Enhance Access to Trusted Doctors and Appropriate Care When and Where They are Needed

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As more and more Americans experience serious health problems, it is vital that they have access to trusted doctors and appropriate care when and where they are needed. Sixty percent of Americans have at least one chronic condition, and 42% have multiple chronic conditions. The percentage of those with multiple chronic conditions is 81% amongst people ages 65 and older. Unfortunately, only half of Americans receive recommended care, and the quality of care varies across conditions, demographic groups, and communities.

If new solutions are not implemented, the United States can anticipate a continued increase in the burden of chronic diseases on the physical and economic health of our citizens. Currently, we simultaneously have underutilization of preventive care and an overutilization of medical care. Just 6.9% of American adults ages 35 and older received all recommended high-priority, appropriate preventive services in 2018, according to the most recent data available from the Department of Health and Human Services Office of Disease Prevention and Health Promotion. And in 2017, physicians reported that 21% of medical care was unnecessary.

To enhance access to care, it is critical for the United States to comprehensively shift away from a healthcare system that is incentivized to treat illness, and toward a system that is oriented around delivering improved individual and societal health outcomes. To do so requires innovative solutions that recognize and engage the complex interplay of economic, behavioral, social, and biological factors that contribute to overall health. Unfortunately, the Biden Administration’s agenda of broader one-size-fits-all government involvement in healthcare doubles down on the policies of the Affordable Care Act (ACA), which has failed to solve these problems.

Enrollees in ACA plans have less ability to choose their doctor as covered provider networks for ACA plans shrink. In 2020, health plans on the individual market with more restrictive networks consisted of 78% of the plan offerings in the exchange market. For comparison, plans with more restrictive networks represented 54% of the exchange market in 2015. While narrow network designs can help keep premium costs lower for enrollees, it may mean that preferred doctors and healthcare facilities are not covered by a chosen insurance plan. This is very problematic because the foundational relationship between doctors and patients — and the ability to receive appropriate care — are essential elements of improving the health of Americans. This highlights Obama’s infamous broken ACA promise: “If you like your doctor, you can keep your doctor.”

One way to enhance access to trusted doctors is through direct primary care (DPC). In this model, patients pay a monthly membership fee (typically ranging from $40 to $85 per person) to a clinical practice and receive access to a defined set of services, usually consisting of primary care and preventive services. In general, DPC doctors do not contract with insurers or government payers, but they may contract with self-funded employers. They typically have smaller patient panels, which results in expanded access to clinicians, including longer office visits and same-day or next-day appointments.

Many DPC practices can also provide laboratory tests and dispense common medications at discounted rates. Patients benefit from expanded access in this model. One case study found that DPC was associated with 30% lower out-of-pocket costs and 20% lower employee premiums. Another case study found a 40% reduction in emergency department utilization. Increased access to direct patient care models would benefit patients.

Additional policy priorities should provide better care for Americans by removing barriers to competition and promoting free-market solutions. These include maximizing the supply of clinicians and appropriate facilities by removing barriers to entry and addressing misaligned incentives. Doing so would increase access to care for those who need it most.

The federal government can implement site-neutral payment policies in Medicare to ensure the same rate is paid for the same clinical care provided at different facilities. This policy change could reduce Medicare spending, reduce premiums and cost-sharing for Medicare facilities, and result in significant private sector savings through spillover effects. Importantly, it would remove misaligned incentives to provide care in higher-cost facilities, which limit patients’ access and choice.

State regulations and licensing requirements should promote increased supply in the market. This includes allowing clinicians to practice at the top of their licenses and join medical licensure compacts. The latter would allow doctors to practice medicine across state lines and allow patients to maintain continuity of care. This would increase patient access to necessary care, including from highly trained clinicians at specialty centers such as MD Anderson Cancer Center and Mayo Clinic. It also involves removing bureaucratic processes regarding the development of necessary healthcare facilities through certificate of need requirements.

Additionally, patients should be able to receive care at the location that best meets their needs. Payment differentials that encourage care in higher-cost settings should therefore be equalized, and expanded access to telehealth services should be maintained in a manner that maximizes the benefit to patients and doctors. 

THE FACTS

• Direct primary care has been associated with 20% lower employee premiums, 30% lower out-of-pocket costs, and a 40% reduction in emergency department utilization.
• Approximately 90% of the $4.1 trillion in annual health expenditures are used to treat people with chronic and mental health conditions.
• Sixty percent of Americans have at least one chronic condition, and 42% have multiple chronic conditions.
• Five percent of the population accounts for 50% of the healthcare expenditures, and 50% of the population accounts for 97% of expenditures.
• Only 7% of United States adults ages 35 and older received all the high-priority, appropriate clinical preventive services in 2018, according to the most recent data available.

THE AMERICA FIRST AGENDA

At the federal level, support policies that:

• Allow Medicare and Medicaid to reimburse and contract with direct patient care providers.
• Make Medicare site-neutrality policies permanent and expand as appropriate.

At the state level, support policies that:

• Define direct primary care as a medical service outside of state insurance regulation.
• Ensure state participation in the Interstate Medical Licensure Compact and other health professional licensing compacts.
• Eliminate certificate of need requirements as appropriate.
• Allow telehealth licensing registration to facilitate the ability of out-of-state providers to care for in-state patients.
• Allow clinicians to practice at the top of their licenses.

REFERENCES

2020 Exchange Plan Networks Are the Most Restrictive Since 2014 by Chris Sloan and Elizabeth Carpenter, Avalere (Dec. 2019).

Center for a Healthy America Overview by Former Gov. Bobby Jindal and Heidi Overton, M.D., America First Policy Institute (Aug. 2021).

Direct Primary Care: Evaluating a New Model of Delivery and Financing by Fritz Busch, Dustin Grzeskowiak, and Erik Hut, Society of Actuaries (May 2020). 

Direct Primary Care: Update and Road Map for Patient-Centered Reforms by Chad D. Savage, M.D., and Lee S. Gross, M.D., Heritage Foundation (June 2021).

Equalizing Medicare Payments Regardless of Site-of-Care, Committee for a Responsible Federal Budget (Feb. 2021).

Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services by Amanda Borsky, Chunliu Zhan, Therese Miller, Quyen Ngo-Metzger, Arlene S. Bierman, and David Meyers, Health Affairs (June 2018).

Health and Economic Costs of Chronic Diseases, National Center for Chronic Disease Prevention and Health Promotion (March 2022).

How Do Health Expenditures Vary Across the Population? by Jared Ortaliza, Matthew McGough, Emma Wager, Gary Claxton, and Krutika Amin, Peterson-KFF Health System Tracker (Nov. 2021).

Increase the Proportion of Adults Who Get Recommended Evidence- Based Preventive Health Care—AHS-08: Data by Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services (March 2022).

Multiple Chronic Conditions in the United States by Christine Buttorff, Teague Ruder, and Melissa Bauman, RAND Corporation (2017).

Overtreatment in the United States by Heather Lyu, Tim Xu, Daniel Brotman, Brandan Mayer-Blackwell, Michol Cooper, Michael Daniel, Elizabeth C. Wick, Vikas Saini, Shannon Brownlee, and Martin A. Makary, Plos One (Sept. 2017).

Plans with More Restrictive Networks Comprise 73% of Exchange Market by Caroline Pearson, Elizabeth Carpenter, and Chris Sloan, Avalere (Nov. 2017).