Your health should not depend on your ability to game out the risk of waiting to see a doctor, hoping the $150 you save today won’t set you up for a $15,000 hospital bill in a week.
But for many in Idaho — even those with health insurance — taking such risks is reality. And that is prompting patients and doctors to get creative about making basic medical care affordable.
Mardi Stacy is one of those patients.
“There was always this tension of, ‘Am I $250 sick?’” she says. “I thought, ‘This isn’t good for my health.’”
That led Stacy to seek out an alternative form of health care that is increasingly popular in the Treasure Valley: direct primary care, sometimes known as “concierge care.” It’s like having your doctor on a retainer.
The doctor is a type of primary care “home,” where the patient can go for routine checkups, treatment of minor injuries and illnesses, prescription drugs and other basic health needs. In that way, it is similar to the statewide “primary care access plan” that Gov. Butch Otter proposed this legislative session as an alternative to Medicaid expansion.
Stacy, a 59-year-old psychologist in Boise, had a deluxe health plan through her husband’s employer. When he switched jobs, Stacy switched to a high-deductible plan. It had lower premiums but meant she would have to pay the full cost of doctor visits, lab tests and medications.
“I’m much more aware of the prices of things. [And] whenever I saw my doctor, I felt like she was busy,” she says. “I had pink eye once, and it was like, ‘The next appointment is in two weeks.’”
Stacy realized her choices were to spend more than $100 for an urgent-care visit or to wait out minor ailments. By the end of last summer, she was frustrated.
A friend told her about direct primary care, and she signed up with Dr. Julie Gunther of Spark MD in Boise.
Gunther, a self-professed “fanatic about direct primary care,” opened her practice almost two years ago, after working for St. Luke’s Health System as a primary care doctor and hospice medical director from 2009 to 2013.
“I always had a vision for the kind of doctor I wanted to be,” Gunther says. But working for the hospital system, with 2,300 to 3,000 patients and the attendant paperwork and administrative tasks, she says, “I felt like I was losing my connection with my patients.”
She believes health insurance is “very important,” but in her job as a primary care doctor, dealing with insurance was where she felt the process had “started to break down,” she says. “The overhead is so high, which means patient load has to be high.”
In fall 2013, at an annual meeting of family doctors, Gunther says she had an “epiphany.” She heard a direct primary care physician talk about his job. She recorded it; she still has that recording.
“I called my husband and said, ‘This is it. I’ve figured it out,’” she says.
The following spring, she and her husband sold their house and car and consolidated their finances. Gunther took a second job as urgent care doctor for a workplace clinic.
Around the same time, Dr. Andrea Axtell was opening her practice after spending three years as a primary care doctor at St. Luke’s. She was feeling the same stress and dissatisfaction Gunther felt.
“I was constantly running behind, constantly having to bring patients back for follow-up visits,” she says. “I was burned out and contemplated leaving medicine altogether and was determined to find a practice model that would work better for me.”
Axtell researched direct primary care and launched Alliance Concierge Care, at 5995 State St. in Boise, in July 2014.
Gunther gave her notice in May 2014 and began a transition away from St. Luke’s. She said she was careful not to poach her St. Luke’s patients. But as she let them know she wouldn’t be their St. Luke’s doctor anymore, some of those patients chose to follow her to her new practice, which opened that summer.
AN OPTION FOR THE UNINSURED
Many of Gunther’s early patients were the uninsured family members of people she had treated at St. Luke’s.
In fact, many of the current Treasure Valley direct primary care customers do not have insurance. They are in the Medicaid gap — not qualifying for Medicaid in Idaho, not insured through work and earning too little to qualify for a federally subsidized health plan. One physician says one-third of her direct primary care patients are in the gap.
The program offered by Gunther, Axtell and others is not health insurance. It does not meet the universal-coverage mandate of the Affordable Care Act. If direct primary care patients go uninsured, and they don’t qualify for a hardship exemption, they could be required to pay a tax penalty.
Some patients who cannot afford insurance pay for direct primary care anyway, because even though the monthly memberships are expensive for low-income Idahoans, they’re significantly cheaper than the full premiums of an insurance plan, which is the only insurance option for Idahoans in the Medicaid gap.
“People who are signing up now are uninsured,” says Dr. Brian Crownover, who opened Treasure Valley Family Medicine at 2428 N. Stokesberry Place, Meridian, in 2014 with a direct primary care option.
Crownover has about 1,100 patients, with most on public or private insurance. About 40 to 50 have signed up for the direct primary care option.
He would like to have more patients taking that option, but because of requirements in his contracts with private insurance companies, he says he cannot knowingly sign up an insured patient for direct primary care.
“I’ve got a 75-year-old who only has Medicare Part A and can’t afford [non-hospital Medicare coverage],” he says. That patient pays $70 a month and comes in twice a month, he says.
Crownover hopes a company will offer an option for both insurance and direct care. Utah has such plans, and so does Washington, which has 50,000 people on direct care, he says. The savings compared with traditional insurance are about 25 to 30 percent, he says.
Gunther and others stress the importance of health insurance, or some other arrangement to cover catastrophes, because a direct primary care membership cannot help with cancer, back surgery or a car crash.
Gunther moved Spark MD into a building she purchased, at 302 W. Idaho St., Boise, in September 2014.
She has a partner in the practice: Dr. Kathryn Potter, who came to Spark MD from Terry Reilly Health Services in October.
The business plan for Spark MD consists of two to three physicians, with 500 to 600 patients per physician. That whole clinic would have fewer patients than she alone saw at St. Luke’s, she says. And currently, with the low overhead, the clinic needs just one employee, whom Gunther calls “wonder woman.”
Growth is steady, Gunther says. She currently has about 400 patients, not shared with Potter. She expects to start taking home a paycheck by 2017.
She says she broke even in January, ahead of schedule.
“In December, I bought a pill counter. That was the last major purchase,” she says.
Axtell says her biggest challenge has been getting word out.
“I think a lot of people assume it’s going to be expensive, or they have insurance so they don’t ‘need’ direct care services,” she says. “What I do works well with insurance and can actually save money.”
She gave herself three years to fill her practice and is about halfway there, she says, though she declines to say how many patients she has now.
A SOLUTION TO BURNOUT?
Mark Grajcar is one of the newest on the block. He opened his direct primary care practice about two months ago. In the first six weeks, Grajcar had signed up 16 patients.
A former Saint Alphonsus Medical Group physician, Grajcar opened Initial Point Family Medicine in 2007. The office is on Eagle Road at Easy Jet Drive in Meridian.
But since the Affordable Care Act began to take full effect over the past few years, Grajcar has studied the direct primary care model. He attended three conferences and eventually hired a San Diego lawyer to help him overcome the legal and practical hurdles of switching to it.
Initial Point Family Medicine is now a “hybrid” practice, still seeing patients with health insurance — including Medicare and Medicaid — but also offering memberships.
“It’s less disruptive to patients, and it allows you to have a more gradual transition into the direct-care world, without seeing a dramatic drop in patient [numbers] and revenues,” he says.
Grajcar has about 2,700 patients. By the time he is fully switched over to a direct primary care practice, he says he will limit himself to 800 patients or fewer.
The huge cutback in the number of patients per physician under the direct-care model is seen by skeptics and critics as potentially harmful.
Especially in a state like Idaho with a severe physician shortage, if every doctor switched to direct primary care, seeing just 20 percent of the patients she sees now, what would happen to the other 80 percent? Would people who cannot afford a membership get worse care? And does the system take advantage of Idaho’s low-income patients, offering them just enough care to suffice as long as they stay relatively healthy?
Gunther and others say those concerns are unwarranted.
They believe legislation and new types of health plans could alleviate those concerns — allowing patients to use health savings accounts to pay membership fees, or offering ‘wraparound’ plans that pair catastrophic insurance for high-cost medical needs with direct primary care for the basics.
Even if all doctors stopped taking insurance, the lower burnout rates for middle-aged doctors, and the allure of being able to practice medicine instead of practicing insurance, could populate the field so well that it would help make up for the smaller number of patients per doctor, they say.
“If direct primary care is seen as being a successful model, it may attract more young physicians,” Grajcar says.
He also sees it as a path to sustaining independent physician practices — which increasingly are joining larger hospital systems in part to simplify physicians’ lives, to ease the pain of managing 25 health insurance contracts, Medicare billing, coding and electronic medical records.
“When you work for Luke’s and you’ve got 20 people who can stay on top of that, it makes it a lot easier,” Grajcar says.
He and others says the direct primary care model does away with the hassle and hours spent on billing, coding and insurance contracts. The doctor still has to run a business. But the negotiations and overhead stressors are minimal, he and others says.
“The overhead for DPC — all it is is sending out a monthly statement like your cable company does,” Crownover says. “You have predictable income stream, you have a place where people can go and they don’t have to worry.”
And they say they’re relieved to be able to respond to patients any time. To offer more personal care and attention. To be less confined by the limits of insurance. To spend an hour with a first-time patient. To not have to schedule follow-ups because two other patients are in the waiting room.
“What a lot of people don’t understand, I think, is there are physicians out there who became physicians for the right reasons and are becoming so downtrodden and burned out ... that they would take a job in which they would not make any income for two years just to get back to being doctors again,” Gunther says. “It sounds very Pollyanna, but just taking care of people is so satisfying.”
When she is feeling under the weather or has a question, Stacy says she can email or call Gunther. She even sends text messages.
Gunther doesn’t mind. She says she works more now than she did at St. Luke’s, but she’s spending more of that time on patient care, so the hours are more fulfilling. And she’s “way more” available for her family.
Stacy figures that after a recent illness, she saved money — or at least broke even — on her membership to Gunther’s practice.
“When I signed up, I had no idea I was going to get pneumonia,” she says. “I called, and I got a same-day appointment.”
Gunther prescribed her two types of antibiotics and a steroid medication — all of which she was able to fill at the office for $7.36.
The follow-ups included a phone call on a Sunday, a five-minute conversation and an office visit the day after that.
Stacy thinks that if she had gone to a different medical practice, she might have walked out with a bill for an X-ray and other diagnostic tests that Gunther decided were unnecessary.
She still has health insurance for catastrophes, and she recently went in for a mammogram that is fully covered by her health insurance.
“If I have something I need to run through insurance, I would go to [my traditional primary care doctor], but she’s in a system that is working so hard,” she says. “I’m just excited that we’re coming up with alternatives.”
Gunther says that feeling of security is common.
“A theme is many of my patients have had a touchpoint recently in their health care experience where the system failed them,” she says. “My hope is if I’m able to make this work, that physicians that are more risk-averse than me will say we can take back this sort of profession.”
Audrey Dutton: 208-377-6448, @IDS_Audrey. This story appears in the March 16-April 19, 2016, edition of the Idaho Statesman’s Business Insider magazine as part of a special section on the business of health.
What Do They Cost?
Memberships to local direct primary care practices vary. They all charge one-time startup fees that range from $10 to $60. Some offer a pay-as-you-go option, with a membership kicking in once the patient meets a certain threshold. Some charge extra for after-hours care, house calls, labs and other services.
These are the basic monthly fees for practices in this story as of March 2016. Visit their websites for more details.
Alliance Concierge Care (adults only): $49 for ages 18 to 64; $59 for ages 65 and up
Spark MD: $10 for members ages newborn to 20 years if enrolled with an adult, $30 without an adult; $60 for adults ages 21 to 100; $1 annually for adults over 100
Treasure Valley Family Medicine: $70 for first adult; $50 for second adult or spouse; $30 for each child