Understanding Direct Primary Care Medical Homes
HEALTH BENEFITS UPDATE
KEVIN C.
LYONS
While the State Health Benefits Plan Design
Committee works out the final details for the
2016 plan year, one of the additions that will
likely be made to the plan is the access to Direct
Primary Care Medical Homes (DPCMH)
through a pilot program for the PPO plans
(Direct and Freedom models) and EPO Plans (a
new plan that will likely be introduced in 2016)
within the State Health Benefits Plan.
In January, the labor side of the committee
met with all of the other public employee
unions and agreed to investigate the possibility of initiating a
voluntary pilot program using the DPCMH model. It is important that our membership be educated on the model so each of
us can make an educated decision to determine if this is a viable
option for you and your families. Please know that neither the
NJ Sate PBA, nor I, are endorsing this program at this time, but
nor are we condemning the pilot. The fact of the matter is that
current health care delivery is expensive and inefficient, and we
are attempting to find ways to control costs.
The model of a DPCMH is obviously based on primary care
physicians who manage a member’s health care from A-to-Z.
This is crucial for chronic disease management in situations
Edmond P. Brady, CPA – Partner
[email protected]
such as diabetes and heart disease. Studies have shown that
with constant monitoring and medical intervention, downstream costs can be controlled by keeping people healthy. In any
health insurance model, it is widely accepted that 10 percent of
the members use 90 percent of the health care dollars,
increasing costs for all of us. This is greatly driven by specialists
and hospital costs.
Currently, in the U.S., there are two specialists for every primary care doctor. This is the opposite of almost every country in
the world, and is greatly due to financial incentives for doctors
in the current fee-for-service model. Doctors are financially
incentivized to bill as many services in a visit as they can. In the
current model, each primary care doctor has a patient panel of
2,500 to 3,500. In the DPCMH model, doctors can have a maximum panel size from 1,000 to 1,200 and are paid on a per- member-per-month basis. That is to say, that for every patient that is
in their panel, doctors will be paid a set amount every month.
This allows doctors to have adequate time to manage your
health. In the model we are exploring, any members enrolling
will have 24-7 access to primary care doctors and will be guaranteed much longer appointments (the current primary care
visit last six-to-eight minutes). This allows them to actually practice medicine instead of pumping out patients, which
potentially allows them to miss issues that may be underlying
causes to health problems.
With regards to larger health issues, the DPCMH will also have
a cadre of specialists that can treat more serious issues. They will
have immediate access to all of your records, and the primary
care doctor can coordinate with any specialists that you might
have to visit.
The DPCMH doctors must answer to a high standard, which
is determined by industry quality metrics. The metrics are determined by doctor performance and patient surveys. These will be
compiled and reviewed on a regular basis by both the division
and the Design Committee.
The incentive for our members is that anyone who enrolls will
have copays waived when using the DPCMH, notwithstanding
the proposed higher level of care that you will receive. Another
potential benefit is the ability to move to a lower-cost plan (not
HMOs) and actually receive a higher-level benefit than what you
are currently receiving, which could reduce your current chapter
78 contribution. With regards to services not offered by the
DPCMH, you will able to use the benefit in your current packages.
Responsible for more than 300 PBA’s in
New Jersey and New York
Licensed in NJ, NY and Mass.
Livingston, NJ • Yonkers, NY
Phone (973) 535-2880 • www.mbccpa.com
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NEW JERSEY COPS
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JULY 2015
While the program is a three-year pilot that can only be
extended by an affirmative vote of the Design Committee, any
enrollee that is not satisfied can still use their normal benefit
and leave the pilot at any time.
While no program is perfect, the DPCMH is an attempt to
control costs, geographically and medically. It may or may not
be for you, but in any event it is an attempt to control costs and
give you another healthcare option. d