Kristina Behringer, MD stands in the exam room of her office in Cheyenne.
By Tom Lacock
Wyoming Medical Society
CHEYENNE — In an industry so dominated by insurance companies, a form of primary care without insurance administration is beginning to gain popularity as two more physicians have recently opened Direct Primary Care (DPC) practices in Wyoming
DPC is a model of healthcare that has patients pay a physician directly and receive services with both parties agreeing not to bill insurance. Contracts allow patients to see physicians as often as they want or need to, and physicians receive the service by subscription in some cases and ala carte in others.
What sort of physician is attracted to DPC?
Hint Health is a Membership Management and Billing Platform for Direct Care, Direct Primary Care and Concierge Medicine Providers based in the Bay Area. Michael Lubin is the vice president of sales and marketing for Hint and says most DPC physicians fit a similar profile. He says Hint’s primary clients have hit a wall practicing in the insurancebased fee-for-service world. He adds Hint’s clients try to improve their quality of life and get away from feeling like they are working for insurance companies instead of the patient.
That might describe the dean of DPC in Wyoming, Dr. Grace Gosar. The Buffalo physician practiced in Marbleton, Powell and Buffalo in traditional family practice settings before she broke away two years ago to start her own DPC practice. She says she felt she spent most of her day faxing and making requests to a thirdparty payer for permission on behalf of her clients. It was a wall she couldn’t overcome — and a system she decided she wouldn’t be a part of.
“One day I decided this is not right, I am not going to do it anymore and I am lending my energies to something I disagree with,” Gosar says.
Kristina Behringer hung out her DPC shingle this May in Cheyenne, leaving the Cheyenne Regional Medical Center. She says her practice, Grasslands Medicine, came about through a level of frustration over time being dictated by quotas of patients seen or the requirements of health insurance companies. She says there is less stress and points out she is “just a doctor” now instead of worrying about billing codes and how many minutes she can devote to a patient.
“I am very happy because the stress is gone,” she says. “It is a different type of stress because I am running a business, but as far as the medicine I am practicing, it is much more gratifying professionally. What we do is about relationships with people. This allows us to do that.”
“If this were about money, I could have stayed at what I was doing,” said Mike Tracy who recently opened a DPC practice. “I am turning 50 in a couple weeks. If you look at demographics of primary care physicians, there are a lot of people in the age range of 5065 thinking about doing something different.”
Research by Direct Primary Care Journal shows 60 percent of DPC physicians report the size of their patient panels were less than 300. Eighty percent of those in the DPC business are family physicians and more than 80 percent of DPC physicians operate in a solo practice. Among the other 20 percent is 307Health in Powell, where Tracy and Dr. Bob Chandler opened their new facility at the end of July.
Tracy is coming off 13 years working at Powell Valley Healthcare and said he and Chandler expect to offer their new patients their cell phone as the main form of contact with their physician.
“If you are a patient in my new practice, instead of having an office phone number that will yield you several hurdles clinically, every patient just has my cell phone as the primary means of communication,” Tracy said. “This way the patient and I can decide together if they need to come in for a visit or if they don’t need to come in for a visit.”
Payment model
There appear to be two common models in DPC subscription based and ala carte. Direct Primary Care Journal’s survey of DPC practitioners suggested that 68 percent of fees inside most DPC practices cost between $25 and $85 per month. Behringer and 307Health will each use a model that allows patients to see their physician an unlimited number of times in exchange for a monthly fee. Gosar said she used to charge $60 for 20 minutes and $120 for more than 20 minutes. She adds that she issued an invoice the client could submit to insurance.
She says some did, particularly for preventative and wellness services mandated by the ACA. However, submission of claims wasn’t always an easy venture. “If a client filed with insurance or Medicare, they engaged the same tedious system, and many had some small understanding of how the third parties behave and why a person can go mad constantly dealing with them,” says Gosar.
Some DPCs require oneyear contracts. Direct Primary Care Journal’s survey of DPC providers suggests 53 percent of DPC offices require cash/debit/credit card payments only. Tracy says his shop will have a monthly membership model as they believe it will allow for better relationship building. Tracy says part of the reason for his interest in leaving traditional primary care is a lack of pricing transparency. He also hopes to convince payers to recognize virtual visits whether it be via phone or online.
“I think medicine lacks transparency in terms of its pricing structure,” Tracy said. “Restaurants post their menus and customers make decisions based on their prices and I think medicine has fought that in some ways because medicine feels like we need to take care of people no matter the cost.”
For Behringer, the decision to go with a monthly cost has to do with her interest in working with patients who would like to be seen for chronic issue such as diabetes or weight management and the pricing model that includes unlimited visits per month allows for a deeper conversation.
“We are now discussing lifestyle and how to follow a plan and takes time and it takes dialog and I never had that before.”
What sort of patient is attracted to DPC According to Direct Primary Care Journal, there are some similar characteristics of DPC patients. The industry tends to attract its clients through low monthly fees generally millennials and generation Xers.
Gosar said she believes the market for DPC is still being defined, but from her experience in Buffalo, she said social networks and younger users of her service tended to gravitate to the ability to make sameday appointments online and pay for services rather than force them to purchase insurance, or in some cases, notify their parent’s insurance. Gosar said it took her a little over a year to accumulate nearly 600 patients.
“In a college town like Laramie, my client would be someone under 30 whose home base for care may be wherever they come from,” Gosar says. “They would use this for online scheduling, ease of access and predictability of cost. I would save that person a ton of hassle and money, and they would get in to see me, likely within 24 hours.”
Perhaps few research the concept of DPC as intensely as Dr. Philip Eskew. He has put together DPC Frontier, a website he hopes will be a resource for those looking into DPC. Eskew has recently finished his final year of family medicine residency at the Heart of Lancaster, a practice in Pennsylvania. Before medical school, Eskew was an attorney and has used his education to advise state and federal lawmakers on DPC, as well as sitting on the steering committee of the Direct Primary Care Coalition.
He says DPC appeals to the priceconscious and pointed out the toughest patients to attract to the DPC model are wellinsured with no copays and no deductible. He adds that with the Cadillac Tax implementation coming up, he sees this as a shrinking group.
“DPC physicians negotiate cash prices for MRIs, CTs, specialty visits, etc.” Eskew says. “But if it is more cost effective for the patient to use his insurance policy for these referrals, then that is what will be done. Typically the DPC fees do not count toward the patient’s deductible since no insurance claims are filed, but usually the DPC fees are so low this does not make much difference.”
Gosar believes DPC may be one alternative to the state’s efforts to grapple with uncompensated care and Medicaid expansion. Gosar said setting up five DPC clinics around the state and offering a publicprivate partnership with physicians to see what would otherwise be a Medicaid patient at a negotiated price would save the state money and add to the state’s payroll while also allowing lawmakers the ability to put forth a solution that is Wyoming-specific.
“They could spend a lot less than the $10 million than they spent for hospital uncompensated care last year,” Gosar said. “Logistically, it isn’t even hard. But right now with Medicaid, clients are accessing the highestprice care (ER) with the least continuity and preventative management attached to it.”
What’s Next for DPC physicians in Wyoming?
As the state grapples with a new form of primary care in DPC, there are several questions from a legislative standpoint (see Healy column) that will be worked out with the help of the WMS. On a national level the Direct Primary Care Coalition has two key components to its legislative agenda. The first is to ensure a pathway for Medicare and Medicaid to pay doctors using the DPC model in the same way another payer working with an employer or a private payer would.
Currently, Medicare does not have a way to pay the fee. The other component of the DPC agenda is making it easier to use HSA with DPC. Tracy and Chandler have gone from physicians to interior decorators as they open their new facility in Powell. Gosar has recently shuttered her practice as she is receiving treatments for cancer.
“One weakness in this model is that the solo provider has to remain well,” Gosar said. “I got sick and that’s kind of ironic.”
Meanwhile, Eskew has completed his residency and will open his own DPC clinic in Cheyenne later this summer. As he gets his clientele built up he is working with correctional medicine in Torrington.
Behringer’s traffic through the office is picking up, but for a new provider the stress of purchasing everything from tongue depressors to medical malpractice insurance — as well as acting as your own medical assistant — is new.
“There is something sort of easy about pulling up, walking in and your patient is roomed for you,” she said. “You just have to do your thing and walk in and walk out. But there again, I don’t think I could ever go back to that because I don’t have pressure in running the business, though.”