February 9, 2018

Guest Perspective By Rep. Joe Sanfelippo

Americans across the country have discovered that the Affordable Care Act has been anything but affordable.

Many Americans and businesses are struggling financially to pay for healthcare. At the same time, the primary care experience has declined in quality for both patients and providers. Patients have seen their access to primary care decline, for many reasons. With the trend towards specialization among medical professionals, the percentage of primary care physicians has dropped significantly in recent years. This is also part of the reason that average wait times for initial visits to family physicians in major cities have increased from 20.3 days in 2009 to 29.3 days in 2017. In mid-size cities, that wait climbs to over 54 days. As more people are forced into high-deductible health plans, many patients can’t afford to pay for visits or take the time off of work to get to their doctors, even when they can schedule an appointment.

In typical insurance-paid practices, doctors spend roughly 50% of their time dealing with procedure coding and insurance requirements.

Doctors don’t like this trend, either. In typical insurance-paid practices, doctors spend roughly 50 percent of their time dealing with procedure coding and insurance requirements, and need expensive administrative staffs to help manage complex billing and records systems. The result is that doctors need to see more patients to achieve profitability, which means less time with each patient.

Many doctors, frustrated with this experience, have begun shifting to a new business model known as direct primary care, or DPC. Under a direct primary care model, which is not health insurance, patients pay a low monthly fee, typically between $50 and $100, depending on age, with no further co-pays or deductibles. For that fee, they receive unlimited 24/7 access to their primary care doctor. Because doctors have a fraction of the administrative costs as under a managed-care model, they can spend more time with patients: whereas under a managed-care model, doctors see their patients for an average of 8 minutes, DPC visits average 35 minutes in length, and often go much longer. This extra time allows doctors to get to know their patients better and provide more accurate diagnoses. And because DPC doctors typically accept roughly 500 active patients compared with 2,500 in traditional practices, doctors are available to their patients 24/7, whether for same- or next-day appointments, phone calls, or even house visits. Switching to a DPC model can save a doctor as much as 40 percent on their administrative costs by freeing them of insurance billing requirements.

Under direct primary care, patients receive better healthcare for less money.

Under direct primary care, patients receive better healthcare for less money. While over 80 percent of a person’s healthcare can be provided in a primary care setting, DPC patients still carry catastrophic insurance for coverage should they experience a serious illness. However, because they receive more regular and in-depth preventative care, patients under a DPC model experience better healthcare outcomes. This translates to massive cost savings. Hospital costs for potentially-preventable conditions (those that statistically respond well to increased primary care) represent roughly $30 billion annually, or 10% of all hospital expenditures. DPC patients are 52% less likely to require hospitalization than patients under a traditional model. If we can even marginally reduce the 4.4 million annual potentially-preventable hospital stays, we can make a revolutionary impact on our healthcare problem.

That’s why Senator Chris Kapenga and I have been working on legislation to formally codify and regulate direct primary care in Wisconsin. There are already a growing number of successful DPC clinics in the state, like Solstice Health in New Berlin and Dr. Suzanne Gehl in Delafield, and we want to build consumer confidence in the DPC model by formally regulating these clinics. We’ve crafted this legislation by working closely with the Department of Health Services, as well as healthcare providers throughout the state, and have the full support of Wisconsin doctors through the Wisconsin Academy of Family Physicians.

There’s been a six-fold increase in DPC clinics in the United States since 2014, with about 3 percent of doctors nationally practicing under this model. So far, twenty-three other states have direct primary care defined in their laws, including other Midwestern states like Indiana and Michigan. Recently, the federal Department of Health and Human Services announced that they will be working with states this year to incorporate direct primary care into their Medicaid programs. That’s why this legislation also directs DHS to study how we can best incorporate direct primary care into our own Medicaid system, and to craft a pilot program that we hope to implement as soon as next year.

Direct primary care is one of the most promising solutions towards tangibly improving patient access to healthcare, achieving better patient outcomes, and realizing tremendous cost savings.

Direct primary care is one of the most promising solutions towards tangibly improving patient access to healthcare, achieving better patient outcomes, and realizing tremendous cost savings. I hope that legislative Democrats join us in providing Wisconsinites with more affordable healthcare options. There’s incredible momentum behind direct primary care at the state and national levels, and we need to be sure to capitalize on this opportunity to keep Wisconsin at the forefront of healthcare innovation.

Rep. Joe Sanfelippo (R-New Berlin) represents Wisconsin’s 15th Assembly District.