Executive summary

On February 5, the Senate HELP Committee held a hearing titled "How Primary Care Affects Health Care Costs and Outcomes." Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) touted the importance of primary care in managing chronic conditions and preventing future health care costs, giving examples of various employer groups and primary care entrepreneurs that are bending the cost curve through the delivery of high-value care. Those testifying in front of the committee included primary care physicians and academics leading innovative primary care models such as Direct Primary Care (DPC) practices and hub-and-spokes models for various diseases and conditions, along with an expert in employer health benefits.

Throughout the hearing, the committee members expressed their concern about rising health care costs and asked the panel how increased access to primary care and innovative models are helping to bend the cost curve and increase access to high-quality care. All of the witnesses spoke about the importance of primary care as a high-value service that prevents higher-cost care in the future, noting the shortage of providers and other barriers that impede access. Dr. Josh Umbehr spoke about how DPC enables providers to deliver higher-quality primary care without being bogged down by insurance obligations. Drs. Kripalani and Bennett spoke about the need to provide more resources to primary care physicians to help them deal with complex issues such as behavioral and mental health care, and how the use of telehealth, hub-and-spokes models, and other supports can benefit the delivery system and allow for better integration. Ms. Watts discussed how employer innovators are transitioning from volume to value through mechanisms such as on-site clinics and direct contracting. The group also flagged barriers such as inadequate payment (e.g., for telehealth, chronic care management, and integration of behavioral and mental health), increased administrative burden for primary care providers, lack of sustained funding for workforce enhancement programs, and the need to change health savings account (HSA) rules and repeal the "Cadillac Tax" to allow for more innovation and first dollar coverage of high-value services.

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Opening statements

Lamar Alexander (R-TN): "Adam Boehler, who leads the Center for Medicare and Medicaid Innovation, recently told me … that primary care is only 3-7 percent of health care spending but affects as much as half of all health care spending. And as Dr. Roizen of the Cleveland Clinic has said before this Committee, regular visits to your primary care doctor, along with keeping your immunizations up to date and maintaining at least four measures of good health, such as a healthy body mass index and blood pressure, will help you avoid chronic disease about 80 percent of the time. This is important because, according to Dr. Roizen, over 84 percent of all health care spending is on chronic conditions like asthma, diabetes, and heart disease … There are other ways to lower health care costs through expanded access to primary care. Dr. Gross' direct primary care clinic is one example. Another is community health centers, which we talked about at our last hearing and that are where 27 million Americans go for their primary care. And employers are increasingly taking an active role in their employees' health and in the cost of health care." Full statement.

Patty Murray (D-WA): "Families across the country want quality health care to be accessible and affordable — no matter where they live, how much they make, or what health challenges they face … And when it comes to keeping families healthy, and care affordable, how we approach primary care is a key piece of the puzzle … Boeing found that by delivering care that was more coordinated and personalized, they not only lowered costs for patients by one fifth by preventing expensive care like hospital admissions. They also increased access to care, and improved their employees' health outcomes … In fact, when people don't have access to primary care, they don't just miss out on care that can improve their health and drive costs down — this lack of access can actually drive costs higher. Patients go to the ER for non-urgent medical care, or worse, go without medical care entirely, until non-urgent issues become urgent ones — ones that are more expensive to treat, more debilitating, and more challenging to overcome … [Community health centers] provide 27 million people across the country with affordable care close to home. So I'm glad Chairman Alexander has joined me in introducing a bipartisan bill to ensure they have stable funding for the next five years." Full statement.

Witness testimony

Josh Umbehr, M.D., Atlas MD: A family physician from Wichita, Kansas, Dr. Umbehr believes that DPC (Direct Primary Care) is part of a growing solution to fixing health care. Their practice charges a monthly membership fee based only on age, costing around $10 for kids and $50 for adults, which provides unlimited work, home, and telehealth visits. The model removes bureaucracy and paperwork burdens from the equation by operating outside of insurance. Included in the fee is free testing along with wholesale prices for medications and labs, often at prices that are 95 percent  less than at other primary care practices. While he supports the concept of insurance when it is used appropriately, Dr. Umbehr believes we must bend the cost curve of primary care by making it affordable and accessible while relying on more meaningful and affordable health insurance for other, non-primary care needs. Full testimony.

Sapna Kripalani, M.D., Assistant Professor Of Clinical Medicine, Division Of General Internal Medicine And Public Health, Vanderbilt University Medical Center: Dr. Kripalani is a primary care physician who believes they are the front line of health and wellness, helping to educate, treat, and bridge the gap in critical services such as mental health while coordinating care across the entire health team. She encouraged the committee to support primary care as a cost-effective measure to improve health outcomes. Only 6-8 percent  of spending in the U.S. is for primary care, with a decline in spending between 2012 and 2016. Meanwhile, spending increased for specialists and nearly every other developed country invests more in primary care, which is associated with reduced overall spending. She stressed the need to invest in the primary care workforce, which will only worsen as the population continues to age. The gap in salary and administrative burdens are driving providers into other specialties, with every hour of primary care treatment resulting in one to two hours of administrative tasks. Full testimony.

Katherine A. Bennett, M.D., Assistant Professor of Medicine, Division Of Gerontology And Geriatric Medicine, University of Washington School of Medicine: Dr. Bennett spoke about Project ECHO (Extension for Community Health Outcomes), which uses a hub and spoke model to increase access to specialty care through teaching and case consultations. For a Hepatitis C project, they reduced wait times from eight months to two weeks and have since launched ECHOs for many difference complex conditions. Her focus is on geriatrics, as many primary care providers have not received adequate training to care for the elderly. Since 2016 they have trained over 300 providers and see clear improvements in care over time. There are 10 geriatrics ECHOs across the country but they need additional funding to get outcomes data. Investments in the geriatrics workforce enhancement bill and other sustained funding mechanisms will help to support Project ECHO and develop a strategy for longevity. Full testimony.

Tracy Watts, Senior Partner, National Leader for US Healthcare Reform, Mercer: Ms. Watts spoke about employer investments in primary care, such as the increase in on- or near-site clinics, which has increased from 17 percent  in 2007 to 24 percent  in 2012 and 33 percent  in 2018, with another 10 percent  now considering them. Of those with clinics, 61 percent  say they have been successful in managing cost increases and improving wellness, seeing anywhere from a 1:1 to a 4:1 return on investment. In Mesa, Arizona, Boeing launched a DPC arrangement for primary care where they are paying the capitated fee, and uptake in just nine months for those with chronic conditions has been impressive. While 80 percent  of employers offer telehealth, utilization is currently low but consumers are getting increasingly comfortable with the idea. Ms. Watts suggested full repeal of the "Cadillac Tax" to encourage use of things such as onsite medical clinics, which are included in the calculation of the tax. She also suggested measures to enable pre-deductible use of DPC and other similar arrangements without the risk of losing HSA eligibility. Full testimony.

Q&A

Sen. Lamar Alexander (R-TN) asked about barriers to expansion of the DPC model. Dr. Umbehr said they need to educate people about the model and think about broadening the IRS interpretation of what can be done, including exploring a direct care model for specialty care, which is gaining traction. When asked about worksite primary care, Ms. Watts said HSA-eligible plans must apply all non-preventative care expenses to the deductible, so they have to charge the value of the onsite visit and that results in an added administration expense. Regarding telemedicine barriers, Dr. Kripalani said the issue in Tennessee is that services are only covered if they present to a rural health care facility. Sen. Alexander later asked about how Dr. Umbehr purchases prescriptions directly from suppliers. Dr. Umbehr said they can do it in 44 states and that pharmacists can do it in all 50 states, however most physicians and pharmacists don't know they're able to. He added that many are surprised to find out what the true cost are.

Sen. Patty Murray (D-WA) noted that by 2025 there will be a national shortage of 27,000 geriatricians and asked how we can improve outcomes for seniors. Dr. Bennett said they are just starting to look at outcomes from their work, but that this work has resulted in reductions of constraints in nursing homes, more appropriate prescribing that lessens the risk of falls and cognitive impairment, and better screening for falls — which are a big cost to health systems. When asked about the cost of prescription drugs for employers, Ms. Watts said specialty drug spend is the number one concern for employers and makes up about 35 percent  of the prescription spend, which is likely to grow to 50 percent  in coming years. She also said employers are looking at sites of care where it's less expensive to administer specialty drugs, such as in the home, and carving out specialty spend through specialty pharmacy vendors.

Sen. Pat Roberts (R-KS) asked about increasing access to DPC. Dr. Umbehr said the typical fee-for-service practice needs to have two to three thousand patients to be viable, along with a healthy mix of insurers, while a DPC practice only needs 600 due to the decrease in overhead. He said they can decrease small business health insurance premiums by 60 percent  and improve access to care. He added that they want to increase their reach and add 20-30 practices a month.

Sen. Tim Kaine (D-VA) asked for advice on loan forgiveness programs and said he is working on reauthorizing higher education legislation. Dr. Umbehr said that the current structure perpetuates the status quo due to the requirement that physicians accept state insurance in many cases. In response to a question about immigrant physicians, Dr. Kripalani said many struggle to find residency programs. When asked about the use of ECHO for opioids, Dr. Bennett said the model includes an interdisciplinary care team that develops best practices for care of certain populations.

Sen. Susan Collins (R-ME) discussed the existence of certain models that help engage patients with diabetes and noted that a lot of the work they do is often not reimbursed. When asked about how payment impedes or helps drive such models, Dr. Kripalani said that diabetes management is very important and that the services of designated care coordinators, for example, are extremely valuable to make sure their needs are being met. Ms. Watts added that some employers carve out diabetes management programs that can monitor and even project out A1c levels, preventing higher costs of care down the road. Dr. Bennett added that geriatrics is made to save money through the prevention of costly falls and keeping people living in their homes for longer.

Sen. Maggie Hassan (D-NH) said she is a fan of medical homes and coordinated care, asking how they can increase the number of geriatricians and get more primary care providers to help out in geriatrics. Dr. Bennett said the most important things for geriatrics are 1) doing what matters most for the patient, 2) screening for cognitive impairment and addressing issues when found, 3) mobility and falls, and 4) managing medication and multiple conditions. When asked about improving the integration of metal health care, Dr. Kripalani said primary care providers aren't equipped to handle complicated cases and need to be able to easily refer people to behavioral health, although it can often take months in Tennessee. Dr. Umbehr said DPC's ability to operate outside of insurance allows them to more easily extend training to behavioral health care and for patents to have extended conversations with providers.

Sen. Mitt Romney (R-UT) asked about near site clinics. Ms. Watts said the theme for employers is the transition from volume to value, which includes directly contracting with providers and how to improve health risk and drive outcomes. When asked about the lower costs associated with DPC, Dr. Umbehr said it enables them to focus on solutions and frees them from paperwork burdens.

Sen. Robert Casey (D-PA) asked about partnerships between primary care and aging resources groups. Dr. Bennett said that many primary care providers don't know such resources exist at the state and they've created primary care liaisons through they model to make sure they know of the agencies that can help. The agencies can help with care coordination and other chronic care needs that save millions of dollars to the system.

Sen. Bill Cassidy (R-LA) asked aboutmonetary incentive rules in the ACA and HSA restrictions for chronic condition management. Ms. Watts said that some employers use personalized coaching to help manage conditions such as diabetes. She added that for benefit plans to be HSA eligible all expenses must be applied to the deductible unless they are included as "preventive care," which doesn't include chronic conditions. Sen. Cassidy said he is a big fan of changing the HSA requirements and wouldn't mind eliminating the "Cadillac Tax." When asked about telehealth, Dr. Kripalani said Vanderbilt is working on a model but reimbursement is difficult.

Sen. Jacky Rosen (D-NV) said Nevada is 48th in terms of primary care physicians per capita. Dr. Umbehr said they will certainly have a shortage if they continue with the current status quo due to inefficiencies. Dr. Kripalani said they must finds ways to combine mental and behavioral health services in real time, which is much more impactful for patients, and need funds to employ additional resources. Dr. Bennett added that primary care has lower reimbursement than other types of care.

Sen. Mike Braun (R-IN) spoke about how hard it is to get the industry to listen to their needs, saying they need to shed more light on the process and increase transparency about the true cost of care. He added that entrepreneurs such as DPC are driving out costs.

Sen. Elizabeth Warren (D-MA) asked about behavioral health and noted that more than ½ of Massachusetts residents seeking behavioral health care struggle to find treatment. Dr. Kripalani said that in Tennessee, 20 percent  or more suffer from behavioral health issues and that primary care providers are not equipped to deal with it all. She said they need more support for complicated mental health care issues and it can often take months to get seen by a specialist, many of whom don't accept insurance. Dr. Bennett said project ECHO can help primary care providers get more resources and is well suited for the issue of specialist shortages.

Sen. Tammy Baldwin (D-WI) asked about the development of project ECHO and outcomes data as well as potential gaps. Dr. Bennett said that they do local needs assessments initially but are just starting to look at outcomes, which will help them to change the services offered and eventually improve care. When asked about family caregivers, Dr. Bennett said it is central to geriatrics work and that there are fantastic family support programs that primary care needs to do a better job of connecting people to.

Sen. Tim Scott (R-SC) spoke about Boeing's preferred partnership program and how they've helped to lower costs while improving outcomes. Ms. Watts added that employers like Boeing continue to innovate and that on-site clinics can be stood up for employer with as few as 500 employees or employers can band together to offer them. She also said that to reinforce the value of primary care they must address the first dollar coverage issue for HSA-eligible plans as well as repeal the "Cadillac Tax."

Sen. Doug Jones (D-AL) asked about the originating site rules in reimbursement for telehealth. Dr. Kripalani said that low physician coverage at a rural site allows them to communicate with providing sites, however barriers such as lack of transportation are not considered. When asked about pre-existing condition protections, Dr. Umbehr said that going through insurance is a greater disincentive and that they develop relationships with employers and accept all patients.

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