Physicians cast wary eye on new insurance model

Innovative business models for physicians’ practices have proliferated over the last decade, from so-called Cadillac concierge services for the well-heeled to cash-only offices for the uninsured.

Those practices, like the rest of us, are now busy determining how the new healthcare law will affect them.

The Affordable Care Act reaches a milestone next month: enrollment begins via the new state exchanges. Those marketplaces go live on New Year’s Day, acting as a conduit for millions of Americans now required to carry health insurance.

The biggest concern for many is the newly-insured will flood the market, taxing already over-subscribed physicians.

That’s a problem Renown’s Premier Care, a two-year old, two-physician membership model practice offered by the Reno hospital, is already grappling with.

“The big thing we’re always facing, and if we look ahead the next 10 years, is we’re not producing enough physicians,” says Larry Trilops, vice president of ambulatory services. “If we move a doctor to this model, we have to be able to fill in elsewhere.”

That’s because the physicians see fewer patients, the goal being to spend more time with each one. The practice sees an average of 10 to 12 patients a day and each physician carries what is called a panel of 500 to 700 patients in total, compared to a national average as high as 2,500 patients. The practice offers same-day appointments and seven-day a week messaging, among other perks, for a monthly membership fee of $35 for adult under 55 and $55 month for adults 55 and older.

Another challenge for membership-based services, if they continue to take insurance, is to make sure they are not charging extra for medical services now covered under the healthcare law.

That’s not a problem for Medical Direct-Gorski, a Reno physician’s practice that opened in May by internist Dr. Dale Gorski. The practice does not take insurance and currently charges $75 per office visit. The practice isn’t concerned, though, that the cash-only model will lose appeal once most people are required to carry health insurance.

“Obamacare is not going to be solution for everyone. It protects hospitals from loss from all the people who go there and never pay their bill,” says Cathie Wimby, nurse manager at the practice. “Everyday medical care will still be an issue for people who can’t afford their high deductible or $200.”

Wimby says many people will continue to carry policies with high deductibles that are hard to meet. So it will make more sense to pay a smaller fee for more visits at a lower-priced cash-only practice than pay a higher fee at another physician’s office and chip away at a deductible that will likely never be met in a given year, she says.

But cash-only offices, which enjoy lower overhead by not complying with insurance, often see patients who require a lot of the physician’s time. Wimby says Medical Direct-Gorski is raising its fee to $100 per visit Oct. 1 because many of the half dozen patients it sees daily have not been to a doctor in years and require more physician’s time than anticipated.

The healthcare law is trying to address issues like that by encouraging a practice model called patient-centered medical homes. The concept is to have a team of physicians coordinating care proactively with the aim to prevent some health problems rather than treat them after they arise.

The University of Nevada School of Medicine already operates what it calls the Patient-centered Family Medicine Clinic in Reno. The clinic has about 10 part-time physicians, with access to nutritionists and other specialists, seeing an average of 20 patients per day. A care coordinator keeps track of each patient and is proactive about their care, scheduling appointments for patients ahead of time, for example, rather than waiting for patients to call.

“The idea is to be more preventive than reactive,” says Dr. Daniel Spogen, chairman of department of family medicine at the medical school. “The current model allows patients to decide when to see doctors. It’s sickness driven. Through disease management, we help predict what a patient needs in advance and how we stop you from developing diabetes or hypertension.”

In some states, although not in Nevada, preventive care is incentivized by so-called pay for performance in which physicians are rewarded for achieving healthier outcomes, says Spogen.

The healthcare law is also affecting alternative insurance products like that offered by Access to Healthcare Network, a statewide non-profit that offers its paying members discounted access to a network of providers and hospitals. The insurance product look-alike is available for a family of three, for example, making between $19,200 and $60,000 annually.

Access to Healthcare Network’s system does not qualify under the new healthcare law so the nonprofit is partnering with Saint Mary’s to offer members insurance and continue to provide other services such as medical counseling to help them navigate the healthcare system.

Niki King, chief operating officer, says the group is reaching out to its members now, about half of which will soon qualify for Medicaid under the expansion of that program, and some who will receive waivers from insurance under the new healthcare law.

King says her job is now consumed with tracking the healthcare law and its effect.

“It’s changing the entire company,” says King. “It’s all I do all day.”