May 21, 2012 - The New York Times
By Bruce Japsen
On the road 50 hours a week, the drivers who work for Becker Trucking, headquartered in Seattle, have little trouble finding cheap eats at the all-night diners lining the interstates of the Pacific Northwest.
But many drivers were struggling with chronic poor health, and the company’s health costs were rising fast. What his employees really needed, the company president realized, was better access to doctors.
So he turned to a novel solution. Becker pays $54 per employee per month to a primary care provider called Qliance. Employees get unlimited doctor visits, 24-hour e-mail access to the medical staff, and same-day or next-day appointments. There is no insurance involved in their primary care: no expensive premiums, no complicated claims, no mysterious denials.
“Drivers are notorious for not being the best in using health care,” said Frank Riordan, president of Becker Trucking. “But now they can go into the clinic as many times as they want, and participation is high.” Two drivers no longer need blood pressure medication, Mr. Riordan added.
This type of health care model is called direct primary care, and it is getting a closer look not just from businessmen like Mr. Riordan, but also from researchers and government officials who see it as an effective way to lower costs.
“It is a very promising and good model,” said Dr. Arnold Milstein, a professor of medicine at Stanford University and head of the Stanford Clinical Excellence Research Center. “It is speedy and economical, and these practices are making themselves available to working people.”
Direct primary care derives from an unlikely source: the so-called concierge practices that began appearing a decade ago, catering primarily to the affluent. Concierge practices generally do not accept insurance, either; instead, members are charged thousands of dollars annually for unlimited access to their doctors.
The setup often is lucrative for doctors but “less accessible to patients who cannot or choose not to pay a membership fee,” according to a federal report issued in 2005.
“The concierge model carries a lot of baggage in being health care for the wealthy,” said Dr. Erika Bliss, a family physician and Qliance’s chief executive. “We want to grow this and bring the price point down to average Americans.”
Call it concierge medicine for the masses. The idea is that routine, mundane primary care should not require expensive insurance and can be cheaper without it. Direct primary care practices charge $50 to $60 a month for adults, with lower fees for children. Depending on the practice, the monthly fee also may cover certain lab tests, basic X-rays and stitches for cuts.
But the fee does not cover anything beyond primary care. Typically employers combine direct primary care with high-deductible insurance plans, needed to cover hospitalizations and visits to specialists.
“Health insurance is supposed to protect you against risk, like car insurance does,” said Dr. Bliss. “We don’t insure our cars for tire changes and tune-ups.”
Even though Becker pays Qliance for primary care and pays half of each worker’s $5,000 annual deductible for insurance, the company’s costs dropped 11 percent in 2010. Costs had been rising about 14 percent annually, Mr. Riordan said.
Doctors who work for Qliance are salaried, Dr. Bliss said, reducing the financial incentive to order unnecessary tests. Direct primary care practices keep costs low by sidestepping the bureaucracy associated with insurance and reducing unnecessary and expensive trips to the hospital or emergency room, she said.
Direct primary practices are also less likely to refer to a specialist for something they can handle themselves, Dr. Milstein said.
Such practices already operate in 24 states, treating more than 100,000 patients, according to the Direct Primary Care Coalition. Physicians at Qliance, one of the larger practices, will care for more than 10,000 patients this year, double last year’s number. Another provider, MedLion, headquartered in Monterey, Calif., plans to open clinics in Miami, New Mexico and Oregon, according to the company’s chief executive, Dr. Samir Qamar.
Clients tend to be individuals without insurance, small businesses and unions.
Jan Mayrhofer, a 61-year-old bookkeeper at Safeway, is enrolled in Qliance through her union, United Food and Commercial Workers Local 21 in Renton, Wash. Direct primary care has been a dramatic change from traditional care. “I have never waited longer than five minutes in the waiting room,” she said. “And I don’t feel like I am being rushed.”
She may soon have more company in the waiting room. If the Supreme Court upholds the Affordable Care Act, direct primary care practices will be permitted to offer plans on state insurance exchanges by which millions of uninsured Americans can shop for coverage once subsidies are available in 2014.
At the moment, however, laws in many states make it difficult for physicians to contract directly with patients; such an arrangement is sometimes viewed as a form of insurance, subject to regulation because states view it less as a doctor practice than as a prepaid health plan.
But direct primary care may well have its biggest impact in Medicare. Officials are desperately seeking ways to rein in the rising costs for the more than 48 million beneficiaries in the program.
A bill introduced late last year in the House would create pilot programs in which direct primary care is offered to Medicare beneficiaries. Monthly fees could not exceed $100 for Medicare beneficiaries. The practices in the pilot would have to provide services that include primary care, wellness counseling and preventive services with the ability for patients to make appointments seven days a week and have 24-hour access by phone for urgent care consultations.
Without a change in federal law, doctors who contract directly with patients cannot treat Medicare patients. Direct primary care doctors tend to be those who have opted out of Medicare and can charge whatever they want, but they cannot bill Medicare for reimbursement, nor may their patients.
“Our doctors do have to drop out of the Medicare system, because there are laws that don’t allow physicians to charge rates lower than Medicare rates,” Dr. Qamar said. “We think we can save money for the Medicare program and improve quality by preventing downstream admissions.”