Wednesday, June 20, 2018
Health

A different kind of doctor's office: Patients pay directly, keeping insurance out of it

CLEARWATER — Dr. Trinette Moss runs her family practice a little differently than most physicians.

Instead of taking insurance, she prefers cash, check or credit card.

Billing at her office works like this: Patients between 18 and 49 years old pay $60 a month. The fee covers unlimited office visits, urgent care services and an annual physical. It costs $15 a month to add a child.

Moss says the model, known as direct primary care, makes financial sense. She doesn't have to hire anyone to file and track insurance claims. And she collects enough in monthly fees to keep her practice small.

"You know your patients better," she said. "You have more time to spend with them."

Moss isn't the only physician who likes the concept. Since Congress passed the Affordable Care Act in 2010, the number of practices like hers has jumped from about 20 to more than 400 nationwide, according to the Direct Primary Care Coalition.

The number could soon grow in Florida. Lawmakers are considering a proposal (HB 37/SB 132) that would ensure direct primary-care providers don't run afoul of state insurance laws, paving the way for more doctors to contract directly with patients.

"This is a cost-efficient way for physicians to deliver care, and it's affordable for patients," said Tim Stapleton of the statewide doctors association, which supports the bill.

The concept of direct primary care isn't unique. It bears some similarities to concierge medicine, which also requires patients to pay a monthly fee.

There are some key differences. Among them: Concierge practices typically offer a more robust menu of services, including home visits and immediate access to the doctor via telephone or text. They are also more expensive. One practice in St. Petersburg charges patients between $2,500 and $5,000 annually.

"Direct primary care is meant to be accessible to everyday people," said Jay Keese, executive director of the Direct Primary Care Coalition, an industry group.

Although the model has been around for nearly two decades, it didn't really enter the mainstream until the Affordable Care Act included it as an acceptable form of health coverage — if paired with a catastrophic plan.

Moss first read about it two years ago in a medical journal. She had long wanted to open a family practice, but feared she would have to see more than 3,000 patients to be financially solvent.

When she read the article, something clicked: If she went the direct primary-care route, the monthly fee from about 750 patients would be enough to cover rent, malpractice insurance, the salary for one office assistant and her own salary.

What's more, she wouldn't have to worry about fighting with insurance companies, which sometimes deny claims or delay payments several months.

"This seemed like a way to make it work," she said.

Last year, Moss left her job at an outpatient clinic in St. Petersburg associated with the BayCare hospital network and opened her own small office in Clearwater.

Most of the patients who followed her to the new practice were receptive to the idea of paying directly, she said, though she allows a handful to continue using insurance.

She hopes they will all be on board in the future.

One of Moss' longtime patients, 53-year-old Kathy Cress, already takes full advantage of the new system. She is working to lower her blood pressure and cholesterol, and drives from Seminole for monthly office visits.

Her most recent visit lasted an hour, and included a checkup as well as discussion of several health-related articles Cress had read in Bloomberg Businessweek and Self. She also asked Moss to review her food and exercise log.

"I definitely couldn't do this at a regular doctor's office," Cress said, recalling rushed visits when Moss worked at the outpatient center.

That individualized approach can make for a busy practice. Moss sometimes has to work nights and weekends to accommodate patients. She makes the occasional home visit, too.

Dr. Eric Crall, a direct primary-care doctor in Lutz, says the dynamic is different when physicians are hired by their patients.

"You get patients who are much more engaged in their care," he said. "They are paying you a monthly membership fee. They think they might as well take advantage of it."

Crall sees another advantage: It provides an alternative for small businesses that can't afford to provide traditional health insurance benefits to their employees.

In recent months, direct primary care has caught the attention of state lawmakers, who see it as a way to improve access to health care and drive down costs. The Legislature is currently considering a bill seeking to clarify that a direct primary-care agreement does not constitute insurance — and thus is not subject to state insurance regulations.

"There's a doctor in my area who is doing this and is concerned state insurance regulators are going to say it isn't legal," said Rep. Fred Costello, the Ormond Beach Republican sponsoring the bill in the House.

The proposal has bipartisan support with virtually no opposition. House Democrats did make one tweak: They added language pointing out that direct primary care alone won't satisfy Obamacare's individual mandate.

When asked about the bill, Audrey Brown, president of the Florida Association of Health Plans, said her group "always supports increased access to primary care." She added a similar caveat: "It is important to note that this product does not constitute health insurance."

Moss plans to follow the debate in Tallahassee as best she can. But between flu season and her efforts to recruit more patients — she now has about 500 — she'll likely be busy in Clearwater.

She is hopeful lawmakers will see the value of direct primary care.

"It just seems like this is the right thing to do," she said on a recent afternoon, while scrolling through text messages from a patient. "You can help everyone from waitresses making minimum wage to executives, and be more accessible to them all."

Contact Kathleen McGrory at [email protected]

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