When Doctors Dump Insurance for Subscription Model, Who Benefits?

Dr. Lorraine Page with one her patients, Ann Caponio, 59, in Half Moon Bay, Calif.  (David Gorn/KQED)

Dr. Lorraine Page, believe it or not, makes house calls.

One place she visits is the home of Ann Caponio, a one-bedroom apartment in Half Moon Bay, California. You can tell a knitter lives there: baskets of wool and hanks of yarn adorn the room, and in the corner sits a wooden spinning wheel.

But arthritis has put an end to that hobby. And for a while, Caponio, 69, wasn't even getting out.

"I kind of stopped going downtown," she says, in her Midland, Texas twang, a holdover from childhood. "Omigod those stairs."

She's talking about a steep, 17-step staircase leading to her front door. Three hip replacements left negotiating them a dangerous proposition.

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"I tend to fall. And I fell on those damned stairs once."

And that's where Lorraine Page enters the picture.

Besides the house calls, Page provides a little more than Caponio might expect from a primary care doc  available through Medicare. Page, for instance, has aided her patient with a number of safety issues, including helping her find someone to rig up a chairlift on those stairs. Now, she can sit on a seat at the top and glide to the bottom.

"It opens up a whole new world for me," Caponio says.

A Different Model

A whole new world is what Dr. Page herself has been experiencing, ever since she left the traditional clinic setting to try something different. She does have a small office, but prefers to visit most of her patients in their homes.

She's one of a growing number of doctors who have cut loose from what she calls the "assembly-line, volume approach" that most of her colleagues have experienced. These breakaway docs are now using a health care delivery model called direct primary care. Page has cut back on the number of patients she sees, and spends more time with the ones she does. She doesn't take insurance and deals mostly in cash. Page charges each time she sees a patient, but most direct primary care doctors bill a monthly fee for unlimited visits.

In her previous practice, Page says, the pressure to see more patients in less time wore her down, as did the need for an army of support staff to process the copious paperwork required by insurance companies.

"At our office, we had six full-time doctors. And we had seven full-time insurance people. So [that's] more than one full-time person trying to get reimbursement for patients I was seeing."

The benefits of leaving that bureaucratic load behind includes more time with patients but shorter days as her total load has been reduced.  And she's doing the kind of family-care medicine for which she was trained.

"And I enjoy it a lot more," Page says. "Let's not minimize that."

What Doctors Want

A 2012 Medscape study found that 46 percent of primary care physicians showed such dissatisfaction with their careers, they wouldn't pursue medicine if they could choose again. Another study, from the Physicians Foundation, found 60 percent of primary care doctors would not recommend a career in medicine. Just six percent described the morale of their colleagues as positive.

Overall, says Wanda Filer, president of the American Academy of Family Physicians, primary care doctors feel overworked and ineffective. "Most patients are just rushed out the door," she says. "That's not what doctors want to do. This new model of care gets the physician and the patient out of that hamster-wheel model."

Filer says about three percent of the organization's 69,000 primary care doctors have made the move to direct primary care in the past couple of years, and that number is increasing rapidly as other physicians see it succeed.

In fact, Filer says, her organization has taken the unusual step of convening informational seminars for the large number of family doctors who have expressed interest in getting off the grid and starting a kinder, gentler practice.

Cash and Care

Dr. Emilie Scott of Irvine, Calif.
Dr. Emilie Scott of Irvine, Calif., says the direct primary care model has put 'the heart back in medicine' for her. (David Gorn/KQED) (David Gorn/KQED)

While direct primary care has some similarities to concierge medicine, it differs in that direct primary care rejects insurance. And, because concierge medicine sprang from wealthy patients’ desire for greater access to their doctors, patients can pay up to thousands of dollars a month for same-day appointments, round-the-clock phone access, house calls and other services.

In contrast, direct primary care doctors charge a relatively small monthly fee. While that can be an extra cost for those who also need insurance to cover more serious medical problems, many patients have high-deductible plans, making the monthly expense of direct primary care a good deal, especially for those who go to the doctor a lot.

For doctors, the main idea behind direct primary care is to simplify -- scale down, deal mostly in cash and focus on taking better care of fewer patients. This includes a good deal of listening and analysis of how a patient's current environment or life situation may be affecting their health.

This type of service took off as a movement in 2011, and the model was first evaluated in a 2013 study by the California Health Care Foundation. It's gaining significant traction, says Laurence Baker, the chair of Stanford University's Department of Health Research and Policy.

"Absolutely it's a growing segment of primary care," he says. "The model we have is challenged in a lot of ways, the longer a patient waits to see a doctor, the shorter time spent with the doctor. So we have to think about what else we can do to change that.

"I would be surprised if it took over the world," Baker added, "But I certainly wouldn't be surprised if it grew substantially more in the next few years."

'Doctors Will Be in Mass Exodus'

The reason doctors need to see so many patients in rapid succession is because of huge overhead, says Pamela Wible, a physician in Eugene, Ore., who helps doctors set up their ideal practice using the direct primary care model. In fact, she says, most doctors see just a small fraction of gross earnings.

But the kind of streamlined operation found in direct primary care allows doctors to keep a greater share of the money coming in, she says, even if they make less overall than in a traditional practice.

"My expenses are so low, they're now about 10 percent of my practice," Wible says. "And it used to be 74 percent."

Wible says the direct primary care model has at its heart the relationship between doctor and patient. She says doctors "will be in mass exodus" once they learn they can run their practice differently and "get off the production line."

Dr. Emilie Scott did just that, in March.  She had worked in an academic medical setting for many years, then in a large group practice for another five before venturing out on her own.

There are no waiting room magazines in her tiny Irvine medical office, because there is no waiting room. And that's because there is no waiting.

She charges her patients $59 per month. Just five months in, she says, her practice is already breaking even.

"For me, it puts the heart back in medicine," Scott says, grinning. In the past, "I had to see patients in a rapid style, trying to get patients out the door. It wears on you."

She understands the fear some doctors have of taking the leap, in part because of the massive debt they've incurred from medical school. But, she says, "The point here isn't to become a millionaire. You make a good living, and you can practice in line with your values."

Scott said some of her patients are surprised at how little her service costs.

"I had one woman who said she couldn't afford it but said she'd listen, and then I explained it, and she was like, 'Are we on Candid Camera or something?  What's the catch?'"

Shrinking the Physician Pool?

Janet Coffman, a health policy professor at the University of California, San Francisco, says she doesn't expect direct primary care to explode on the medical scene. Rather, she believes it will make slow and steady inroads. She doesn't think insurance companies will fight the model, even though it cuts them out of the medical care delivery system.

But one major effect direct primary care could have, she said, is to further shrink the already inadequate pool of primary care physicians.

"If I were an insurance company, I think I'd be more concerned about recruiting and keeping PCPs because of this," Coffman says.

Betsy Imholz,  director of special projects for Consumers Union, agrees that could be a concern if direct primary care catches on.

“Primary care is one of the least lucrative areas for doctors to go into,” Imholz says, “and therefore sometimes difficult for insurers to get sufficient numbers of.”

Imholz sees some other potential problems with the model.  While she understands why both doctors and patients are attracted to direct primary care — “the old Marcus Welby model,” as she puts it — she thinks it’s a move in the opposite direction of the current push for an integrated health care system. Ideally, doctors would have access to patients’ electronic health records, and all-payer claims databases, at least theoretically, would allow purchasers of insurance to compare costs.

“It goes against this coordinated care model that the Affordable Care Act and the U.S. is coming to,” she says, “having things not fragmented but coordinated [in a way that] enables us to check, make quality assessments.”

Imholz is also concerned this type of practice could attract healthier people, who might see direct primary care as a substitute for insurance rather than an extra. And that could deprive the ACA risk pool of the very type of patients needed to keep cost increases manageable.

Consumers in California, Imholz said, should also keep in mind a little-known benefit of the plans offered on the state’s health care exchange, Covered California: those plans are required to offer three visits outside of the deductible, costing only a co-pay.

Ultimately, she says, if patients do want to go the route of direct primary care, they should create their own personal health record for each visit, in case at some point they need to visit a specialist for a serious health problem.

As to whether direct primary care will positively impact patients' health,  Laurence Baker says it's not clear whether or not the longer office and home visits end up providing better care.

"I'm not sure we know if this makes you healthier at the end of the day," Baker says. "It will make you happier, definitely, but the jury is still out about whether it improves outcomes."

'It's Lovely'

Back in Half Moon Bay, physician Lorraine Page says she doesn't need data. She tries to find the words for the improvement she has seen in her life and the lives of her patients.

"It's … lovely," she says with a laugh. "It's just lovely. The patients do better, I get to see the whole person, the whole family. It's true family practice. And it's very straightforward. I see the person, I get paid. It's simple."

This type of practice, she says, is what many young doctors-to-be have in mind when they first think about entering medicine.

It's an odd twist that Page's current work is considered the cutting- edge of primary care medicine, when it so closely resembles a kind of 1950s Norman Rockwell painting of what a general practitioner is.

Most doctors don't even think about what they want anymore, Page says. They get caught up in the system and don't realize there's another choice.

But leaving was surprisingly easy.

"Look, your skills are in your mind," Page says. "You can do that anywhere."

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Jon Brooks contributed to this report.

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