Real Change News | Scrapping insurance to save money

March 31, 2010
Vol: 17 No: 14

News

Scrapping insurance to save money

by: Julia Cechvala , Contributing Writer

Health care reform already underway at one local provider

Clinic co-founder Dr. Garrison Bliss on resurrecting the doctor-patient relationship: “One of the central reasons that primary care has been decimated… is that we signed contracts with insurance companies and governments that turned the pricing of our services over to them.”

Photo by: Lucien Knuteson , Contributing Photographer

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With the nation’s health care system in a state of transition, doctors and patients here in Washington are finding ways to save money and improve quality through a focus on primary care.

Dr. Garrison Bliss has big plans for Qliance, the primary care clinic he helped found in 2006. Qliance takes no insurance; instead, patients pay directly, through a monthly fee system that, like a gym membership, gives them unlimited access to services. The fee ranges from $39 to $129 depending on the patient’s age and level of care. It includes all primary care: check-ups, routine screenings, flu shots, management of chronic illnesses like hypertension or diabetes, and urgent care for minor infections, sprains, and fractures.

The focus on primary care is where the savings come in. Dr. Bliss says primary care has nearly become a “dying breed,” yet it’s the “least expensive and most effective” area of health care. If patients can receive prompt primary care they can often prevent a trip to a specialist or even the hospital.

Both cost and inconvenience prevent people from accessing primary care when they need it, and Qliance removes those obstacles. Patients can expect same or next day appointments lasting 30-60 minutes, as well as access to a doctor via phone or email any time of the day or week – all without co-pays, deductibles, or insurance.

It’s a radical departure from the fee-for-service insurance model. “The way things are currently structured in the United States, everybody does great as long as the price continues to go up,” says Dr. Bliss. “It’s a little like the housing market.” Doctors are paid more for seeing more patients and doing more tests, whether necessary or not, and patients who have insurance want to use it because they’re paying for it. Meanwhile as insurance companies continue to raise rates, there reaches a point where patients, or more likely their employers, can’t pay. “We’re rapidly reaching that point,” says Dr. Bliss.

Employers are interested in Qliance and other monthly fee primary care models as options for their employee’s benefits package. Qliance has a pilot project with the United Food and Commercial Workers International Union (UFCW) Local 21 and is currently talking with another large union. The unions represent a “potentially mammoth market for us,” says Dr. Bliss.

In order to keep costs down, Qliance must run a frugal clinic. The downtown quarters are simple and neat; Real Change talked to Dr. Bliss in a conference room the size of a cramped kitchen, and he showed off another small space where they do their own laundry. “The more we look at the way we do things, the simpler they get,” says Bliss. This means Qliance is currently unable to do some of the more expensive screenings, even if they are routine, such as mammograms and colonoscopies.

Some minor tests, like blood draws and X-rays, however, are included in the monthly fee. Dr. Bliss explains that X-rays may be sent out to a radiologist for more expert interpretation, but patients pay for this service at cost, a mere $17. Qliance is also able to provide at cost a stock of around 125 commonly needed generic medicines that pharmacies usually mark up significantly.

Such efforts to maintain affordability are especially important for patients who don’t have insurance (around 10 percent of Qliance’s patients). Debbie Jo Reid, a patient of Dr. Lester Pittle at Qliance’s Kent clinic, doesn’t have insurance due to a job loss and financial difficulties. She previously didn’t have a place to go for primary care. Now at Qliance she is pleased with the care she gets. “Dr. Pittle is very thorough and never rushes our visits. He and his nurse, Heather, go out of their way to be of assistance,” Reid said in an email correspondence. She says the clinic even helped her work out deferred payments and free medicines during her husband’s unemployment.

Are monthly fee clinics a panacea for health care reform? No. People still may need specialist care, and in times of serious illness or emergency, still need to go to the hospital. While Qliance doctors can coordinate this care for their patients, it is not included in the monthly fee. Qliance recommends that patients carry wrap-around insurance in case they need advanced or emergency treatment. Having primary care to cover most of their needs, however, may allow them to choose a less expensive plan with a high deductible.

Some patients cannot afford even a $40 monthly fee, let alone back-up insurance. Swedish Medical Center, which has recently started its own pilot of a monthly fee primary care clinic, recognized that it can still save money by giving such patients access to primary care rather than waiting until they show up in the ER. Around 10 percent of the patients seen by the clinic have very low incomes and are seen for free, says Dr. Jay Fathi, medical director for primary care outreach at Swedish.

They also see a number of Medicare/Medicaid patients, as well as some whose care is paid through their employer via Premera Blue Cross. Of the pilot program with Swedish, Eric Earling, senior communications manager at Premera Blue Cross, says that “this is the first of what we hope will be multiple partnerships in Washington and Alaska to focus on quality of care, rather than the traditional fee-for-service system’s approach that tends to favor quantity instead.”

Qliance does not take reimbursement from Medicare/Medicaid or any insurance company, but only from patients. They will accept payment in the form of a single check from employers who are subsidizing their employees’ monthly benefit, but Dr. Bliss emphasizes that reimbursement will not be dictated by third parties. It is the agreement between a doctor and patient that decides the care provided and its value, he says.

Dr. Bliss’s purist view comes out of his experience practicing under traditional insurance models. “One of the central reasons that primary care has been decimated in the last 20 years is that we signed contracts with insurance companies and governments that turned the pricing of our services over to them,” says Bliss. With primary care undervalued and undercompensated, doctors had to see more and more patients to balance the clinic’s books. Under a managed care organization he practiced with briefly, Dr. Bliss had close to 3,000 patients in his panel. Now he has no more than 800.

Dr. Pittle experienced a similar crunch. The Pike Market community clinic where Pittle worked (“A doctor’s oath,” RC July 29 – Aug. 4, 2009) received government funding to treat patients without insurance. The money was never enough, though, so the doctors had to keep seeing more patients to make ends meet. Pittle now sees fewer than half the 20-24 patients per day he was seeing previously. He no longer puts in 15-hour days, which he says is better for both him and his patients.

Hundreds of monthly fee primary care practices have sprouted up around the country, many inspired by Qliance’s model, according to Dr. Bliss. Qliance plans to open two or three more clinics in the coming year, probably on the Eastside. They’d eventually like to open clinics in other states as well. Bliss is inspired to keep striving to improve the monthly fee primary care model.

“I think health care actually matters,” he says. “We’re not just making widgets. Whether we do it well or badly makes a big difference to a lot of people.”

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