A new, monthly fee-based health care model that does away with insurance billing got legal approval from Montana’s top insurance watchdog this week to be rolled out by a Missoula company.
CostCare, a Missoula-based medical walk-in clinic, will be changing its Mullan Road location to the new system, called direct primary care, on the first day of 2018.
For a monthly fee of $70 for adults and $25 for children under 18, patients will have access to routine medical care and access to a personal physician with no charge for office visits and minimal to no charges for lab work and routine procedures.
"We're looking to re-establish the patient-doctor relationship," said Dr. Carol Bridges, co-founder of CostCare. "We're doing away with insurance. So we're going to do everything to keep people healthy and we're going to do everything we can to keep people off medications. We're finally getting out of that 'do more, bill more' concept that is bankrupting our health care system."
While patients who become members of CostCare will still need to have a high-deductible, low monthly cost insurance plan for catastrophic medical emergencies, they may be able to save money by not having a high monthly premium, low-deductible plan with this new model.
“What we have found, and what nationally proves to be the case, is a vast majority of doctor visits are for routine medical issues such as strep throat, bladder infections or diabetes visits,” Bridges said. “High health insurance premiums are crippling many of us, and most of the time patients are still paying for routine office visits, lab work, etc., on top of their health insurance. This model offers an alternative.”
Bridges said the family practice clinic will be capped at 600 adults; their children won't count towards the cap.
"These people are going to have full-time access to me through cellphones and email and other technology," she said. "For example, I have a patient that was out of the country and she was so glad she could talk by email with me every day. She had constant access. So many patients have issues that can be done over the phone. And the only way I'm going to get paid without forcing them to come to the office, and maybe leave work, is by taking the insurance company out of the equation."
On Monday, Montana insurance commissioner Matt Rosendale issued an advisory memorandum clarifying that direct primary care provider agreements are non-insurance health care options, meaning they are not regulated by his office.
“Montanans should have as many options on the table as possible to meet their health care needs as they see fit,” Rosendale said. “Direct primary care is yet another way for consumers to access routine, preventative, or preliminary health care. These agreements between patients and their doctors are not insurance products, and will not be regulated by my office as insurance.
"While direct primary care provides a good alternative for many people seeking routine or basic health care treatment, it’s important for Montanans to have insurance coverage for major and unexpected health care costs,” he added.
CostCare was established in 2007 as a small, fee-for-service “no insurance, no problem” walk-in clinic, according to Bridges. She said it is changing that model in response to the high costs and unpredictability of health care.
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With the new direct primary care model, patients can be seen in the office at no additional expense. That means they can address issues much earlier and prevent urgent care and emergency room visits. House calls are available, and patients can expect 24/7 access to their doctor, same-day office visits and included wellness expenses such as Pap tests, HPV and flu shots as well as much-reduced procedure and lab fees. Those routine tests are also included in most insurance plans.
“Here’s an example of how this model saves a patient money,” Bridges explained. “Consider a simple mole biopsy. Today, a typical mole biopsy would cost $370 for the procedure and around $175 for the pathology fee from the lab, for a total cost of $545. The cost through direct primary care for the same procedure would be $20 for the procedure and $50 for the pathology fee (for the specimen to be sent to the lab for the pathologist to look at). The total cost would be $70. That’s a difference of $475, just for one procedure.”
Bridges applauded Rosendale’s memorandum on Monday.
“In this ever-changing health care environment and increasing deductibles, Direct Primary Care (DPC) is a monthly membership model that not only provides a cost-effective solution to the increasing cost of health care but at the same time renews the patient-doctor relationship while using modern technology including tele-medicine, FaceTime, email and text.
"Because providers are readily accessible, urgent care and ER visits are also minimized. The monthly fee covers all of the office visits and typically in-clinic testing. Procedures and other labs are priced at cost with savings typically 80 to 90 percent.”
She is quick to stress that she agrees that direct primary care should not be confused with insurance, so people should still have some type of plan.
“This is not an insurance policy and does not strive to replace health insurance, but rather to be coupled with a cost-effective high-deductible plan to cover catastrophic medical events,” she said.
The direct primary care model got its start in the 1990s in the Seattle area, according to Business Insider. It is similar to concierge medicine, but concierge providers still bill insurance companies. Direct care providers do not take insurance at all, and thus don’t have to worry about denials, pre-certification or collecting co-pays.
According to the Kaiser Family Foundation, more Americans than ever — 51 percent of workers — are buying high-deductible insurance plans, meaning that they will have to pay at least $1,300 as an individual in out-of-pocket expenses before insurance kicks in.
A spokesman for Rosendale’s office, Kyle Schmauch, said the commissioner believes that this new system will give people options but they should still do their own research and make an informed decision based on their own personal situation.
The Urgent Care clinic CostCare location at 3031 Russell Street in Missoula will remain insurance-billed, as will the Helena location, for now.