AAPS Kentucky Chapter Offers Solutions to CMS to Empower Patients

Re: Comments on “Patient Protection and Affordable Care Act: Reducing Regulatory Burdens and Improving Health Care Choices To Empower Patients”

Docket No. CMS-9928-NC, RIN 0938-ZB39

On behalf of the Association of American Physicians and Surgeons (AAPS) Kentucky Chapter, I am pleased to submit comments on ways to successfully meet the goals of Executive Order 13765.

In general, we believe that 3 things – growth of Direct Care (which is private contracting between medical professionals and patients without insurance involvement), expansion of Health Savings Accounts (fewer restrictions on amounts allowed, who or what entities may own one, and what they can be used to purchase), and freedom for health insurance to function primarily as coverage for unexpected and expensive events – would revolutionize healthcare in the United States by making it better and more affordable for everyone, including and very importantly lower income individuals and Medicaid beneficiaries.

Direct Care has led to drastic savings on healthcare spending for self-insured businesses, often in the range of 20-50 percent or more.  There are several reasons for this.  First, the typical 4 to 5 fold (or more) mark up for facility based services billed to insurance is eliminated because the overwhelming administrative support required for billing and coding for insurance reimbursement is not involved and prices are transparent.  Also, particularly in the area of primary care, there is remarkable downstream savings as better access leads to less need for ER visits, advanced imaging, specialty care, and hospitalizations.  In addition, Direct Care helps many individuals with high deductible plans realize that they can find much more affordable options by simply paying for services rather than using their insurance.  If allowed to grow, Direct Care would naturally lead to drastically more affordable care and lower insurance costs, especially if there were free market forces in play.

We believe HHS and CMS can reduce current barriers to the growth of Direct Care in the United States.

First, Medicare and Medicaid patients should be free and encouraged to privately contract with physicians and other medical professionals if they choose to do so, especially since access to timely and high quality care is often an issue.

ACA Section 6401 (b) apparently requires physicians ordering and prescribing for Medicaid patients to be enrolled in Medicaid for screening purposes, even if they are not billing the Medicaid program.  CMS has declared that state Medicaid agencies may implement a streamlined enrollment process for those providers who only order or refer (similar to the CMS 855-O or opt out process in the Medicare program) and at least one regional CMS office (in San Francisco, CA) has stated that “we are not aware of any statute or regulation that would impose a penalty on a provider for accepting a payment from a Medicaid-eligible individual who voluntarily chooses not to access their Medicaid coverage.”  However, the Medicaid Commissioner in Kentucky has claimed our state’s hands are tied by CFR 447.20, which is not linked to the ACA and apparently was developed to make sure the states and CMS are not paying for care that is supposed to be paid by another entity or person. He is under the impression that Direct Care physicians are prohibited by this regulation from privately contracting with Medicaid patients.  Generally, CMS could clarify the intent of ACA Section 6401 (b) and the unrelated regulation CFR 447.20 and encourage all states to allow increased freedom of physician choice for Medicaid patients.  Specifically, 42 CFR 455 subpart E – related to ACA Section 6401 (b) – could be amended to either (a) clarify that ordering and prescribing physicians who are not billing the Medicaid program do not need to enroll in Medicaid or (b) clarify that physicians enrolled in the program only for prescribing and ordering purposes may privately contract with Medicaid beneficiaries for Direct Care.

            While CMS has issued clear rules allowing physicians opted out of Medicare to order, prescribe, and refer for their Medicare patients, contractors administering Part B often fail to properly follow these rules.  Patients of Medicare opted out physicians are frequently finding that claims for services ordered by their doctor are being rejected because of misunderstandings or other issues at the Medicare contractor level.  CMS should hold the Part B contractors accountable for following the rules and processing claims for these patients’ care.

Finally, patients who have commercial insurance should be encouraged to use Direct Care for preventive/routine care and reserve insurance to pay for care for expensive and/or unpredictable medical events and illnesses. 

            ACA section 10104 states “HHS shall permit a qualified health plan to provide coverage through a qualified Direct Primary Care medical home plan that meets criteria established by the Secretary.”  Section 1301 (a) (3) and its corresponding regulations basically define a direct primary care medical home.  HHS and CMS could work with state insurance regulators and encourage insurers to offer qualified health plans designed for pairing with Direct Primary Care medical homes to individuals and employers (not just on the exchanges) as an alternative to expensive comprehensive packages.

Thank you for your efforts and please don’t hesitate to contact the AAPS Kentucky Chapter if we can be of any assistance in helping to make Executive Order 13765 a success.

Respectfully Submitted,

Tracy Ragland, MD

President, Kentucky Chapter, Ass’n of American Physicians & Surgeons



AAPS Kentucky Chapter Comments to HHS on Medicaid Waiver Request

The Honorable Sylvia Burwell
Secretary, Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201

Re: Commonwealth of Kentucky Proposal of Section 1115 Waiver Project, Kentucky HEALTH

Dear Madame Secretary:

On behalf of the physician and medical student members of the Kentucky Chapter of the Association of American Physicians and Surgeons (AAPS), I am pleased to offer comments regarding the proposed Section 1115 Waiver, also known as Kentucky HEALTH.

AAPS applauds Governor Bevin’s courage to address the serious problems that Kentucky’s Medicaid program and its beneficiaries face. Contrary to what is frequently written in our state’s newspapers, Kentucky’s Medicaid expansion in 2014 under the terms of the Affordable Care Act (ACA) has not meaningfully addressed the problems it was supposed to tackle – namely, improving overall health and access to high quality care for Kentucky’s most vulnerable citizens. Further, it has paradoxically made health insurance premiums nearly completely unaffordable for many Kentuckians and has not offered taxpayers any hope of effectively making the program sustainable without dramatically higher costs in the future.

Kentucky HEALTH has the potential to help our Commonwealth actually achieve the oft-cited TRIPLE AIM of better health for individuals and populations, better patient experience, and much lower costs to the individuals, businesses and governments/taxpayers that are paying the health-related bills. Much has been said about the elements of the proposal that would require more community engagement and personal involvement in health maintenance and improvement for beneficiaries of Medicaid expansion. Likewise, there has been a great deal of focus on the importance of preserving important services for truly needy and medically fragile people. AAPS supports any effort that both helps people help themselves and preserves resources for Medicaid’s primary function of assisting people who cannot pay for their necessary medical and other health-related needs. However, we believe the critical strength of Kentucky HEALTH is its promise to cut the bureaucratic red tape and complexities of medical care delivery that are directly responsible for Medicaid’s high costs as well as the woefully inadequate access to high quality care for its beneficiaries.

It is well-known that since the advent of “managed care” in the 1970’s, which developed as a response to the increasing demand for medical services that naturally came from the 1965 passage of Medicare/Medicaid legislation, America has seen exponential growth in the number of health-related administrative professionals and workers compared to actual medical professionals – and the cost of care has continued to dramatically rise despite all of these attempts at controlling costs. Intelligent utilization of High Deductible Health Plans (HDHP’s) coupled with Incentive Accounts – which presumably will be similar to Health Savings Accounts (HSA’s) – to pay for medical and other health-related costs will dramatically lower costs, promote consumer engagement, and allow patients and their physicians/health professionals the ability to focus on improving health rather than unnecessary reporting, paperwork, and rules that are inherent in a system that relies too heavily on third party payers for managing all aspects of care. By incentivizing Medicaid beneficiaries or their advocates/guardians to purchase relatively inexpensive medical care and other health-related goods and services without accessing insurance, reserving insurance claims for relatively high cost and unpredictable medical needs such as cancer care, complex hospitalizations, and trauma, we will cut out a myriad of unnecessary middlemen whose expensive services could be put to better use elsewhere.

The ground has already been laid for many patient-centered and innovative delivery models to further develop under the implementation of Kentucky HEALTH. The ACA section 1301 and amendment section 10104 together allow for catastrophic or high deductible insurance plans to be offered to consumers as qualified health plans, as long as they are coupled with medical practices offering one such innovative model, Direct Primary Care (DPC), an affordable, compassionate, and comprehensive subscription-based primary care model that does not involve insurance billing for services rendered. Across the country, DPC practices are working with entities as diverse as self-insured businesses, unions, and local governments to lower overall health-related costs of their organizations’ employees and members, often by ranges of 20 to 50 percent, and they are doing it while simultaneously improving access to care, patient satisfaction and quality of care. If this is working for businesses and other entities, why not Medicaid and the commercial/employer based insurance markets as well? Health policy leaders have spent far too much time on failed strategies to cut the RATE OF GROWTH in medical and other health-related spending by imposing restrictions on patient choice and price controls on medical professionals’ services. What if we could actually lower OVERALL SPENDING (not the rate of growth) by 20 percent or more by cutting unnecessary bureaucracies and allowing more freedom and choice in our medical delivery systems? It is exciting to consider the possibility of saving taxpayers literally billions of dollars in a relatively short period of time and watching Kentucky’s health statistics move from perennially low marks to excellent A’s and B’s.

The Kentucky Chapter of AAPS offers its support of Governor Bevin and Kentucky HEALTH. We hope to be able to help make this great potential a reality for the Commonwealth of Kentucky.

Tracy L. Ragland, MD
Kentucky Chapter, Association of American Physicians and Surgeons