Primary Care With a Twist: Docs Go Uninsured

For as long as I've covered healthcare, I've heard both policymakers and big-time health system CEOs complain about the problems the uninsured cause—not in a blaming sort of way—rather, in a way that bemoans the system and the costs.

What they're really saying is that it's a problem that should be easier to solve than it is. Government insists these people be treated, at least in emergency situations, but seems less concerned that they run up huge bills that no one is willing to pay for.

Don't misunderstand me. I'm not even close to saying that the vast majority of the uninsured are going around without health insurance because they just want to stick it to the man. And to its credit, government is trying to do something about it by covering a huge percentage of them under the reform law.

But in a sense, the uninsured is a problem created by the government. Less than a hundred years ago, after all, just about everyone was uninsured. So what's my point? At least one doctor believes that health insurance, as we've created it today to pay for just about everything health-related, is not really insuring against catastrophe, which is the definition of most forms of insurance.

We've all been through that argument before, comparing health insurance to homeowner's insurance or auto insurance. And this is not that argument. But this physician is backing up his talk by going uninsured. That is, the medical group he runs doesn't take it, file for it or get paid by it. His patients pay cash, but they don't fit the wealthy profile you may assume.

Boutique medical practices aren't new, and in a sense, Garrison Bliss's practice is as much a boutique as any of them. But to take a look at what it costs his patients to come there, and the first word that comes to mind to describe it most definitely wouldn't be "boutique."

Bliss, a 60-year-old MD, and president of Qliance Medical Group in the Seattle area, hasn't "taken a nickel of insurance money since 1997," he says. Forming a practice that would survive and thrive under that model, he says, has been an "intentional effort to create an ecosystem for healthcare beginning at the foundation, which is primary care. Healthcare here is designed to get better and cheaper rather and worse and more expensive."

In short, Bliss believes in the power of shopping and the free market to cut prices for medical care, and remove the complexity—at least from the primary care system. It all began about 15 years ago, when two of his then-partners began the first monthly fee practice in the US. Patients paid a monthly fee and then were allowed to contact their doctors as much as they wanted, and see them whenever they wanted, for a flat retainer fee.

"That seemed crazy at $1000 a month," he says.

It probably was. It was also prime shooting gallery material, with detractors rightly claiming monthly fee practices were only for the rich.

So Bliss refined the offering for himself and his practice.

"I decided to do something just like that but I would do it at the lowest effective price," he says. The highest price for any of the practice's patients (usually the oldest) was $65 a month. It was $30 for children and teenagers. In return, patients got all their primary care free, including 24-hour access to physicians, clinics open 12 hours a day, and needed x-rays and lab work—and sometimes prescription drugs--is included. Further, their docs would admit them to hospital if needed.

The price has risen since then, to between $44 and $84 a month, but the services remain. That allowed his patients to obtain insurance for truly catastrophic events—at much lower rates, in most cases.

"This is a great front end for a health plan," Bliss says. "If you're offering high-deductible health plan, and making employees pay a big deductible, they're very invested in not getting into co-pays or deductibles, and you're highly invested as an employer too."

Such a system allows employers to self insure in the small-dollar arena, says Bliss, "where most insurance companies are making their money right now."

It's also better in that doctors are incented to do the right things, says Bliss.

"We don't get paid for doing stuff. We don't get paid to refer to the hospital. We don't get paid if the insurance company makes more."

Bliss is highly interested in the national appeal and scale of the idea. In fact, he's banking on it. Bliss has partnered to start up a company called Qliance, which includes Qliance Medical Group as well as Qliance Medical Management. The latter assists other practices in setting up similar insurance-free business models.

"We will provide tech infrastructure and access to patient sources we've developed. We'll also measure quality and performance, and provide access to a medical record system," he says.

Who's interested? You might be surprised.

"Anyone who now wants the price of healthcare to go down," says Bliss. "Insurance companies used to have no vested interest in lowering costs. But there are places where insurance commissioners are now saying they can't raise rates to levels they would like. When that stuff happens, insurance companies become very interested in controlling costs when they have previously looked the other way."

Bliss calls the Qliance system a "power tool for them," adding that his practice has demonstrated reduced ER use by 62%. Hospitals too, are now getting interested, he claims.

"They are in an uncontrolled cost rise environment and the ACO animal is knocking at their door. They're realizing that all of their centers of excellence, which I call centers of income, will start to be cost centers in this new world."

Put simply, they're looking for a model that can produce healthier patients at a lower cost.

Don't think Qliance is the only game in town for this kind of medical care. Deep in the health reform law is a reference to "direct practice." That's the preferred name Bliss calls his idea. And it's an option in how the insurance exchanges are allowed to be designed. Stay tuned.