Doctors who let patients or their employers pay a monthly fee for primary care, outside of health insurance, could continue the arrangements free from insurance regulations under a proposed bill in Wisconsin.
In direct primary care, a national trend with mixed financial success, people pay $20 to $100 a month or more for unlimited primary care services, such as routine visits and lab tests.
Many of the patients carry high-deductible or catastrophic health insurance to cover major medical expenses.
The model helps patients with significant deductibles afford primary care and frees up doctors from paperwork, said Rep. Joe Sanfelippo, R-New Berlin, who is seeking sponsors for the bill, along with co-sponsor Sen. Chris Kapenga, R-Delafield.
“It cuts out any government bureaucracy, or an insurance company, from being in the middle of that relationship,” said Sanfelippo, head of the Assembly’s health committee.
A few doctors provide direct primary care in Wisconsin. Nationally, about 3 percent of doctors surveyed by the American Academy of Family Physicians provide direct primary care.
The bill would make it clear the arrangements aren’t subject to state insurance regulations and don’t qualify as insurance under the federal Affordable Care Act, steps that could expand the practice, Sanfelippo said.
Twenty-three states have similar laws, according to the Direct Primary Care Coalition.
In Wisconsin, the bill would also require the state Department of Health Services to set up a pilot program for direct primary care for Medicaid recipients.
Assigning Medicaid patients to specific doctors for primary care could curb emergency room spending, Sanfelippo said.
“The doctors would be able to keep a better eye on those patients,” he said.
Michael Heifetz, the state’s Medicaid director, said direct primary care can manage costs in the private sector.
“As you look at it for the Medicaid program, it becomes a bit more complicated because of numerous federal requirements — minimum benefit requirements, which are, in comparison to the private sector, quite generous,” Heifetz said.
Heifetz said it’s not clear if the federal government would approve direct primary care in Medicaid, the state-federal program for the poor.
The Wisconsin Academy of Family Physicians supports the bill, saying it would be especially helpful for the 15 percent of doctors in the state who are not part of large medical practices, said Larry Pheifer, executive director of the group.
“It allows those that maybe are not part of large groups ... to offer different kinds of patients an opportunity to get coverage in a reasonable way, with reasonable cost,” Pheifer said.
The Wisconsin Medical Society hasn’t taken a position yet, said Mark Grapentine, senior vice president of government relations.
Dr. Suzanne Gehl started a direct primary care practice in Delafield in September after working for several years in a similar, employer-based model.
She charges $20 to $100 a month, depending on the patient’s age, to cover basic services, including some minor procedures. Patients can also buy some medications and tests not covered by the monthly fee at “bargain basement” prices, she said.
She plans to take on no more than 500 patients, making herself available to them by phone call, text, email, webcam or office visits lasting at least half an hour.
In traditional clinics, family medicine doctors are typically responsible for 2,000 to 3,000 patients. Gehl said that in a previous job, she had to see 12 complex patients in three hours one day.
“You cannot deliver quality, comprehensive care with a schedule like that,” she said. “Physicians feel like they’re on a hamster wheel.”
Dr. Erica Rotondo provides direct primary care through Serenity Osteopathic on Madison’s West Side, according to her website and the group Direct Primary Care Frontier. Rotondo didn’t return messages seeking comment.
Dr. Will Schupp provided direct primary care in Madison for a few months in 2013 before shutting down the practice, according to The Capital Times.
Schupp, who now works at a traditional family medicine practice in Iowa, blamed the demise of his direct primary care practice on the website for the Affordable Care Act’s insurance exchange. The website had many problems in late 2013 before coverage on the exchange started in 2014.
Qliance Medical Management, a Seattle-based chain of direct primary care clinics that was considered a national model for the practice, closed in May after 10 years.
The company “ran up against overwhelming financial difficulties,” Dr. Erika Bliss, CEO and co-owner, told the Seattle Times. The health-care system is “hostile to change,” and “it has been literally an uphill battle the whole way,” Bliss said.
Gehl said Qliance may have set its rates too low.
Dr. Aaron Dunn, an SSM Health Dean Medical Group doctor in Mineral Point who also works at the Community Connections Free Clinic in Dodgeville, said direct primary care could become an important alternative to regular medical care.
“It cuts the insurance payer out of the picture,” Dunn said. “When you do that, you reduce your overhead and you reduce health care costs.”