Should health insurance include primary care?

Insurance protects against losses from unexpected events. Health insurance that protects against the unlikely risk of major surgery or hospitalization makes sense, since the financial impact of a major medical event can be devastating. Primary care is different. Frequent visits to a primary care provider (PCP) are expected to promote health and diagnose and treat conditions that are not catastrophic. We need to differentiate sick care from health care.

There are common, but low emergent, health conditions for which many of the nearly 210 million adults in the United States may experience in a given year, including chronic pain (50 million), diabetes (34 million), anxiety (40 million) and major depression (16 million). Although these conditions are not rare, the treatment is included in the same insurance plans as costly unexpected acute events, such as gallbladder removal (1.2 million), total knee replacement (715,000) and coronary artery bypass surgery (200,000). 

Primary care is designed to treat the whole person through the diagnosis and treatment of acute and chronic conditions, as well as address health promotion and disease prevention. According to the American Association of Family Physicians, primary care services should be integrated and accessible. A visit to a primary care provider is not an unexpected event, and conversely, should be encouraged to promote health and manage chronic conditions.

Similarly, there is strong demand for behavioral health care among American adults. The majority of adults want mental health services for themselves or family members, but many are unable to obtain it. Improved access to treatment for depression and anxiety can help with chronic disease management, as well as deliver a significant return on investment. A 2018 study revealed that lack of access to mental health services is one of the root causes of America’s mental health crisis. Barriers to treatment include high cost, insufficient insurance coverage, a dearth of local providers and social stigma.

Chronic pain is another high prevalence condition that can be overtreated, undertreated and even mistreated. Spine and joint surgery is overutilized when conservative approaches can produce similar results that are less costly with lower risk. Physical therapy is underutilized, since only 7 percent of low back pain patients use physical therapy as a point of entry for evaluation. Mistreatment can occur when opioids are routinely prescribed rather than using conservative treatment with NSAIDS.

Insurance coverage for high value and low cost services such as primary care, behavioral health and physical therapy is problematic, particularly when patients must pay deductibles, copayments and coinsurance to access these services. That does not mean employers or the Centers for Medicare & Medicaid Services (CMS) should not offer these benefits, but rather these should be available outside of a major medical insurance offering.

Some employers are choosing to bypass third party insurers by directly contracting with primary care providers on behalf of their employees. This is known as direct primary care (DPC). DPC is a membership-based model where patients (or employers) pay a membership fee directly to a primary care physician or practice for unlimited onsite, virtual, text and email access to a PCP. Costs vary by practice and geography, but usually average less than $100 per month. DPC also appeals to physicians who don’t want to deal with insurers. However, fewer than 2,000  of the more than 200,000 primary care physicians in the U.S. currently participate in a DPC arrangement.

Access to primary care and behavioral health care, as well as physical therapy, was previously limited to onsite visits. Recently, virtual access has accelerated as a result of the COVID-19 pandemic, which has meant greater opportunity for virtual care providers such as Teladoc, Doctor on Demand and First Stop Health. Unfortunately, when these services are available to employees, they are typically part of the overall health insurance plan. Deductibles, copayments and coinsurance still apply, and these services represent an additional expense to the employer.

Besides DPC, employers are also bypassing traditional insurance to contract with fee-based pharmacy benefit managers that do not rely on spread pricing or rebates, as well as negotiate direct access to centers of excellence that utilize reference pricing for surgery and diagnostic imaging. The employer can then purchase stop loss insurance to protect against high cost claims.

Primary care is the epicenter of health care. Over the last 30 years, hospitals, health plans and pharmacy benefit managers have become dominant players in health care financing and delivery. Employers and the 160 million employees and dependents that rely on them for their health care are beginning to disrupt the status quo.

Steve Delaronde is senior manager of product, population and payment solutions at 3M Health Information Systems.