that number isn't, is not bymistake.
If you look at what M-D-V-I-Pcharges for an annual agreement,
that's the baseline.
So, you know, I think there wassome thought behind that.
We didn't ask for that, by theway.
It was put in there to, to, totemper the, the, the high score
of the bill and the score is,you know, what, what the bill
(31:44):
would cost in, in, in lost rerevenue to the treasury and,
and, and, and look people, thisis a$2.8 billion tax cut that
was given to the American peopleto allow them to spend that
money on you.
So this is a pretty good deal.
So I would say this, if you arecharging more than 150 a month,
(32:06):
you're probably well above thenorm and that's fine, but.
You are, you are gonna beoperating under current rules.
There is no change for you.
In other words, if you areoperating like this before,
you're gonna be able to operatelike, like that afterwards at
$150 a month.
You just simply won't becompatible with an HSA high
deductible health plan, anindividual that has an HSA high
(32:28):
deductible health plan and yourdecision is, do I lower my price
(33:01):
or do I not offer it to peoplethat have HSAs?
I don't see a problem with this.
At the federal level, they nevermade a stink about exactly what
the frequency of periodic neededto be.
Lots of states do, and so you,you're gonna, you're gonna find
yourself with an escrow burden.
And if you try to enforce thosekinds of things and say certain
things are non-refundable,you'll also find yourself
(33:23):
burdened with board complaints.
So it's generally something Idiscourage for a variety of
reasons, but in the specifics ofthis tax discussion, I don't
think it's gonna make a bigdeal.
Thank you for that.
The next question is from KaiIda.
So if our membership is$200 amonth, can patients still use
$150 a month from their HSA and$50 a month out of pocket?
(33:45):
No.
Next question is Dr.
Valla, excuse me if I butcheredyour name.
If our DPC fees are above 150then is our clinic ineligible or
can patients pay partially withHSA?
Same question.
No, it's pretty clear, folks,you, you to qualify for the
exception.
To qualify to be part of this$2.8 billion tax cut that was
(34:07):
given the American people, youhave to charge less than$150 a
month.
It was designed for affordable.
It says affordable directprimary care agreements right in
the language.
So, the Congress is determinedfor the purposes of HSAs only.
What, what, what that means.
You can charge whatever you wantto somebody that doesn't have an
HSA, but if you want to besubject to these new rules, you,
(34:30):
you know, that that fee has tobe less than$150 a month.
The next question is from Dr.
Canarium.
Does the bill clarify who can doquote unquote primary care?
IE can a naturopath beconsidered a primary care and do
DPC as well?
That is still gonna becompletely up to state law.
The Medicare title does havesome things to say about it, but
it is that we can get, we canget you the site there.
(34:53):
I believe it's it's part of theSocial Security Act on, on who
is a primary care provider.
So me, Medicare has somethoughts about that, but and,
and I, I, I do, I do think that,that the IRS will probably weigh
in verbally on, on, on what theyare and, and, and, and, and
itemize those.
But if, if you are eligible tobill for primary care services
under Medicare, whether you're aMedicare participating provider
(35:16):
or not, if you would beeligible, you would, you would
be in this.
And I don't know what, I don't,I don't are naturopaths in that.
I know they are h where theyhave, where they have
prescribing rights.
Arizona comes clear on that yet.
Money?
Yeah.
Okay.
Yeah.
Next.
We'll I mean, you know, this wasdesigned to not be a scope
issue.
So we, we we purposely didn'twant go down that path for lots
(35:39):
of reasons.
Number one, we would've neverpassed a bill.
Num number two again, it is astate by state thing, so by and
large, the federal governmentlets the states do their own
things with regard to you know,licensure and the business of
healthcare for, to the state.
So you're gonna really belooking to your own state to,
to, to what, to what that is.
But I think you guys, it's safeto say the do and the MD crowd
(36:01):
here has a leg up on everybodyin this market.
And again, especially if youhave more questions, this is
where joining the DPC Coalitionis a great place to ask these
questions, especially becausethe DPC coalition is on the
forefront the next question isfrom Greg Miller.
If I sign up a family of eightpeople, can I charge more than
$300 by using h?
(36:21):
No.
It's it's, it's$150 or 300 for amulti multifamily agreement, and
I realize that that.
Is, is, is is difficult for for,for some folks here.
I think there's probablyworkarounds to this by having
separate agreements for the kidsand stuff, but there's no
(36:41):
requirement that you offer afamily agreement at all.
Yeah.
So I think you're, I think well,I think you again, we'll, we'll,
we'll see how that plays out.
I, I don't, I don't really know,I don't really know the answer
to, could you have like, youknow, six six child child
agreements and that, that sortof thing.
I, I, I also think at a certainpoint you know, the market's
(37:06):
gonna drive this.
And it's gonna drive behavior interms of what, what you're
charging if we're gonna grow newDPC practices.
I, I know my, my wife and I areat the point now and in our
practice where I'm about to goon, on on, on Medicare and, and
you know, we understand we'reutilizing more at, at 65 and
(37:29):
it's brushing up against that,you know, maybe 300 bucks.
300 bucks A-A-A-A-A month.
But but again, I think that'sstill on the high side in the
market.
That's certainly what thesurveys have said.
And and my bigger concern hereis, is this gonna, you know, is
this gonna cause the new marketbased price to be 150 bucks?
I don't think a lot of marketswill bear that because the
(37:51):
national average is now 75.
Or roughly there.
I think the, the hint hint guysdid a survey on this and we're
about to get the survey backfrom Milliman, the, the next
survey back.
Well, we should have that at theApril summit, so we'll have some
new data on that.
But but yeah, this wasn'tintended to drive price.
It might and I think if itdrives it, it'll, it'll drive it
up.
(38:11):
But you know, the reality isit's still well within market
range, and it is indexed everyyear for inflation.
That$150 and$300 are indexed tothe CPI every year for
inflation.
So that'll go up just like theHSA number goes up.
And that answered the lastquestion that just came in from
Dr.
Martin.
But when it comes to a follow-upquestion about family agreements
(38:34):
do they clarify what is afamily?
Is a physical, is it a physicalhousehold?
And if you break it up for HSAmultiple, all individuals.
Yeah.
So that answers Dr.
Karim's question, that the nextquestion is could we price
discriminate?
Could we change, could we charge$150 a month to folks with HSAs
and$200 a month to everybodyelse?
Yes, I believe that'll be fineunder the, under the rules,
(38:56):
unless the IRS, you know,freelances and says, no, you
can't.
But I, I don't, I don't, I don'tanticipate that happening.
So Jay, I was thinking what ifthe delta, you know, the
difference, the doctor saying,oh, I can't charge more than$150
using HSA dollars.
What if the employer providedHRA dollars to help offset those
(39:20):
expenses?
I think it's I think the IRS isgoing for the, for the HSA
exclusion is going to look atthe contract and the agreement,
not, not what the employer isputting into the, into the HSA.
You know, the HRA, the mainproblem with the HRA is that not
a lot of people use it.
It's a perfectly good vehicle.
And in fact, it's a, it's a,it's a natural vehicle.
(39:44):
If you wanted to put$60 a monthfor each employee into an HSA,
so they could spend it on DPC,if they wind up not spending it,
it goes back to the employer.
So there's an incentive on the,on the employee to spend it.
Both of them are good models.
I am not sure about the taxstatus of using both.
(40:05):
I don't, I don't know.
Phil might have some thoughts onthis.
I.
I don't know why, I don't knowwhy you would do it, but I
don't, I don't know that there'sa prohibition against having a
hybrid plan that puts a certainamount into an HSA and a certain
amount into an HRA.
I can't think of anybody who'sdoing both the, remember the Fs,
(40:26):
the FSA and HRA were already nota problem because they rely only
on two 13 D and all we had tofix was 2 23 C with this, right?
Mm-hmm.
Yeah.
I just, and to Jay's pointearlier, if you were, if you've
got some people that you'recharging 151 and some people
you're charging 1 49, the pointbehind the 1 49 is to give them
(40:48):
a bright line.
Clear cut.
Very conservative tax approachwhere they're making an argument
that it's not a gap plan for the1 51.
You could still do that and thepatient can decide on their own
if they wanna make a taxargument out of it in the event
they're audited.
And I still don't think theywill be because the IRS hasn't
done that in a decade.
(41:09):
And then Garrison, I thinkGarrison Bliss.
Yep.
Yeah, go ahead Garrison.
I just wanted to, to say acouple of words to the DPC
people that the demand is aboutto go up.
In a big way.
And the tendencies, this iswhere you have to start worrying
about the good news being aproblem, which is you're gonna
(41:30):
have to choose where you, whereyou wanna go, who you wanna take
care of, which, which deals youwanna take.
When it comes to dealing withyou know, plans.
Make sure that you, that, that,that you are controlling the
rules.
Don't just sign something'causethey hand it to you.
'cause that's how we got in thisproblem in the first place.
(41:52):
And the other thing that Ireally wanna make sure everybody
understands is we still takecare of our patients and don't
do something that will make ithard for you to do that.
It's gonna be tempting.
To have a panel of 800 people,it's gonna be tempting to raise
your price to the point at whicha lot of people can't afford
you.
As this demand grows, it's alsogonna be tempting to be sucked
(42:14):
into a deal with somebody who's,who is you know, venture
capitalizing us.
And who wants to make use of us.
Suck it dry as much as they can,collect as much of our money as
they can, and then wander awayand leave us with huge panels
and no way to get rid of the,the burden that we have.
So I I I, I want you to rememberthat you should still have
(42:38):
contracts for people.
It should.
And the purpose of the contract,it is to make sure that they
know what it's gonna cost.
And you know what you'repromising.
The promises are what drivethis.
This is healthcare, right?
So be, be sure that we don't gettoo much in business gear, that
we understand that we are hereto serve.
And also that if things startgetting crowded in your office,
(43:02):
get, get a partner.
Start expanding this.
We need a lot of people doingthis.
We need probably to triple theworkforce in primary care, maybe
more.
So it's time to open the doorfor everybody else.
Let them know it's safe to comenow and start having contact
with your, the medical schoolsnear you, do all the things that
(43:23):
we have to do to, we have todemonstrate that we can, we can
grow and not have our, our carediminished.
So I'm just, I, I'm encouragingeverybody to remember what that
the central drivers of primary,of direct primary care so that
we don't get sucked into greatdeals that make us a lot of
money or someone buys us out andthen, and then destroys our
(43:47):
practice.
So all of those things but I,I'm just glad we're here.
This is the place we wanted toget to, and now we have to start
thinking about how are we gonnamake this available to everybody
in the United States at areasonable price and make it
real care.
Don't, don't create a practicewhich you can't take care of.
(44:08):
Jay's got not only a thumbs upat hearts, and so yes, I love
that we're talking abouthealthcare and not insurance.
And Jay has said before, thereis a day that direct primary
care will simply be primarycare.
So with that Jay, as I wait forany less minute questions to
come into the chat can you sharewith the audience how can people
get involved if they've nevertalked to their policymakers,
(44:31):
they've never talked with aninsurance broker before?
How do people get involved?
I wanna say, I wanna thank youMarielle for moderating this
today and, and, and, and for allof your amazing advocacy in your
work.
On Capitol Hill, the, the, thebest and, and, and most
efficient way is for you to jointhe Direct Primary Care
Coalition.
The, you can go dp care.org,click the join button, join us.
(44:54):
As I said, we won't be havingany additional fly-ins this
year, but next year we will.
And lemme tell you one of thethings you've probably heard
recently, the president has madesome remarks about the idea that
instead of extending the a CApremium tax credits, maybe we
ought give that money back tothe people and put it into an
HSA so that the people can spendit the way they want.
(45:15):
I will say that we're in prettydeep negotiations with several
senators on what this might looklike.
I think the odds of this windingup in the next few days in
whatever final agreement we haveon these tax credits as a
solution are, are fairly slim.
But I will say that there isgrowing bipartisan support for
the idea that we, we, we, wecould help people afford a
(45:39):
better a CA bronze level plan,which now we can do with these
new tools that are in HR one andthat DPC will be a part of that
equation.
So, we're excited to be a partof that conversation.
We think it'll take a couple of,probably a couple of years to
get anything like that acrossthe finish line if it does get
across the finish line.
(46:01):
We're also working prettyclosely with CMS on the next
round of CMMI innovation modelsto see if we can get a model
where.
You know, maybe you can takethis HSA money and use it, you
know, use it on, on your DPC inMedicare.
So, lots of different ways toskin that cat.
Don't wanna get into too many,too many details today, but if
(46:22):
you wanna be a part of theconversation moving forward with
your colleagues in the industry,we work by consensus.
Join the coalition and, and, andcome and join us.
And uh, you know, any, anybodythat needs any specific help
with a legislator, feel free toreach out to me directly.
Feel free to reach out toMaryelle, who works pretty
(46:43):
closely with us on the advocacyside of this.
And we'll, we'll make sure youhave you know, as a member of
the DPC coalition, access to anyof the information you need to
to help, to help with that.
And it really doesn't, it's notlimited to just, you know, what
do I say to a person?
For example, in California, wedon't have law that protects DPC
(47:04):
as of this di this recording.
But, you know, I had somefrustrations around my husband
getting eliminated and ourpatients in our area no longer
having access to an insuranceaccepting doctor that offered
full scope care.
And that is what I call Jayabout.
So literally, if there's anyfrustrations that you're having
about, this is so messed up thatthis is happening in our
community and you don't evenknow who to talk to.
(47:26):
DP care.org is where you go.
Well, I wanna thank you all forbeing such strong supporters.
This was a long journey.
You know, you know, theChancellor of Germany, Otto, of
on Bismarck once said one wholikes fine sausage or
legislation should watch neitherbeing made.
I think this is a perfectexample of that.
It took us well over a decade toget this done, but it's good.
(47:48):
We've done good things for theAmerican people.
We've, we've, we've said to theAmerican people, we want your
health benefits to be better.
And we want them to include yourability to choose the doctor of
your choice and pay'em outtayour own money that your
employer's putting into your HSAor you're putting into your HSA.
And I think that's a really goodfoundation from which we can
(48:08):
build and grow.
And you know what everybodysays, world domination for DPC,
right?
Amazing.
Thank you everybody for joiningtoday.
Thank you so much, Dr.
Bliss, and for Jay.
Thank you both for your work andgetting us to this point.
Thanks for tuning in to My DPCStory.
If this episode inspired you,please leave a five star review
(48:29):
on Apple Podcasts.
It helps more physicians findthese stories when they need
them the most.
If you're new to DPC, you'rejust beginning your journey.
Head to the Start Here age@mydpcstory.com.
I've put together a practicalstartup guide and highlighted
the episodes I think areessential for beginners.
Got a question or a challengeyou want to hear addressed on
the show?
Go to the Contact Pagemydpcstory.com and leave me a
(48:50):
voice message.
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There's something for everyonewith both free content and a
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mydpcstory.com.
Until next time, this is MaryalConcepcion.
Today's episode is a veryimportant conversation.
As of July 4th, we are standingat a true inflection point for
direct primary care, and everyphysician, employer, broker,
patient and advocate whobelieves primary care should be
personal, accessible, and freefrom insurance, middlemen is
gonna wanna tune in.
In this special session, I'mjoined by Jay Keese, executive
director of the Direct PrimaryCare Coalition, who has spent
(00:22):
more than a decade at the frontlines in Washington DC fighting
specifically for DPC together webreak down what HR one, the
major tax bill signed into lawthis year actually means for
DPC.
This includes the historic winwhere HSAs are now fully
compatible with direct primarycare for the first time ever,
what patients can do startingJanuary 1st, specifically using
(00:43):
tax-free HSA dollars to pay forDPC memberships without losing
HSA eligibility.
We talk about how this changesthe landscape and how new
opportunities can be formed withemployers, brokers, high
deductible plans, and even a CAbronze catastrophic plans.
We talk about what stays thesame, what's evolving and what
rulemaking from the IRS willfinalize.
And finally, we talk aboutwhat's coming next, how DPC can
(01:05):
scale responsibly andsustainably as demand
accelerates If you've everwondered how policy actually
becomes reality or what thefuture of DPC looks like on a
national scale, you'll want tolisten closely.
This episode is equal partscelebration, clarification, and
a roadmap for what comes next.
So with that, let's dive in.
(01:28):
Direct Primary care is aninnovative alternative path to
insurance-driven healthcare.
Typically, a patient pays theirdoctor a low monthly membership
and in return builds a lastingrelationship with their doctor
and has their doctor availableat their fingertips.
Welcome to the my DPC storypodcast, where each week.
(01:50):
You will hear the ever sorelatable stories shared by
physicians who have chosen topractice medicine in their
individual communities throughthe direct primary care model.
I'm your host, Marielleconception family physician,
DPC, owner, and former fee forService.
Doctor, I hope you enjoy today'sepisode and come away feeling
inspired about the future ofpatient care direct Primary
(02:13):
care.
I'm Mariel Conception.
I'm a family doctor.
I just came from clinic and alsohost the podcast, my DPC story.
And I am super excited to bejoined by Jay Keese of the DPC
coalition who arm in arm.
We've been going to DC andtalking to policymakers to make
inroads.
And we truly have as of thisJuly 4th.
(02:35):
So I will turn the mic over toJay, and then I'm going to share
screen so that we can go throughour slide deck.
Tha thank you everybody forshowing up.
I appreciate this coming to youlive from the nation's capital.
As you can see behind me, thatis a fake background, but you
know, we're, I'm, I'm, I'mpretty close anyway it's been
it's been an interesting year.
(02:55):
It's been a while since we'vegotten together and part of the
reason is that since thebeginning of the year, obviously
I think we've been, we've beenvery busy trying to make sure
that pieces of the DPC agendaare, are, are covered and and,
and are gonna be part of thecongressional agenda.
I think we've done a fairlydecent job at that this year,
because I think you can, I thinkit's suffice to say one of the
(03:18):
top pieces of our agenda for thelast 10 years making HSAs
compatible with direct primarycare has been mission completed.
So we'll get into that in aminute.
A a little bit of housekeeping.
I don't anticipate given thebrevity of the rest of the
session that we'll be doinganything, anything else in DC
this year.
We will more than likely beforeApril have a, a virtual meeting
(03:41):
to begin to set the tone for thenext session.
But with that we can go to thenext slide and, and and, and
jump into jump into our timelinehere.
I think as everybody is aware Iworked pretty closely with this
guy on my right here namedGarrison Bliss to make sure that
we got as a part of the DPCcoalition's first body of work,
to be sure that we got adefinition of direct primary
(04:03):
care into the Affordable CareAct.
We, we were, we were successfulin that and then, then worked to
pass 34, 35 almost state lawsthat.
Sort of harmonized with the a CAprovision.
But, but, but one of the thingsthat was clear from that
definition is that the thedepartment of Health and Human
Services did accept the, the,the definition that was in the
(04:28):
state law in Washington and isin all.
The other 35 state laws as DPCbeing a medical service offered
outside of an, of, of, ofinsurance regulation.
And treated it as such the onearea of federal regulations that
did not, however, was the taxcode.
And, and as Marielle pointed outin HR one which has been
(04:50):
referred to by a, a lot of, lotof titles the big beautiful Bill
was the official name of thebill.
But it was a series of majorhealth tax incentives.
And I wanna go over not only theprovision that addresses DPC,
but two other provisions thatcould work in combination with
DPC.
And we'll have some time to,talk a little bit about how
(05:13):
these three provisions, two ofthem in particular, are gonna
work together and, andpotentially maybe um, in a
position to change the way weget our health benefits in the
long run for the better.
And I do wanna make sure that weleave at least half of our
allotted hour open forquestions.
So, we will take q and a afterthis is over.
(05:34):
I'm think Muriel, we can do thatas live q and a.
And I think there's also a chatoption as well.
I see Muriel nodding, so, thatshould be good.
But I really wanna have an opendialogue and make sure we answer
all of your questions.
So I guess we'll start with therationale behind the primary
Care Enhancement Act, which was,you know, this bipartisan bill
that we was this rock.
(05:54):
We've been pushing up the hillfor well over a decade with
very, very bipartisan support.
We had Bill Cassidy, who is thea, a Republican physician from
Louisiana.
As our primary sponsor of thebill, he's chairman of the
Senate Health Committee that hada lot to say about what was
going into the legislation thatwent into hr, HR one, the, the
(06:15):
tax bill.
And we had, you know, EarlBlumenau, who missed that
deadline by a few months, wasretired before the end of the
year, but was one of the mostsort of liberal democrats.
So we had a conservativeRepublican, a liberal democrat
who worked hard on thislegislation.
Representative Jason Smith fromMissouri, who chaired the house
(06:37):
Ways and means committeerepresentative, lloyd Smucker,
who's a subcommittee chair onthat committee as well, backed
this so did Kim Schreyer fromWashington State democratic
physician, but we had, weliterally had support from all
over the place and took us awhile to get it.
But the, the, the IRSdefinitions of, of who is
(06:57):
eligible to fund an HSA sort ofdid not include DPC because
those, those rules that were setback in 2003 in the Medicare
Modernization Act said that ifyou had a health savings
account, that it had to bepaired with a high deductible
health plan, and that you couldnot have another health plan or.
(07:18):
Other coverage which which,which, which provided things
that were, even if they wereonly marginally covered things
that were covered in the highdeductible health plan.
Since high deductible, healthplans have to, to some degree
cover, cover using an air quotesprimary care direct primary care
agreements, even though they hadbeen been defined by the
(07:40):
Affordable Care Act and 35 Statelaws was considered by the IRS,
some form of other coverage thatcomes in between an individual
and that high deductible healthplan when funding that HSA.
What HR one did it is adoptedthe language from the Primary
(08:01):
Care Enhancement Act that saysas long as you have a direct
primary care agreement that'saffordable and less than$150 per
month, per individual per month,with a maximum of$300 per month
that these, these funds can beused first and foremost to, to
(08:22):
take out of your HSA and bespent on a direct primary care
agreement.
And it also, perhaps even moreimportantly says that if you
have a direct, primary careagreement, you are no longer.
As you were before January oneof this year, as of January one
of this year, you will no longerbe ineligible to fund the HSA
(08:46):
because of the simple act of youhaving that agreement with the,
with the primary care doctor.
So these are two reallybreakthrough concepts.
Number one, that, you know,simply having a DPC agreement
does not make you ineligible tofund your HSA and number two,
that you can take money outtathat HSA, it's triple tax
(09:08):
preferred money.
You can, you can, it, it, it isnot, tax is not collected on
that money when it goes into theHSA.
It is not collected on thatmoney while it is sitting in the
HHSA.
And then when you take it outand use it on direct primary
care, it will not be taxed andyou will also not be prohibited
by IRS law from having an HSA.
(09:31):
So obviously this is a major,major breakthrough for us to be
able to work with highdeductible health plans with
HSAs, which now represent morethan two thirds of all
employer-based health plans thatare offered.
So imagine you going intobusiness and direct primary
care, looking at the privatemarket and insurance and saying,
(09:51):
well, two thirds of the peoplethat are covered by employer
based coverage, which is morethan half of all the coverage
that's offered in America,you're not gonna be eligible to
work with DPC so that thatceiling has been taken care of.
And now if you have an HSA,you're able to safely use your
your, your HSA funds to spendthat on the monthly fees for
(10:12):
DPC.
You're also able to continue tocontribute to that HSA year in
and year out, the maximum levelof contributions every year
while you have a DPCarrangement.
There were two other provisionsin the act in hr, one that were
added as well.
In addition to the primary CareEnhancement Act, one treated
telehealth arrangements in asimilar way that number one
(10:37):
wouldn't be, wouldn't be treatedas something that prohibits you
from.
From funding an HSA, and then ofcourse, dollars could be taken
out to pay for telehealtharrangements.
Most of these are offered byemployers.
So all of these things, andpresumably DPC agreements too,
by virtue of where they're putin the tax code, would also
potentially in a plan that isbundled together with DPC or
(11:00):
with telehealth these would comebefore the deductible.
So potentially in a highdeductible health plan depending
on the way the rules come out,not only is the DPC agreement
and the telehealth agreementable to be used with the HSA if
it's, if it's bundled in with anHSA agreement and a, and a
health and a high deductiblehealth plan it would, it would
(11:21):
naturally, as primary careexpenditures come before that
deductible.
So a$6,000 deductible if youspend a thousand dollars over
the course of the year onprimary care basically becomes a
$5,000 deductible.
In addition to that, anotherprovision that I want to talk
about, which, you know, reallycould be groundbreaking,
particularly as we're in thedialogue that we are in right
(11:42):
now in Washington aboutextending the a CA premium tax
credits for another year or twoand potentially making some
changes in there.
I'll get to those in a minute.
The, the HR one also had aprovision that says that.
HSAs would now be compatiblewith high deductible health
plans offered in bronze levelplans and catastrophic plans in
(12:05):
the exchanges.
So imagine a world in whichthere was a bronze level or a
catastrophic plan offered in ana CA Obamacare exchange that
worked together with a DPCagreement where you could take
your dp, your, your, your HSAmoney that you know whatever the
employer or you are putting intothe HSA and spend it on DPC.
(12:26):
Another potential new growtharea for DPC is working with
both the payers and theindividuals who own these bronze
level plans.
So, you know, really it's kindof on the DPC movement now to
get out there and execute andand to begin to work with these
individuals that are in theAffordable Care Act.
(12:46):
Exchanges.
I am one of those individuals.
So it's gonna be interesting tosee how this plays out for
years, truly.
And me and my wife, at least forthe next few months before I get
into Medicare.
And you can see with my, my, my,my, my Medicare credentials
right here.
You know, I think it's gonna bevery interesting to see how this
plays out.
But suffice to say between theemployer markets, two thirds of
(13:07):
which now offer HSA highdeductible plans and the bronze
and catastrophic level exchangeplans, there is a big new market
out there for HSA, highdeductible plans and DBC.
So I am gonna stop talking.
I've given you sort of myoverarching view of, of where we
are at this minute.
I do wanna talk about the IRSand the rulemaking process,
(13:31):
which we are undergoing rightnow.
But I'd be happy to answer anyquestions'cause I'm sure there's
lots of questions about how dothese work timelines.
Whatever, whatever you have outthere you wanna know more about
the story about how we got here,I'm happy to talk about that as
well.
But let's let's open the let'sopen the field up Mariel for
some questions.
Yep.
So, just as a reminder, Jayalready mentioned he's going to
(13:53):
be speaking at Hint Summit.
It's gonna happen April 8th inNashville, Tennessee.
You can go to summit.hint.com toregister for that.
And Go ahead.
Jeff Turner.
Jeffrey Turner.
Yep, go ahead.
First of all, I just want to saythank you for the, the hard work
that you guys have put in and inmoving this forward.
I know that it, it's taken a lotof effort, time, and just, you
(14:16):
know, people in general.
So I am actually not aphysician.
I am a health insurance broker.
And I'm in Northern California,which is predominantly an HMO
market.
And we have very few DPC doctorsin this area as of right now.
But I have connected with acouple of'em and we've been
(14:37):
discussing how we can bring thisto the masses here, if you will.
So I'm very excited about thisbecause I think it's gonna give
those of us that are in myindustry that truly are
interested in making changes andimpacting the healthcare system,
that this is gonna really giveus another arrow in the quiver,
if you will, to, to pro to movethat forward.
(15:00):
So my question to you, Jay, iskind of twofold in terms of, of
my industry as a whole and thenthe carriers.
Where do you see that this goingin, in, in that regard?
And let maybe the carriers, arethey gonna kind of get on board
with this?
Yeah, good question.
Well, I was just recently inAustin, Texas.
I was invited there by the TexasAssociation of Health Plans to
(15:23):
come and sit on a panel to talkabout this.
And I will tell you, I thinkbecause there is a large market
of DPC in Texas unlike sort ofNorthern California where there,
you know, mariel's up there, butmaybe not too many other
practices.
But I think if you look at themap Phil SKU's mapper Texas has
a lot of dots on it.
(15:43):
So they are already familiarwith this.
Employers in Texas are reallyclamoring to do this, so there's
a lot of attention around it.
And I would say the and by theway, the American Association of
Health Plans ahip did supportthis bill.
So writ large, the NationalGroup of Health insurers
supported the concept of DPCbeing compatible with H dps, of
(16:08):
which they sell a lot.
And and, and so I, I, I don'treally look at insurers as the
adversary, sort of the way wesaw them in the state
legislatures when we were tryingto get the state laws to define
direct primary care as a medicalservice outside of insurance
regulation.
(16:29):
Because, you know, in thatcircumstance, the insurers were
very comfortable with theirstate regulators, most of whom
used to work for them.
And, and it was a, it was a, abrave new world.
DPC has been around a while.
It's a known quantity.
Insurers in Medicare Advantageare trying to do DPC or DPC,
like things and I don't expectthe pushback that we got over
(16:54):
the course of the last decadefrom big insurance the way we
have had it.
Now, I don't have a greatcrystal ball about what things
are gonna look like here in ayear.
Obviously, this ruling, sincethe rules are not out yet, has
come too late for this comingplan year.
But I would say this brokers orDPC practices that want to be
(17:19):
either a part of a, a privateinsurance arrangement with
employers, whether that's a.
Being bundled into A DPC, youknow, PPO or, or, or HDHP plan,
or it's just makingrelationships with the payers so
they know they're out there forthese HSA plans to be able to
(17:41):
use those.
I think it's a good time tostart exploring those
relationships, thosepossibilities.
And please just, you know, docsgo look at this as a new market
and not as the adversary asyou've looked at the insurance
industry in years gone by.
They're gonna, Jeff, I think youprobably more than anybody can
(18:03):
tell them they're gonna try to,you know, screw you.
No question about it.
They're gonna try to nail you tothe wall on price and things.
If you're deal, if you'redancing with the devil, know who
you're dancing with.
But the reality is.
These insurers are looking forthings to create more value and
there is nothing out there rightnow in the health plan market
(18:27):
that I believe can create morevalue than bolting on DPC in
some fashion.
Now, this law allows us to lookat two different perspective
models.
We've talked about bundling intoa plan, and you know, Jeff, for
you that might be like the idealsituation'cause you can use your
services to get involved and andhelp create some of those.
(18:51):
But it also envisions a world inwhich an employer can put.
$60 a month into your HSA andallow you to go out there and
pick whoever your DPC doctor is,which I think you know, let me
see.
Just in the visual show ofhands, who would like that idea
here?
Right?
Who among our docs here wouldlike that idea?
Can I see hands raising?
(19:11):
I would like that idea.
I think there's going to be alot of excitement around, around
that concept.
But to be honest with you, Ithink that employers are
probably looking for people to.
Join into their ecosystem asthey know it.
So I would urge everybody tolook at both of these kind of
(19:31):
options.
And I would say both.
There's gonna be a thousandflowers sort of blooming from
this, but look at the optionsthat are gonna be on the table.
It's gonna require a dialogue.
It's gonna require you know, we,we do not have a unified
national health system.
So this is gonna be state bystate, locality by locality,
employer by employer.
That's the way it works.
But you know, folks like theHealth Rosetta Group and, and
(19:55):
you know, the, the brokers likeJeff, who are interested in DPC,
have been good allies in this.
The National Association of LifeUnderwriters, which is now
called nabi, was a major ally insupporter of this bill.
They joined Boeing and theemployers, people like the
Chamber of Commerce, theNational Association of
Manufacturers, the ERISAIndustry Committee.
You know, we had employers,Boeing, Amazon, major employers
(20:18):
down to small employers, NFIB,and the local gas stations and
flower shops.
Everybody supported getting thison board to give more options
into what, what is anincreasingly you know, skinny
environment in in, in, in thehealth plan world.
So, long-winded answer, but I, Ithink there's a great
opportunity here for both DPCand, and insurers to offer
(20:40):
individuals a benefit thatreally brings a lot of value.
Fantastic.
We have another question fromDr.
Duffy, but I will say before weget to that question this is an,
an important time also for ifyou are wanting to get involved
and make sure that we mold thefuture of where Direct Primary
Care is going.
The the best way is to go to DCand talk with your policymakers.
And dp care.org is where you goto sign up for becoming a, a
(21:04):
part of the DPC coalition.
It's not just physicians, it'salso policymakers patients,
people who are advocates forDPC.
So, Dr.
Duffy is asking, how do weconvince the patient that HSA is
okay to use and that the fundscount towards their deductible?
Is there a form that is needed?
How do they submit the expensereceipt to have it count
annually?
So a couple of weeks ago we tooka group of, of our allies in the
(21:28):
employer world and the bankersand others into a meeting with
the IRS.
The IRS is going to the IRS isgoing to do a, a guidance on
this.
So if you, if you, if you go tothe Internal Revenue
Commission's the, the internalRevenue Services website, you
will see pages and pages andpages of guidance on, on, on on
(21:48):
tax issues.
This is going to be issued morethan likely, not as a, as a, as
an administrative, a fulladministrative rulemaking, but
as a guidance.
So the IRS will on someday inthe near future, hopefully
nearer sooner rather than later.
Publish.
Exactly their guidance on howthis works.
So I think it's gonna be verysimple.
(22:09):
You will, will have a, a link orperhaps even a something can
print out and put at, at yourclinic that will show people
exactly you know, the, the, thefacts that the IRS approves of
this now.
And you'll have a good sourcethere that's not just you, you
know, you or the coalition, butit, it'll be the IRS.
We had a good meeting with theIRS.
(22:30):
I don't think there's going tobe many surprises in this.
There's one, there's actuallytwo areas that we're working
with them on, and we we're alittle uncertain about exactly
how they're gonna rule.
But I have no doubt that as ofJanuary one there, there will be
some kind of guidance from IRSbefore then that will say, you
know, how, and, and the factthat it is you are eligible with
(22:53):
an HSA now to have a DPCagreement and that you can use
those funds towards your, your,your, your DPC there, there are
some conditions, again, thesehave to be affordable
agreements, less than$150.
PMPM.
They can't bundle.
Pharmaceuticals or labs thataren't traditionally covered in
a, in a primary care setting ininto the agreement.
(23:16):
And, and the, the servicesbasically have to be for primary
care only.
So, you know, you can't offerprimary care and you know, hey,
we're gonna get you we'll dogeneral surgery too.
Things that would requireanesthesia.
You know, there's certain rulesaround it that the IRS is going
to be, I think, pretty p prettyspecific in their guidance that
will say, these are the thingsthat count, these are the things
(23:37):
that don't.
But we have no doubt that mostpeople's agreements would be
able to fall into this.
I see.
Phil Escu is on the line too.
He may wanna comment on this alittle bit, but.
My, my, you know, we mightanticipate that some people
might have to make some discretechanges in their, in their
agreements potentially, but,but, but more than likely not.
(23:59):
So, so Phil, I don't knowwhether you had any comment,
commentary on that or anythingelse.
I've, I've said before we go toanother question, but I, I think
that this, this comes in theenforcement and legal side and,
and, and Phil's a great sourcefor that.
So I, I agree with yourinterpretation, Jay.
There, there you can make somesmall changes to try to fit in
there, but ultimately theydidn't have, they really didn't
(24:19):
say what had to be in orexcluded from the monthly fee.
You're still allowed, you know,most people don't charge for an
EKG, we include that, butthere's nothing that says you
couldn't itemize certain things.
And in fact, they're encouragingyou to itemize some labs and
meds, which was already done bymany state insurance
commissioners anyway, thatdidn't like you bundling those
in and subjecting yourself toprice risk that that would
(24:40):
change.
(25:16):
Yeah, the legislation doesactually for a definition of
primary care.
It doesn't look to a range ofCPT codes or, or, or, or any,
any site in the law.
It actually looks to I believeit's 1833 x of the Social
Security Act that describes forthe purposes of Medicare, what a
(25:37):
primary care doctor does.
So basically it says if you areoffering the services that an
offer, that a primary caredoctor who follows Medicare
offers, then you're good.
Our next question is from Dr.
Tipton, can you review some ofthe main decisions slash
strategies that will be in therulemaking process for the HSA
eligible funds to DPC?
(25:57):
So, it's dovetailing off of whatyou just spoke of, but don't
know if you have anything moreto add.
I don't work for the IRS, so Ican't probably reveal any of
that'cause I don't know.
I will say that we had a veryfruitful and polite and good
meeting.
They asked questions that seemedlogical to ask, like.
What is it that you all do, youknow, for a monthly fee?
(26:20):
And they, they asked a lot ofquestions around
pharmaceuticals, around theprice of pharmaceuticals and
what did you charge?
Did you charge anything special?
You know, and we, we, we toldthem, you know, that as far as
pharmaceuticals are concernedabout.
Three quarters of DPC docsdispense pharmaceuticals, but
they're sold separately on acash pay basis is the normal
(26:41):
course of action.
So they didn't seem to see, Imean, that's not all that
different than Mark Cuban orcost Plus or any of that stuff.
So the, there were not a ton ofquestions.
We had been talking to the IRSfor a decade and a half about
this.
The team that we've been talkingto all of these years perhaps
(27:01):
surprisingly or unsurprisingly,is still there.
So, the, the lead, the leadperson on this is the first
person we talked about this,this, this inequity back in
2011.
So we're, we feel good aboutwhere we are, we'll see exactly
what the IRS says in a matterof, I would suspect a matter of
days.
So next, Dr.
Canarium has a question.
(27:22):
Will FSA be treated the same wayas HSA and then Dr.
Chaco, I'll call on you next?
No, FSAs are treated differentlyin the tax code than, than than,
than HSAs and FSA at the end ofthe year has to be turned back
into the gu, into the, into the,into the, into the employer.
So, but there was never arestriction on using you know,
(27:44):
on, on having an a, an HSA,excuse me, an FSA with DPC.
And you know, I think that thethe, the.
2019 ruling out of thetransparency executive order in
the last Trump administration,if it hadn't been clear before,
made it pretty clear that DPCservices, as long as they were
(28:06):
all primary care services, werequalified medical expenses.
So no hangup using an FSA or anHRA health reimbursement
arrangement with your DPC beforethis or after a no change,
basically.
Okay.
Go ahead, Dr.
Chaco.
Regarding pricing and how therule is written, the 150 a
month.
I know there's several questionsin the chat.
What do you do if your pricingis above one 50?
(28:28):
That is not my question.
My question is let's assume themembership is gonna show up on
the invoice.
Primary care, direct primarycare, one 50 a month.
Can you still bill it annually?
Can you bill it?
Is it okay to bill that one 50per month upfront?
Annually?
Because we do that for year one.
Patients are good with that.
We're good with that.
We are aligned with the one 50 amonth.
But I just, I, we looked at therule.
I talked to people at Hint, theysaid there's nothing in there to
(28:50):
say otherwise.
I just wanna get your opinion onthat.
It's a good question.
We have not we did not bringthat up with the IRS that I'm
not, if not, I'm not mistaken.
That's a, that's an unusualpractice.
It's a practice that's much moreakin to a concierge fee for
non-covered service practice.
The I think the language saysperiodic fee and, you know, I, I
(29:12):
think a year is a period.
Yeah, I know there are statesthat are different.
Like Washington State has adifferent rule.
I'm in Florida.
We don't have that rule.
We do it that way just becauseclinically we believe it's most
aligned.
Like, I want you the whole firstyear before, you know, but
anyway, so, so we're just gonnalabel it like one 50 per month,
direct primary care membershipand bill it.
But like, that's a question thatI would love to like, I don't
(29:34):
know, hopefully not get screwedon.
Well, here's, here's the goodthing about guidance.
Guidance is sort of like, livinglaw, right?
So when the IRS publishes aguidance, it's never final.
It isn't a notice of final rule.
It isn't, it isn't, you know,we've made, we've proclaimed
from on high.
It's like this is the IRS's viewof this in a snapshot in time.
(29:55):
So if there is pushback to that,which I, I think there's lots of
ways that you could do yourbilling where there wouldn't be
any pushback.
Then, right.
Then the worst thing thathappens in that situation, is
that you would ask the IRSAquestion of whether or not this
is okay.
And they will get you an answerand I would rather not ask.
Right.
But, and I was about to say,never ask the IRS or anything,
(30:18):
you don't know what the answerto the question's gonna be.
So, and, and also just toclarify, given all the great
data on virtual primary carebeing still sort of acceptable,
this will apply to a directprimary care virtual
relationship.
Correct.
It applies to a, a, a telehealthagreement, whether it's direct,
primary care or not.
So, but it certainly applies totelehealth in a virtual
agreement for direct primarycare services.
(30:40):
As long as those services areall primary care.
Excellent.
Thank you so much.
And if anyone ever hearsotherwise, somehow I'll
hopefully find out.
No, I think, I think you'regonna be okay.
Again, Phil, unless you have anydifference of opinion.
I, I think the, the legislativelanguage cer certainly allows
for it.
And if we did get into a, ashoving match with IRS about it,
(31:01):
we could certainly have membersof Congress who wrote the bill
do some oversight and tell theIRS Hey, that's not, that wasn't
our understanding of the, of thelegislative history of the
language.
So I, I got it.
I don't put this on a DEFCONfour scale right now.
I think you're gonna, I thinkyou're gonna be fine.
I'll be fine.
And I know, and last thing I'llsay, I know that there is a
difference between the DPC worldand the concierge world, but
(31:22):
this is very much based upon aone 50 a month membership fee
fee.
Yeah.
And that number isn't, is not bymistake.
If you look at what M-D-V-I-Pcharges for an annual agreement,
that's the baseline.
So, you know, I think there wassome thought behind that.
We didn't ask for that, by theway.
It was put in there to, to, totemper the, the, the high score
of the bill and the score is,you know, what, what the bill
(31:44):
would cost in, in, in lost rerevenue to the treasury and,
and, and, and look people, thisis a$2.8 billion tax cut that
was given to the American peopleto allow them to spend that
money on you.
So this is a pretty good deal.
So I would say this, if you arecharging more than 150 a month,
(32:06):
you're probably well above thenorm and that's fine, but.
You are, you are gonna beoperating under current rules.
There is no change for you.
In other words, if you areoperating like this before,
you're gonna be able to operatelike, like that afterwards at
$150 a month.
You just simply won't becompatible with an HSA high
deductible health plan, anindividual that has an HSA high
(32:28):
deductible health plan and yourdecision is, do I lower my price
(33:01):
or do I not offer it to peoplethat have HSAs?
I don't see a problem with this.
At the federal level, they nevermade a stink about exactly what
the frequency of periodic neededto be.
Lots of states do, and so you,you're gonna, you're gonna find
yourself with an escrow burden.
And if you try to enforce thosekinds of things and say certain
things are non-refundable,you'll also find yourself
(33:23):
burdened with board complaints.
So it's generally something Idiscourage for a variety of
reasons, but in the specifics ofthis tax discussion, I don't
think it's gonna make a bigdeal.
Thank you for that.
The next question is from KaiIda.
So if our membership is$200 amonth, can patients still use
$150 a month from their HSA and$50 a month out of pocket?
(33:45):
No.
Next question is Dr.
Valla, excuse me if I butcheredyour name.
If our DPC fees are above 150then is our clinic ineligible or
can patients pay partially withHSA?
Same question.
No, it's pretty clear, folks,you, you to qualify for the
exception.
To qualify to be part of this$2.8 billion tax cut that was
(34:07):
given the American people, youhave to charge less than$150 a
month.
It was designed for affordable.
It says affordable directprimary care agreements right in
the language.
So, the Congress is determinedfor the purposes of HSAs only.
What, what, what that means.
You can charge whatever you wantto somebody that doesn't have an
HSA, but if you want to besubject to these new rules, you,
(34:30):
you know, that that fee has tobe less than$150 a month.
The next question is from Dr.
Canarium.
Does the bill clarify who can doquote unquote primary care?
IE can a naturopath beconsidered a primary care and do
DPC as well?
That is still gonna becompletely up to state law.
The Medicare title does havesome things to say about it, but
it is that we can get, we canget you the site there.
(34:53):
I believe it's it's part of theSocial Security Act on, on who
is a primary care provider.
So me, Medicare has somethoughts about that, but and,
and I, I, I do, I do think that,that the IRS will probably weigh
in verbally on, on, on what theyare and, and, and, and, and
itemize those.
But if, if you are eligible tobill for primary care services
under Medicare, whether you're aMedicare participating provider
(35:16):
or not, if you would beeligible, you would, you would
be in this.
And I don't know what, I don't,I don't are naturopaths in that.
I know they are h where theyhave, where they have
prescribing rights.
Arizona comes clear on that yet.
Money?
Yeah.
Okay.
Yeah.
Next.
We'll I mean, you know, this wasdesigned to not be a scope
issue.
So we, we we purposely didn'twant go down that path for lots
(35:39):
of reasons.
Number one, we would've neverpassed a bill.
Num number two again, it is astate by state thing, so by and
large, the federal governmentlets the states do their own
things with regard to you know,licensure and the business of
healthcare for, to the state.
So you're gonna really belooking to your own state to,
to, to what, to what that is.
But I think you guys, it's safeto say the do and the MD crowd
(36:01):
here has a leg up on everybodyin this market.
And again, especially if youhave more questions, this is
where joining the DPC Coalitionis a great place to ask these
questions, especially becausethe DPC coalition is on the
forefront the next question isfrom Greg Miller.
If I sign up a family of eightpeople, can I charge more than
$300 by using h?
(36:21):
No.
It's it's, it's$150 or 300 for amulti multifamily agreement, and
I realize that that.
Is, is, is is difficult for for,for some folks here.
I think there's probablyworkarounds to this by having
separate agreements for the kidsand stuff, but there's no
(36:41):
requirement that you offer afamily agreement at all.
Yeah.
So I think you're, I think well,I think you again, we'll, we'll,
we'll see how that plays out.
I, I don't, I don't really know,I don't really know the answer
to, could you have like, youknow, six six child child
agreements and that, that sortof thing.
I, I, I also think at a certainpoint you know, the market's
(37:06):
gonna drive this.
And it's gonna drive behavior interms of what, what you're
charging if we're gonna grow newDPC practices.
I, I know my, my wife and I areat the point now and in our
practice where I'm about to goon, on on, on Medicare and, and
you know, we understand we'reutilizing more at, at 65 and
(37:29):
it's brushing up against that,you know, maybe 300 bucks.
300 bucks A-A-A-A-A month.
But but again, I think that'sstill on the high side in the
market.
That's certainly what thesurveys have said.
And and my bigger concern hereis, is this gonna, you know, is
this gonna cause the new marketbased price to be 150 bucks?
I don't think a lot of marketswill bear that because the
(37:51):
national average is now 75.
Or roughly there.
I think the, the hint hint guysdid a survey on this and we're
about to get the survey backfrom Milliman, the, the next
survey back.
Well, we should have that at theApril summit, so we'll have some
new data on that.
But but yeah, this wasn'tintended to drive price.
It might and I think if itdrives it, it'll, it'll drive it
up.
(38:11):
But you know, the reality isit's still well within market
range, and it is indexed everyyear for inflation.
That$150 and$300 are indexed tothe CPI every year for
inflation.
So that'll go up just like theHSA number goes up.
And that answered the lastquestion that just came in from
Dr.
Martin.
But when it comes to a follow-upquestion about family agreements
(38:34):
do they clarify what is afamily?
Is a physical, is it a physicalhousehold?
And if you break it up for HSAmultiple, all individuals.
Yeah.
So that answers Dr.
Karim's question, that the nextquestion is could we price
discriminate?
Could we change, could we charge$150 a month to folks with HSAs
and$200 a month to everybodyelse?
Yes, I believe that'll be fineunder the, under the rules,
(38:56):
unless the IRS, you know,freelances and says, no, you
can't.
But I, I don't, I don't, I don'tanticipate that happening.
So Jay, I was thinking what ifthe delta, you know, the
difference, the doctor saying,oh, I can't charge more than$150
using HSA dollars.
What if the employer providedHRA dollars to help offset those
(39:20):
expenses?
I think it's I think the IRS isgoing for the, for the HSA
exclusion is going to look atthe contract and the agreement,
not, not what the employer isputting into the, into the HSA.
You know, the HRA, the mainproblem with the HRA is that not
a lot of people use it.
It's a perfectly good vehicle.
And in fact, it's a, it's a,it's a natural vehicle.
(39:44):
If you wanted to put$60 a monthfor each employee into an HSA,
so they could spend it on DPC,if they wind up not spending it,
it goes back to the employer.
So there's an incentive on the,on the employee to spend it.
Both of them are good models.
I am not sure about the taxstatus of using both.
(40:05):
I don't, I don't know.
Phil might have some thoughts onthis.
I.
I don't know why, I don't knowwhy you would do it, but I
don't, I don't know that there'sa prohibition against having a
hybrid plan that puts a certainamount into an HSA and a certain
amount into an HRA.
I can't think of anybody who'sdoing both the, remember the Fs,
(40:26):
the FSA and HRA were already nota problem because they rely only
on two 13 D and all we had tofix was 2 23 C with this, right?
Mm-hmm.
Yeah.
I just, and to Jay's pointearlier, if you were, if you've
got some people that you'recharging 151 and some people
you're charging 1 49, the pointbehind the 1 49 is to give them
(40:48):
a bright line.
Clear cut.
Very conservative tax approachwhere they're making an argument
that it's not a gap plan for the1 51.
You could still do that and thepatient can decide on their own
if they wanna make a taxargument out of it in the event
they're audited.
And I still don't think theywill be because the IRS hasn't
done that in a decade.
(41:09):
And then Garrison, I thinkGarrison Bliss.
Yep.
Yeah, go ahead Garrison.
I just wanted to, to say acouple of words to the DPC
people that the demand is aboutto go up.
In a big way.
And the tendencies, this iswhere you have to start worrying
about the good news being aproblem, which is you're gonna
(41:30):
have to choose where you, whereyou wanna go, who you wanna take
care of, which, which deals youwanna take.
When it comes to dealing withyou know, plans.
Make sure that you, that, that,that you are controlling the
rules.
Don't just sign something'causethey hand it to you.
'cause that's how we got in thisproblem in the first place.
(41:52):
And the other thing that Ireally wanna make sure everybody
understands is we still takecare of our patients and don't
do something that will make ithard for you to do that.
It's gonna be tempting.
To have a panel of 800 people,it's gonna be tempting to raise
your price to the point at whicha lot of people can't afford
you.
As this demand grows, it's alsogonna be tempting to be sucked
(42:14):
into a deal with somebody who's,who is you know, venture
capitalizing us.
And who wants to make use of us.
Suck it dry as much as they can,collect as much of our money as
they can, and then wander awayand leave us with huge panels
and no way to get rid of the,the burden that we have.
So I I I, I want you to rememberthat you should still have
(42:38):
contracts for people.
It should.
And the purpose of the contract,it is to make sure that they
know what it's gonna cost.
And you know what you'repromising.
The promises are what drivethis.
This is healthcare, right?
So be, be sure that we don't gettoo much in business gear, that
we understand that we are hereto serve.
And also that if things startgetting crowded in your office,
(43:02):
get, get a partner.
Start expanding this.
We need a lot of people doingthis.
We need probably to triple theworkforce in primary care, maybe
more.
So it's time to open the doorfor everybody else.
Let them know it's safe to comenow and start having contact
with your, the medical schoolsnear you, do all the things that
(43:23):
we have to do to, we have todemonstrate that we can, we can
grow and not have our, our carediminished.
So I'm just, I, I'm encouragingeverybody to remember what that
the central drivers of primary,of direct primary care so that
we don't get sucked into greatdeals that make us a lot of
money or someone buys us out andthen, and then destroys our
(43:47):
practice.
So all of those things but I,I'm just glad we're here.
This is the place we wanted toget to, and now we have to start
thinking about how are we gonnamake this available to everybody
in the United States at areasonable price and make it
real care.
Don't, don't create a practicewhich you can't take care of.
(44:08):
Jay's got not only a thumbs upat hearts, and so yes, I love
that we're talking abouthealthcare and not insurance.
And Jay has said before, thereis a day that direct primary
care will simply be primarycare.
So with that Jay, as I wait forany less minute questions to
come into the chat can you sharewith the audience how can people
get involved if they've nevertalked to their policymakers,
(44:31):
they've never talked with aninsurance broker before?
How do people get involved?
I wanna say, I wanna thank youMarielle for moderating this
today and, and, and, and for allof your amazing advocacy in your
work.
On Capitol Hill, the, the, thebest and, and, and most
efficient way is for you to jointhe Direct Primary Care
Coalition.
The, you can go dp care.org,click the join button, join us.
(44:54):
As I said, we won't be havingany additional fly-ins this
year, but next year we will.
And lemme tell you one of thethings you've probably heard
recently, the president has madesome remarks about the idea that
instead of extending the a CApremium tax credits, maybe we
ought give that money back tothe people and put it into an
HSA so that the people can spendit the way they want.
(45:15):
I will say that we're in prettydeep negotiations with several
senators on what this might looklike.
I think the odds of this windingup in the next few days in
whatever final agreement we haveon these tax credits as a
solution are, are fairly slim.
But I will say that there isgrowing bipartisan support for
the idea that we, we, we, wecould help people afford a
(45:39):
better a CA bronze level plan,which now we can do with these
new tools that are in HR one andthat DPC will be a part of that
equation.
So, we're excited to be a partof that conversation.
We think it'll take a couple of,probably a couple of years to
get anything like that acrossthe finish line if it does get
across the finish line.
(46:01):
We're also working prettyclosely with CMS on the next
round of CMMI innovation modelsto see if we can get a model
where.
You know, maybe you can takethis HSA money and use it, you
know, use it on, on your DPC inMedicare.
So, lots of different ways toskin that cat.
Don't wanna get into too many,too many details today, but if
(46:22):
you wanna be a part of theconversation moving forward with
your colleagues in the industry,we work by consensus.
Join the coalition and, and, andcome and join us.
And uh, you know, any, anybodythat needs any specific help
with a legislator, feel free toreach out to me directly.
Feel free to reach out toMaryelle, who works pretty
(46:43):
closely with us on the advocacyside of this.
And we'll, we'll make sure youhave you know, as a member of
the DPC coalition, access to anyof the information you need to
to help, to help with that.
And it really doesn't, it's notlimited to just, you know, what
do I say to a person?
For example, in California, wedon't have law that protects DPC
(47:04):
as of this di this recording.
But, you know, I had somefrustrations around my husband
getting eliminated and ourpatients in our area no longer
having access to an insuranceaccepting doctor that offered
full scope care.
And that is what I call Jayabout.
So literally, if there's anyfrustrations that you're having
about, this is so messed up thatthis is happening in our
community and you don't evenknow who to talk to.
(47:26):
DP care.org is where you go.
Well, I wanna thank you all forbeing such strong supporters.
This was a long journey.
You know, you know, theChancellor of Germany, Otto, of
on Bismarck once said one wholikes fine sausage or
legislation should watch neitherbeing made.
I think this is a perfectexample of that.
It took us well over a decade toget this done, but it's good.
(47:48):
We've done good things for theAmerican people.
We've, we've, we've said to theAmerican people, we want your
health benefits to be better.
And we want them to include yourability to choose the doctor of
your choice and pay'em outtayour own money that your
employer's putting into your HSAor you're putting into your HSA.
And I think that's a really goodfoundation from which we can
(48:08):
build and grow.
And you know what everybodysays, world domination for DPC,
right?
Amazing.
Thank you everybody for joiningtoday.
Thank you so much, Dr.
Bliss, and for Jay.
Thank you both for your work andgetting us to this point.
Thanks for tuning in to My DPCStory.
If this episode inspired you,please leave a five star review
(48:29):
on Apple Podcasts.
It helps more physicians findthese stories when they need
them the most.
If you're new to DPC, you'rejust beginning your journey.
Head to the Start Here age@mydpcstory.com.
I've put together a practicalstartup guide and highlighted
the episodes I think areessential for beginners.
Got a question or a challengeyou want to hear addressed on
the show?
Go to the Contact Pagemydpcstory.com and leave me a
(48:50):
voice message.
And be sure to check out our myDPC story, Patreon.
As a member of our Patreon,you'll find commercial free
episodes and extended versionsof the regular episodes.
There's something for everyonewith both free content and a
paid tier that helps support theshow.
Follow us on socials@mydpcstoryand check us out online at
mydpcstory.com.
Until next time, this is MaryalConcepcion.
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