Direct Primary Care’s Inflection Point: What HR1 Within the "One Big Beautiful Bill" Means for Physicians and Patients

Today’s episode is one of the most important conversations we’ve had on My DPC Story. As of July 4th, we are standing at a true inflection point for Direct Primary Care—and for every physician, employer, broker, advocate and patient who believes primary care should be personal, accessible, and free from insurance middlemen.

In this special session, I’m joined by Jay Keese, Executive Director of the Direct Primary Care Coalition, who has spent more than a decade at the front lines in Washington, DC. Together, we break down what HR 1—the major tax bill signed into law this year—actually means for DPC. This includes:

• The historic win: HSAs are now fully compatible with Direct Primary Care for the first time ever.
• What patients can do starting January 1: Use tax-free HSA dollars to pay for DPC memberships without losing HSA eligibility.
• How this changes the landscape: New opportunities with employers, brokers, high-deductible plans, and even ACA bronze/catastrophic plans.
• What stays the same, what’s evolving, and what rulemaking from the IRS will finalize.
• What’s coming next: How DPC can scale responsibly and sustainably as demand accelerates.

If you’ve ever wondered how policy actually becomes reality—or what the future of DPC looks like on a national scale—you’ll want to listen closely. This episode is equal parts celebration, clarification, and a roadmap for what comes next.

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Transcript

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Today's episode is a very important conversation. As of July 4th, we are standing at a true inflection point for direct primary care, and every physician, employer, broker, patient and advocate who believes primary care should be personal, accessible, and free from insurance, middlemen is gonna wanna tune in. In this special session, I'm joined by Jay Keese, executive director of the Direct Primary Care Coalition, who has spent more than a decade at the front lines in Washington DC fighting specifically for DPC together we break down what HR one, the major tax bill signed into law this year actually means for DPC. This includes the historic win where HSAs are now fully compatible with direct primary care for the first time ever, what patients can do starting January 1st, specifically using tax-free HSA dollars to pay for DPC memberships without losing HSA eligibility. We talk about how this changes the landscape and how new opportunities can be formed with employers, brokers, high deductible plans, and even a CA bronze catastrophic plans. We talk about what stays the same, what's evolving and what rulemaking from the IRS will finalize. And finally, we talk about what's coming next, how DPC can scale responsibly and sustainably as demand accelerates If you've ever wondered how policy actually becomes reality or what the future of DPC looks like on a national scale, you'll want to listen closely. This episode is equal parts celebration, clarification, and a roadmap for what comes next. So with that, let's dive in. Direct Primary care is an innovative alternative path to insurance-driven healthcare. Typically, a patient pays their doctor a low monthly membership and in return builds a lasting relationship with their doctor and has their doctor available at their fingertips. Welcome to the my DPC story podcast, where each week. You will hear the ever so relatable stories shared by physicians who have chosen to practice medicine in their individual communities through the direct primary care model. I'm your host, Marielle conception family physician, DPC, owner, and former fee for Service. Doctor, I hope you enjoy today's episode and come away feeling inspired about the future of patient care direct Primary care. I'm Mariel Conception. I'm a family doctor. I just came from clinic and also host the podcast, my DPC story. And I am super excited to be joined by Jay Keese of the DPC coalition who arm in arm. We've been going to DC and talking to policymakers to make inroads. And we truly have as of this July 4th. So I will turn the mic over to Jay, and then I'm going to share screen so that we can go through our slide deck. Tha thank you everybody for showing up. I appreciate this coming to you live from the nation's capital. As you can see behind me, that is a fake background, but you know, we're, I'm, I'm, I'm pretty close anyway it's been it's been an interesting year. It's been a while since we've gotten together and part of the reason is that since the beginning of the year, obviously I think we've been, we've been very busy trying to make sure that pieces of the DPC agenda are, are, are covered and and, and are gonna be part of the congressional agenda. I think we've done a fairly decent job at that this year, because I think you can, I think it's suffice to say one of the top pieces of our agenda for the last 10 years making HSAs compatible with direct primary care has been mission completed. So we'll get into that in a minute. A a little bit of housekeeping. I don't anticipate given the brevity of the rest of the session that we'll be doing anything, anything else in DC this year. We will more than likely before April have a, a virtual meeting to begin to set the tone for the next session. But with that we can go to the next slide and, and and, and jump into jump into our timeline here. I think as everybody is aware I worked pretty closely with this guy on my right here named Garrison Bliss to make sure that we got as a part of the DPC coalition's first body of work, to be sure that we got a definition of direct primary care into the Affordable Care Act. We, we were, we were successful in that and then, then worked to pass 34, 35 almost state laws that. Sort of harmonized with the a CA provision. But, but, but one of the things that was clear from that definition is that the the department of Health and Human Services did accept the, the, the definition that was in the state law in Washington and is in all. The other 35 state laws as DPC being a medical service offered outside of an, of, of, of insurance regulation. And treated it as such the one area of federal regulations that did not, however, was the tax code. And, and as Marielle pointed out in HR one which has been referred to by a, a lot of, lot of titles the big beautiful Bill was the official name of the bill. But it was a series of major health tax incentives. And I wanna go over not only the provision that addresses DPC, but two other provisions that could work in combination with DPC. And we'll have some time to, talk a little bit about how these three provisions, two of them in particular, are gonna work together and, and potentially maybe um, in a position to change the way we get our health benefits in the long run for the better. And I do wanna make sure that we leave at least half of our allotted hour open for questions. So, we will take q and a after this is over. I'm think Muriel, we can do that as live q and a. And I think there's also a chat option as well. I see Muriel nodding, so, that should be good. But I really wanna have an open dialogue and make sure we answer all of your questions. So I guess we'll start with the rationale behind the primary Care Enhancement Act, which was, you know, this bipartisan bill that we was this rock. We've been pushing up the hill for well over a decade with very, very bipartisan support. We had Bill Cassidy, who is the a, a Republican physician from Louisiana. As our primary sponsor of the bill, he's chairman of the Senate Health Committee that had a lot to say about what was going into the legislation that went into hr, HR one, the, the tax bill. And we had, you know, Earl Blumenau, who missed that deadline by a few months, was retired before the end of the year, but was one of the most sort of liberal democrats. So we had a conservative Republican, a liberal democrat who worked hard on this legislation. Representative Jason Smith from Missouri, who chaired the house Ways and means committee representative, lloyd Smucker, who's a subcommittee chair on that committee as well, backed this so did Kim Schreyer from Washington State democratic physician, but we had, we literally had support from all over the place and took us a while to get it. But the, the, the IRS definitions of, of who is eligible to fund an HSA sort of did not include DPC because those, those rules that were set back in 2003 in the Medicare Modernization Act said that if you had a health savings account, that it had to be paired with a high deductible health plan, and that you could not have another health plan or. Other coverage which which, which, which provided things that were, even if they were only marginally covered things that were covered in the high deductible health plan. Since high deductible, health plans have to, to some degree cover, cover using an air quotes primary care direct primary care agreements, even though they had been been defined by the Affordable Care Act and 35 State laws was considered by the IRS, some form of other coverage that comes in between an individual and that high deductible health plan when funding that HSA. What HR one did it is adopted the language from the Primary Care Enhancement Act that says as long as you have a direct primary care agreement that's affordable and less than$150 per month, per individual per month, with a maximum of$300 per month that these, these funds can be used first and foremost to, to take out of your HSA and be spent on a direct primary care agreement. And it also, perhaps even more importantly says that if you have a direct, primary care agreement, you are no longer. As you were before January one of this year, as of January one of this year, you will no longer be ineligible to fund the HSA because of the simple act of you having that agreement with the, with the primary care doctor. So these are two really breakthrough concepts. Number one, that, you know, simply having a DPC agreement does not make you ineligible to fund your HSA and number two, that you can take money outta that HSA, it's triple tax preferred money. You can, you can, it, it, it is not, tax is not collected on that money when it goes into the HSA. It is not collected on that money while it is sitting in the HHSA. And then when you take it out and use it on direct primary care, it will not be taxed and you will also not be prohibited by IRS law from having an HSA. So obviously this is a major, major breakthrough for us to be able to work with high deductible health plans with HSAs, which now represent more than two thirds of all employer-based health plans that are offered. So imagine you going into business and direct primary care, looking at the private market and insurance and saying, well, two thirds of the people that are covered by employer based coverage, which is more than half of all the coverage that's offered in America, you're not gonna be eligible to work with DPC so that that ceiling has been taken care of. And now if you have an HSA, you're able to safely use your your, your HSA funds to spend that on the monthly fees for DPC. You're also able to continue to contribute to that HSA year in and year out, the maximum level of contributions every year while you have a DPC arrangement. There were two other provisions in the act in hr, one that were added as well. In addition to the primary Care Enhancement Act, one treated telehealth arrangements in a similar way that number one wouldn't be, wouldn't be treated as something that prohibits you from. From funding an HSA, and then of course, dollars could be taken out to pay for telehealth arrangements. Most of these are offered by employers. So all of these things, and presumably DPC agreements too, by virtue of where they're put in the tax code, would also potentially in a plan that is bundled together with DPC or with telehealth these would come before the deductible. So potentially in a high deductible health plan depending on the way the rules come out, not only is the DPC agreement and the telehealth agreement able to be used with the HSA if it's, if it's bundled in with an HSA agreement and a, and a health and a high deductible health plan it would, it would naturally, as primary care expenditures come before that deductible. So a$6,000 deductible if you spend a thousand dollars over the course of the year on primary care basically becomes a$5,000 deductible. In addition to that, another provision that I want to talk about, which, you know, really could be groundbreaking, particularly as we're in the dialogue that we are in right now in Washington about extending the a CA premium tax credits for another year or two and potentially making some changes in there. I'll get to those in a minute. The, the HR one also had a provision that says that. HSAs would now be compatible with high deductible health plans offered in bronze level plans and catastrophic plans in the exchanges. So imagine a world in which there was a bronze level or a catastrophic plan offered in an a CA Obamacare exchange that worked together with a DPC agreement where you could take your dp, your, your, your HSA money that you know whatever the employer or you are putting into the HSA and spend it on DPC. Another potential new growth area for DPC is working with both the payers and the individuals who own these bronze level plans. So, you know, really it's kind of on the DPC movement now to get out there and execute and and to begin to work with these individuals that are in the Affordable Care Act. Exchanges. I am one of those individuals. So it's gonna be interesting to see how this plays out for years, truly. And me and my wife, at least for the next few months before I get into Medicare. And you can see with my, my, my, my, my Medicare credentials right here. You know, I think it's gonna be very interesting to see how this plays out. But suffice to say between the employer markets, two thirds of which now offer HSA high deductible plans and the bronze and catastrophic level exchange plans, there is a big new market out there for HSA, high deductible plans and DBC. So I am gonna stop talking. I've given you sort of my overarching view of, of where we are at this minute. I do wanna talk about the IRS and the rulemaking process, which we are undergoing right now. But I'd be happy to answer any questions'cause I'm sure there's lots of questions about how do these work timelines. Whatever, whatever you have out there you wanna know more about the story about how we got here, I'm happy to talk about that as well. But let's let's open the let's open the field up Mariel for some questions. Yep. So, just as a reminder, Jay already mentioned he's going to be speaking at Hint Summit. It's gonna happen April 8th in Nashville, Tennessee. You can go to summit.hint.com to register for that. And Go ahead. Jeff Turner. Jeffrey Turner. Yep, go ahead. First of all, I just want to say thank you for the, the hard work that you guys have put in and in moving this forward. I know that it, it's taken a lot of effort, time, and just, you know, people in general. So I am actually not a physician. I am a health insurance broker. And I'm in Northern California, which is predominantly an HMO market. And we have very few DPC doctors in this area as of right now. But I have connected with a couple of'em and we've been discussing how we can bring this to the masses here, if you will. So I'm very excited about this because I think it's gonna give those of us that are in my industry that truly are interested in making changes and impacting the healthcare system, that this is gonna really give us another arrow in the quiver, if you will, to, to pro to move that forward. So my question to you, Jay, is kind of twofold in terms of, of my industry as a whole and then the carriers. Where do you see that this going in, in, in that regard? And let maybe the carriers, are they gonna kind of get on board with this? Yeah, good question. Well, I was just recently in Austin, Texas. I was invited there by the Texas Association of Health Plans to come and sit on a panel to talk about this. And I will tell you, I think because there is a large market of DPC in Texas unlike sort of Northern California where there, you know, mariel's up there, but maybe not too many other practices. But I think if you look at the map Phil SKU's mapper Texas has a lot of dots on it. So they are already familiar with this. Employers in Texas are really clamoring to do this, so there's a lot of attention around it. And I would say the and by the way, the American Association of Health Plans ahip did support this bill. So writ large, the National Group of Health insurers supported the concept of DPC being compatible with H dps, of which they sell a lot. And and, and so I, I, I don't really look at insurers as the adversary, sort of the way we saw them in the state legislatures when we were trying to get the state laws to define direct primary care as a medical service outside of insurance regulation. Because, you know, in that circumstance, the insurers were very comfortable with their state regulators, most of whom used to work for them. And, and it was a, it was a, a brave new world. DPC has been around a while. It's a known quantity. Insurers in Medicare Advantage are trying to do DPC or DPC, like things and I don't expect the pushback that we got over the course of the last decade from big insurance the way we have had it. Now, I don't have a great crystal ball about what things are gonna look like here in a year. Obviously, this ruling, since the rules are not out yet, has come too late for this coming plan year. But I would say this brokers or DPC practices that want to be either a part of a, a private insurance arrangement with employers, whether that's a. Being bundled into A DPC, you know, PPO or, or, or HDHP plan, or it's just making relationships with the payers so they know they're out there for these HSA plans to be able to use those. I think it's a good time to start exploring those relationships, those possibilities. And please just, you know, docs go look at this as a new market and not as the adversary as you've looked at the insurance industry in years gone by. They're gonna, Jeff, I think you probably more than anybody can tell them they're gonna try to, you know, screw you. No question about it. They're gonna try to nail you to the wall on price and things. If you're deal, if you're dancing with the devil, know who you're dancing with. But the reality is. These insurers are looking for things to create more value and there is nothing out there right now in the health plan market that I believe can create more value than bolting on DPC in some fashion. Now, this law allows us to look at two different perspective models. We've talked about bundling into a plan, and you know, Jeff, for you that might be like the ideal situation'cause you can use your services to get involved and and help create some of those. But it also envisions a world in which an employer can put.$60 a month into your HSA and allow you to go out there and pick whoever your DPC doctor is, which I think you know, let me see. Just in the visual show of hands, who would like that idea here? Right? Who among our docs here would like that idea? Can I see hands raising? I would like that idea. I think there's going to be a lot of excitement around, around that concept. But to be honest with you, I think that employers are probably looking for people to. Join into their ecosystem as they know it. So I would urge everybody to look at both of these kind of options. And I would say both. There's gonna be a thousand flowers sort of blooming from this, but look at the options that are gonna be on the table. It's gonna require a dialogue. It's gonna require you know, we, we do not have a unified national health system. So this is gonna be state by state, locality by locality, employer by employer. That's the way it works. But you know, folks like the Health Rosetta Group and, and you know, the, the brokers like Jeff, who are interested in DPC, have been good allies in this. The National Association of Life Underwriters, which is now called nabi, was a major ally in supporter of this bill. They joined Boeing and the employers, people like the Chamber of Commerce, the National Association of Manufacturers, the ERISA Industry Committee. You know, we had employers, Boeing, Amazon, major employers down to small employers, NFIB, and the local gas stations and flower shops. Everybody supported getting this on board to give more options into what, what is an increasingly you know, skinny environment in in, in, in the health plan world. So, long-winded answer, but I, I think there's a great opportunity here for both DPC and, and insurers to offer individuals a benefit that really brings a lot of value. Fantastic. We have another question from Dr. Duffy, but I will say before we get to that question this is an, an important time also for if you are wanting to get involved and make sure that we mold the future of where Direct Primary Care is going. The the best way is to go to DC and talk with your policymakers. And dp care.org is where you go to sign up for becoming a, a part of the DPC coalition. It's not just physicians, it's also policymakers patients, people who are advocates for DPC. So, Dr. Duffy is asking, how do we convince the patient that HSA is okay to use and that the funds count towards their deductible? Is there a form that is needed? How do they submit the expense receipt to have it count annually? So a couple of weeks ago we took a group of, of our allies in the employer world and the bankers and others into a meeting with the IRS. The IRS is going to the IRS is going to do a, a guidance on this. So if you, if you, if you go to the Internal Revenue Commission's the, the internal Revenue Services website, you will see pages and pages and pages of guidance on, on, on on tax issues. This is going to be issued more than likely, not as a, as a, as an administrative, a full administrative rulemaking, but as a guidance. So the IRS will on someday in the near future, hopefully nearer sooner rather than later. Publish. Exactly their guidance on how this works. So I think it's gonna be very simple. You will, will have a, a link or perhaps even a something can print out and put at, at your clinic that will show people exactly you know, the, the, the facts that the IRS approves of this now. And you'll have a good source there that's not just you, you know, you or the coalition, but it, it'll be the IRS. We had a good meeting with the IRS. I don't think there's going to be many surprises in this. There's one, there's actually two areas that we're working with them on, and we we're a little uncertain about exactly how they're gonna rule. But I have no doubt that as of January one there, there will be some kind of guidance from IRS before then that will say, you know, how, and, and the fact that it is you are eligible with an HSA now to have a DPC agreement and that you can use those funds towards your, your, your, your DPC there, there are some conditions, again, these have to be affordable agreements, less than$150. PMPM. They can't bundle. Pharmaceuticals or labs that aren't traditionally covered in a, in a primary care setting in into the agreement. And, and the, the services basically have to be for primary care only. So, you know, you can't offer primary care and you know, hey, we're gonna get you we'll do general surgery too. Things that would require anesthesia. You know, there's certain rules around it that the IRS is going to be, I think, pretty p pretty specific in their guidance that will say, these are the things that count, these are the things that don't. But we have no doubt that most people's agreements would be able to fall into this. I see. Phil Escu is on the line too. He may wanna comment on this a little bit, but. My, my, you know, we might anticipate that some people might have to make some discrete changes in their, in their agreements potentially, but, but, but more than likely not. So, so Phil, I don't know whether you had any comment, commentary on that or anything else. I've, I've said before we go to another question, but I, I think that this, this comes in the enforcement and legal side and, and, and Phil's a great source for that. So I, I agree with your interpretation, Jay. There, there you can make some small changes to try to fit in there, but ultimately they didn't have, they really didn't say what had to be in or excluded from the monthly fee. You're still allowed, you know, most people don't charge for an EKG, we include that, but there's nothing that says you couldn't itemize certain things. And in fact, they're encouraging you to itemize some labs and meds, which was already done by many state insurance commissioners anyway, that didn't like you bundling those in and subjecting yourself to price risk that that would change. Yeah, the legislation does actually for a definition of primary care. It doesn't look to a range of CPT codes or, or, or, or any, any site in the law. It actually looks to I believe it's 1833 x of the Social Security Act that describes for the purposes of Medicare, what a primary care doctor does. So basically it says if you are offering the services that an offer, that a primary care doctor who follows Medicare offers, then you're good. Our next question is from Dr. Tipton, can you review some of the main decisions slash strategies that will be in the rulemaking process for the HSA eligible funds to DPC? So, it's dovetailing off of what you just spoke of, but don't know if you have anything more to add. I don't work for the IRS, so I can't probably reveal any of that'cause I don't know. I will say that we had a very fruitful and polite and good meeting. They asked questions that seemed logical to ask, like. What is it that you all do, you know, for a monthly fee? And they, they asked a lot of questions around pharmaceuticals, around the price of pharmaceuticals and what did you charge? Did you charge anything special? You know, and we, we, we told them, you know, that as far as pharmaceuticals are concerned about. Three quarters of DPC docs dispense pharmaceuticals, but they're sold separately on a cash pay basis is the normal course of action. So they didn't seem to see, I mean, that's not all that different than Mark Cuban or cost Plus or any of that stuff. So the, there were not a ton of questions. We had been talking to the IRS for a decade and a half about this. The team that we've been talking to all of these years perhaps surprisingly or unsurprisingly, is still there. So, the, the lead, the lead person on this is the first person we talked about this, this, this inequity back in 2011. So we're, we feel good about where we are, we'll see exactly what the IRS says in a matter of, I would suspect a matter of days. So next, Dr. Canarium has a question. Will FSA be treated the same way as HSA and then Dr. Chaco, I'll call on you next? No, FSAs are treated differently in the tax code than, than than, than HSAs and FSA at the end of the year has to be turned back into the gu, into the, into the, into the, into the employer. So, but there was never a restriction on using you know, on, on having an a, an HSA, excuse me, an FSA with DPC. And you know, I think that the the, the. 2019 ruling out of the transparency executive order in the last Trump administration, if it hadn't been clear before, made it pretty clear that DPC services, as long as they were all primary care services, were qualified medical expenses. So no hangup using an FSA or an HRA health reimbursement arrangement with your DPC before this or after a no change, basically. Okay. Go ahead, Dr. Chaco. Regarding pricing and how the rule is written, the 150 a month. I know there's several questions in the chat. What do you do if your pricing is above one 50? That is not my question. My question is let's assume the membership is gonna show up on the invoice. Primary care, direct primary care, one 50 a month. Can you still bill it annually? Can you bill it? Is it okay to bill that one 50 per month upfront? Annually? Because we do that for year one. Patients are good with that. We're good with that. We are aligned with the one 50 a month. But I just, I, we looked at the rule. I talked to people at Hint, they said there's nothing in there to say otherwise. I just wanna get your opinion on that. It's a good question. We have not we did not bring that up with the IRS that I'm not, if not, I'm not mistaken. That's a, that's an unusual practice. It's a practice that's much more akin to a concierge fee for non-covered service practice. The I think the language says periodic fee and, you know, I, I think a year is a period. Yeah, I know there are states that are different. Like Washington State has a different rule. I'm in Florida. We don't have that rule. We do it that way just because clinically we believe it's most aligned. Like, I want you the whole first year before, you know, but anyway, so, so we're just gonna label it like one 50 per month, direct primary care membership and bill it. But like, that's a question that I would love to like, I don't know, hopefully not get screwed on. Well, here's, here's the good thing about guidance. Guidance is sort of like, living law, right? So when the IRS publishes a guidance, it's never final. It isn't a notice of final rule. It isn't, it isn't, you know, we've made, we've proclaimed from on high. It's like this is the IRS's view of this in a snapshot in time. So if there is pushback to that, which I, I think there's lots of ways that you could do your billing where there wouldn't be any pushback. Then, right. Then the worst thing that happens in that situation, is that you would ask the IRSA question of whether or not this is okay. And they will get you an answer and I would rather not ask. Right. But, and I was about to say, never ask the IRS or anything, you don't know what the answer to the question's gonna be. So, and, and also just to clarify, given all the great data on virtual primary care being still sort of acceptable, this will apply to a direct primary care virtual relationship. Correct. It applies to a, a, a telehealth agreement, whether it's direct, primary care or not. So, but it certainly applies to telehealth in a virtual agreement for direct primary care services. As long as those services are all primary care. Excellent. Thank you so much. And if anyone ever hears otherwise, somehow I'll hopefully find out. No, I think, I think you're gonna be okay. Again, Phil, unless you have any difference of opinion. I, I think the, the legislative language cer certainly allows for it. And if we did get into a, a shoving match with IRS about it, we could certainly have members of Congress who wrote the bill do some oversight and tell the IRS Hey, that's not, that wasn't our understanding of the, of the legislative history of the language. So I, I got it. I don't put this on a DEFCON four scale right now. I think you're gonna, I think you're gonna be fine. I'll be fine. And I know, and last thing I'll say, I know that there is a difference between the DPC world and the concierge world, but this is very much based upon a one 50 a month membership fee fee. Yeah. And that number isn't, is not by mistake. If you look at what M-D-V-I-P charges for an annual agreement, that's the baseline. So, you know, I think there was some thought behind that. We didn't ask for that, by the way. It was put in there to, to, to temper the, the, the high score of the bill and the score is, you know, what, what the bill would cost in, in, in lost re revenue to the treasury and, and, and, and look people, this is a$2.8 billion tax cut that was given to the American people to allow them to spend that money on you. So this is a pretty good deal. So I would say this, if you are charging more than 150 a month, you're probably well above the norm and that's fine, but. You are, you are gonna be operating under current rules. There is no change for you. In other words, if you are operating like this before, you're gonna be able to operate like, like that afterwards at$150 a month. You just simply won't be compatible with an HSA high deductible health plan, an individual that has an HSA high deductible health plan and your decision is, do I lower my price or do I not offer it to people that have HSAs? I don't see a problem with this. At the federal level, they never made a stink about exactly what the frequency of periodic needed to be. Lots of states do, and so you, you're gonna, you're gonna find yourself with an escrow burden. And if you try to enforce those kinds of things and say certain things are non-refundable, you'll also find yourself burdened with board complaints. So it's generally something I discourage for a variety of reasons, but in the specifics of this tax discussion, I don't think it's gonna make a big deal. Thank you for that. The next question is from Kai Ida. So if our membership is$200 a month, can patients still use$150 a month from their HSA and$50 a month out of pocket? No. Next question is Dr. Valla, excuse me if I butchered your name. If our DPC fees are above 150 then is our clinic ineligible or can patients pay partially with HSA? Same question. No, it's pretty clear, folks, you, you to qualify for the exception. To qualify to be part of this$2.8 billion tax cut that was given the American people, you have to charge less than$150 a month. It was designed for affordable. It says affordable direct primary care agreements right in the language. So, the Congress is determined for the purposes of HSAs only. What, what, what that means. You can charge whatever you want to somebody that doesn't have an HSA, but if you want to be subject to these new rules, you, you know, that that fee has to be less than$150 a month. The next question is from Dr. Canarium. Does the bill clarify who can do quote unquote primary care? IE can a naturopath be considered a primary care and do DPC as well? That is still gonna be completely up to state law. The Medicare title does have some things to say about it, but it is that we can get, we can get you the site there. I believe it's it's part of the Social Security Act on, on who is a primary care provider. So me, Medicare has some thoughts about that, but and, and I, I, I do, I do think that, that the IRS will probably weigh in verbally on, on, on what they are and, and, and, and, and itemize those. But if, if you are eligible to bill for primary care services under Medicare, whether you're a Medicare participating provider or not, if you would be eligible, you would, you would be in this. And I don't know what, I don't, I don't are naturopaths in that. I know they are h where they have, where they have prescribing rights. Arizona comes clear on that yet. Money? Yeah. Okay. Yeah. Next. We'll I mean, you know, this was designed to not be a scope issue. So we, we we purposely didn't want go down that path for lots of reasons. Number one, we would've never passed a bill. Num number two again, it is a state by state thing, so by and large, the federal government lets the states do their own things with regard to you know, licensure and the business of healthcare for, to the state. So you're gonna really be looking to your own state to, to, to what, to what that is. But I think you guys, it's safe to say the do and the MD crowd here has a leg up on everybody in this market. And again, especially if you have more questions, this is where joining the DPC Coalition is a great place to ask these questions, especially because the DPC coalition is on the forefront the next question is from Greg Miller. If I sign up a family of eight people, can I charge more than$300 by using h? No. It's it's, it's$150 or 300 for a multi multifamily agreement, and I realize that that. Is, is, is is difficult for for, for some folks here. I think there's probably workarounds to this by having separate agreements for the kids and stuff, but there's no requirement that you offer a family agreement at all. Yeah. So I think you're, I think well, I think you again, we'll, we'll, we'll see how that plays out. I, I don't, I don't really know, I don't really know the answer to, could you have like, you know, six six child child agreements and that, that sort of thing. I, I, I also think at a certain point you know, the market's gonna drive this. And it's gonna drive behavior in terms of what, what you're charging if we're gonna grow new DPC practices. I, I know my, my wife and I are at the point now and in our practice where I'm about to go on, on on, on Medicare and, and you know, we understand we're utilizing more at, at 65 and it's brushing up against that, you know, maybe 300 bucks. 300 bucks A-A-A-A-A month. But but again, I think that's still on the high side in the market. That's certainly what the surveys have said. And and my bigger concern here is, is this gonna, you know, is this gonna cause the new market based price to be 150 bucks? I don't think a lot of markets will bear that because the national average is now 75. Or roughly there. I think the, the hint hint guys did a survey on this and we're about to get the survey back from Milliman, the, the next survey back. Well, we should have that at the April summit, so we'll have some new data on that. But but yeah, this wasn't intended to drive price. It might and I think if it drives it, it'll, it'll drive it up. But you know, the reality is it's still well within market range, and it is indexed every year for inflation. That$150 and$300 are indexed to the CPI every year for inflation. So that'll go up just like the HSA number goes up. And that answered the last question that just came in from Dr. Martin. But when it comes to a follow-up question about family agreements do they clarify what is a family? Is a physical, is it a physical household? And if you break it up for HSA multiple, all individuals. Yeah. So that answers Dr. Karim's question, that the next question is could we price discriminate? Could we change, could we charge$150 a month to folks with HSAs and$200 a month to everybody else? Yes, I believe that'll be fine under the, under the rules, unless the IRS, you know, freelances and says, no, you can't. But I, I don't, I don't, I don't anticipate that happening. So Jay, I was thinking what if the delta, you know, the difference, the doctor saying, oh, I can't charge more than$150 using HSA dollars. What if the employer provided HRA dollars to help offset those expenses? I think it's I think the IRS is going for the, for the HSA exclusion is going to look at the contract and the agreement, not, not what the employer is putting into the, into the HSA. You know, the HRA, the main problem with the HRA is that not a lot of people use it. It's a perfectly good vehicle. And in fact, it's a, it's a, it's a natural vehicle. If you wanted to put$60 a month for each employee into an HSA, so they could spend it on DPC, if they wind up not spending it, it goes back to the employer. So there's an incentive on the, on the employee to spend it. Both of them are good models. I am not sure about the tax status of using both. I don't, I don't know. Phil might have some thoughts on this. I. I don't know why, I don't know why you would do it, but I don't, I don't know that there's a prohibition against having a hybrid plan that puts a certain amount into an HSA and a certain amount into an HRA. I can't think of anybody who's doing both the, remember the Fs, the FSA and HRA were already not a problem because they rely only on two 13 D and all we had to fix was 2 23 C with this, right? Mm-hmm. Yeah. I just, and to Jay's point earlier, if you were, if you've got some people that you're charging 151 and some people you're charging 1 49, the point behind the 1 49 is to give them a bright line. Clear cut. Very conservative tax approach where they're making an argument that it's not a gap plan for the 1 51. You could still do that and the patient can decide on their own if they wanna make a tax argument out of it in the event they're audited. And I still don't think they will be because the IRS hasn't done that in a decade. And then Garrison, I think Garrison Bliss. Yep. Yeah, go ahead Garrison. I just wanted to, to say a couple of words to the DPC people that the demand is about to go up. In a big way. And the tendencies, this is where you have to start worrying about the good news being a problem, which is you're gonna have to choose where you, where you wanna go, who you wanna take care of, which, which deals you wanna take. When it comes to dealing with you know, plans. Make sure that you, that, that, that you are controlling the rules. Don't just sign something'cause they hand it to you.'cause that's how we got in this problem in the first place. And the other thing that I really wanna make sure everybody understands is we still take care of our patients and don't do something that will make it hard for you to do that. It's gonna be tempting. To have a panel of 800 people, it's gonna be tempting to raise your price to the point at which a lot of people can't afford you. As this demand grows, it's also gonna be tempting to be sucked into a deal with somebody who's, who is you know, venture capitalizing us. And who wants to make use of us. Suck it dry as much as they can, collect as much of our money as they can, and then wander away and leave us with huge panels and no way to get rid of the, the burden that we have. So I I I, I want you to remember that you should still have contracts for people. It should. And the purpose of the contract, it is to make sure that they know what it's gonna cost. And you know what you're promising. The promises are what drive this. This is healthcare, right? So be, be sure that we don't get too much in business gear, that we understand that we are here to serve. And also that if things start getting crowded in your office, get, get a partner. Start expanding this. We need a lot of people doing this. We need probably to triple the workforce in primary care, maybe more. So it's time to open the door for everybody else. Let them know it's safe to come now and start having contact with your, the medical schools near you, do all the things that we have to do to, we have to demonstrate that we can, we can grow and not have our, our care diminished. So I'm just, I, I'm encouraging everybody to remember what that the central drivers of primary, of direct primary care so that we don't get sucked into great deals that make us a lot of money or someone buys us out and then, and then destroys our practice. So all of those things but I, I'm just glad we're here. This is the place we wanted to get to, and now we have to start thinking about how are we gonna make this available to everybody in the United States at a reasonable price and make it real care. Don't, don't create a practice which you can't take care of. Jay's got not only a thumbs up at hearts, and so yes, I love that we're talking about healthcare and not insurance. And Jay has said before, there is a day that direct primary care will simply be primary care. So with that Jay, as I wait for any less minute questions to come into the chat can you share with the audience how can people get involved if they've never talked to their policymakers, they've never talked with an insurance broker before? How do people get involved? I wanna say, I wanna thank you Marielle for moderating this today and, and, and, and for all of your amazing advocacy in your work. On Capitol Hill, the, the, the best and, and, and most efficient way is for you to join the Direct Primary Care Coalition. The, you can go dp care.org, click the join button, join us. As I said, we won't be having any additional fly-ins this year, but next year we will. And lemme tell you one of the things you've probably heard recently, the president has made some remarks about the idea that instead of extending the a CA premium tax credits, maybe we ought give that money back to the people and put it into an HSA so that the people can spend it the way they want. I will say that we're in pretty deep negotiations with several senators on what this might look like. I think the odds of this winding up in the next few days in whatever final agreement we have on these tax credits as a solution are, are fairly slim. But I will say that there is growing bipartisan support for the idea that we, we, we, we could help people afford a better a CA bronze level plan, which now we can do with these new tools that are in HR one and that DPC will be a part of that equation. So, we're excited to be a part of that conversation. We think it'll take a couple of, probably a couple of years to get anything like that across the finish line if it does get across the finish line. We're also working pretty closely with CMS on the next round of CMMI innovation models to see if we can get a model where. You know, maybe you can take this HSA money and use it, you know, use it on, on your DPC in Medicare. So, lots of different ways to skin that cat. Don't wanna get into too many, too many details today, but if you wanna be a part of the conversation moving forward with your colleagues in the industry, we work by consensus. Join the coalition and, and, and come and join us. And uh, you know, any, anybody that needs any specific help with a legislator, feel free to reach out to me directly. Feel free to reach out to Maryelle, who works pretty closely with us on the advocacy side of this. And we'll, we'll make sure you have you know, as a member of the DPC coalition, access to any of the information you need to to help, to help with that. And it really doesn't, it's not limited to just, you know, what do I say to a person? For example, in California, we don't have law that protects DPC as of this di this recording. But, you know, I had some frustrations around my husband getting eliminated and our patients in our area no longer having access to an insurance accepting doctor that offered full scope care. And that is what I call Jay about. So literally, if there's any frustrations that you're having about, this is so messed up that this is happening in our community and you don't even know who to talk to. DP care.org is where you go. Well, I wanna thank you all for being such strong supporters. This was a long journey. You know, you know, the Chancellor of Germany, Otto, of on Bismarck once said one who likes fine sausage or legislation should watch neither being made. I think this is a perfect example of that. It took us well over a decade to get this done, but it's good. We've done good things for the American people. We've, we've, we've said to the American people, we want your health benefits to be better. And we want them to include your ability to choose the doctor of your choice and pay'em outta your own money that your employer's putting into your HSA or you're putting into your HSA. And I think that's a really good foundation from which we can build and grow. And you know what everybody says, world domination for DPC, right? Amazing. Thank you everybody for joining today. Thank you so much, Dr. Bliss, and for Jay. Thank you both for your work and getting us to this point. Thanks for tuning in to My DPC Story. If this episode inspired you, please leave a five star review on Apple Podcasts. It helps more physicians find these stories when they need them the most. If you're new to DPC, you're just beginning your journey. Head to the Start Here age@mydpcstory.com. I've put together a practical startup guide and highlighted the episodes I think are essential for beginners. Got a question or a challenge you want to hear addressed on the show? Go to the Contact Page mydpcstory.com and leave me a voice message. And be sure to check out our my DPC story, Patreon. As a member of our Patreon, you'll find commercial free episodes and extended versions of the regular episodes. There's something for everyone with both free content and a paid tier that helps support the show. Follow us on socials@mydpcstory and check us out online at mydpcstory.com. Until next time, this is Maryal Concepcion.