Cutting out the middleman
Eschewing insurance, direct primary care practices are growing in Grand Junction
Dr. Craig Gustafson can remember back a few years when he was seeing 20-25 patients per day. He spent hours doing paperwork to send to insurance companies to justify the charges for each visit and what he felt was little time practicing actual medicine.
After 10 years at a private primary care practice, he left to pursue another model and founded Appleton Clinics, a direct primary care office that charges patients a monthly fee for unlimited visits and doesn’t use insurance.
“I felt the traditional medical system, at least for primary care, was not serving and primarily focused on the needs of patients. We were ultimately responsible to insurance companies instead of the patient in front of us,” Gustafson said.
In the three years since starting Appleton Clinics as its lone doctor, the practice has grown and he’s hired more primary care doctors as more patients expressed interest and enrolled. The idea behind the practice is to see fewer patients, but spend more time with them. Gustafson said he sees up to 14 patients per day.
One of the doctors he hired, Robert Boyer, had similar feelings on practicing primary care medicine in the insurance-based model. After a stint at Appleton, he broke off and formed his own practice with the goal of spending even more time with patients, forming Trailhead Clinics at 235 N. Seventh St.
“For me, I felt like I wasn’t getting enough time with patients until now,” Boyer said. “I want a way to make money in this model without compromising our product.”
Between them, the clinics now treat thousands of Grand Valley residents and are showing steady growth as direct primary care practices, gaining new members and hiring doctors in what has become a more popular way to handle primary care across the country during the last 15 years.
TYPE OF PATIENTS VARIES WIDELY
Three years ago, Gustafson was the only doctor at the practice. Appleton now has five primary care doctors and recently hired a full-time dietician as the clinic has taken over the entire second floor at 607 25 Road.
At Trailhead, Boyer has added a second physician and has two medical assistants and a membership specialist on staff, with hopes to grow more as membership increases.
Neither clinic would provide membership numbers, but Boyer’s goal is to have 700 patients per physician. He noted that he’s still short of that number between himself and Dr. Kathy Howe, the second physician to join the staff, but said memberships have grown 300 percent in the clinic’s first year. Boyer believes on average a doctor sees one patient per day for every 100 he has.
While 700-1,400 patients sounds like a lot for one doctor, both Boyer and Gustafson say that’s one-third to one-half the amount they saw at insurance-based practices, which meant they were often shuttling patients in and out of the office.
“It becomes a high-volume model where patients are a little bit peripheral, which we think is really sad,” Gustafson said of insurance-based primary care practices.
The type of patients who have come to use direct primary care has surprised Gustafson. He initially expected more financially well-off patients who could afford to spend extra money on primary care to have better access to their doctor while still being on Medicare if older or visit his office in addition to having insurance for everything else.
In reality, both Appleton and Trailhead have seen a wide range of patients: families with one or multiple income providers working for small employers, self-employed patients and lower-income citizens. Twenty to 30 percent are on Medicaid, although Gustafson said Appleton does not keep records on insurance providers.
For Medicaid patients, the issue is most likely that they qualify for the service, but have been unable to find a primary care doctor and can still afford the $69-$89 monthly fee, especially if they have some health issues that require more frequent visits.
Sabrina Atwood and her family of six have followed Boyer to his last three stops. As the owners of Atwood Dentistry in town, Atwood and her husband found it very expensive to buy their own health insurance and provide it through the company and were happy to stay with Boyer as their main doctor.
Atwood likes the easy access she has to Boyer at all times of the day, especially if there is something that needs immediate care. She referenced an incident a few years back when Boyer was still at an insurance-based practice and her daughter had fallen and broken her nose. She tried to bring her in to see Boyer but couldn’t because her daughter was not listed as a patient and hadn’t filled out an application.
“It’s nice to pay for the clinic and have the whole family accepted and not go through the whole application process,” Atwood said.
Jason Dangler, a masonry contractor, visits Appleton Clinics because, he says, he was paying more than $1,000 per month for health insurance and found it less expensive to use Appleton for primary care and enter a health share program to cover large medical costs.
“When you’re paying $1,200 per month for health insurance with a deductible on top of that, I did everything I could to lower the cost,” he said.
Dangler said he spends about half as much per month now on health care between his family’s Appleton membership and the Christian Health Ministries health share, which covers larger medical costs such as hospital visits and other needs outside the realm of primary care.
Health shares or high-deductible insurance plans are still essential to patients of direct primary care as their membership does not cover things such as hospital visits or higher level of treatments if a patient is diagnosed with something such as cancer. Both Appleton and Trailhead can recommend specialists, even some who offer discounts, and have deals in place with facilities that do lab work that will administer tests at a greatly reduced rate if needed. But for an emergency room visit, surgery, or extended hospital stay, some sort of health share or insurance is essential. Direct primary care costs aren’t covered by Medicaid, Medicare or a health share.
“You can have all kinds of insurance and still find ways to come to us,” Boyer said. “We can’t control what a hospital costs.”
Jenny Rosengren and her family have been using Trailhead as their primary care site for a little more than a year. She said she, her husband and their nine children spend $173 per month at Trailhead. The family also pays just under $500 per month to Samaritan Ministries, a health share that covers up to $250,000 in medical expenses. There’s a separate account for a few extra dollars per month that covers the family up to $1 million.
Rosengren said she went to a lab that Trailhead had a deal with that cost her $250 for tests that otherwise would have cost $1,700. She also enjoys the access she has to Boyer, as she can text him with issues and he can reply with a solution or tell her to come by for a visit.
“It’s amazing to have that kind of care,” she said. “I don’t have to even question it anymore. I just text him.”
The growth in direct primary care is not restricted to the Western Slope. The idea has been spreading across the country since the late 1990s.
The Direct Primary Care Coalition, an advocate group that lobbies for legislation in Washington, D.C., and keeps tabs on groups that offer direct primary care in all forms, estimates 250,000 people in the U.S. use direct primary care to see their doctor regularly.
The organization keeps track of and provides links to 700 facilities in 48 states — North and South Dakota are absent from the list — and coalition Executive Director Jay Keese said there could be many more out there that are under the organization’s radar. Trailhead and Appleton both appear on the map, but Dr. April Goggans, a local independent doctor operating her own direct primary care practice, was not. Goggans did not respond to interview requests for this story.
Keese said the size of the practices range from very small to ones that serve up to 20,000 patients.
“It’s just growing all over the place. It’s a popular model,” Keese said of direct primary care. “It’s reducing a lot of administrative expenses and provides a better delivery model for primary care. It creates a doctor-patient relationship that is so important.”
The Direct Primary Care Coalition was formed in 2009 around the time the Affordable Care Act — commonly referred to as ObamaCare — was first discussed to support legislation to include direct primary care as part of the essential health benefits package. The packages consist of 10 items of care the act requires for all individual and small group plans. The organization has also worked on state laws — including in Colorado — and is still working to clarify rules on health savings accounts and hopes to have direct primary care become eligible to receive Medicaid and Medicare payments.
Keese feels direct primary care is the best way to finance primary health care, but recognizes that not everyone will go that route if they have insurance at their job and easy access to a primary care doctor.
“There’s always going to be different options, but I do think we’ll continue to grow and get a larger share of physicians,” Keese said.
In cities where there is a shortage of primary care physicians, Keese believes direct primary care could help bring more primary care doctors into the field, noting the lighter patient load and less paperwork necessary.
“I think direct primary care is a good thing for a shortage because I think it makes a lot of doctors that would consider other specialties think about getting into primary care,” he said. “If you look at direct primary care as a trend and look at the uptick and interest in primary care residencies, I think there’s a correlation.”
Not the only option
Steve ErkenBrack, CEO of Rocky Mountain Health Plans, a Grand Junction-based HMO that provides health insurance to a large number of Mesa County residents, believes direct primary care is an interesting model, but he isn’t sure there are enough doctors in the area to see everyone at the moment.
Regardless of how many doctors enter into direct primary care, ErkenBrack believes there are some who won’t be able to afford the monthly fee and will still rely on Medicaid or Medicare or their own insurance to see a doctor. And if a doctor leaves a practice where he or she is seeing 20 patients a day and starts seeing 10, he wonders where the other 10 patients will go.
“It’s a wonderful idea but I don’t know if we have enough docs out there right now. There’s a lot of people who aren’t able to see anybody. How do you balance that?” he said.
However, ErkenBrack said he believes that primary care is essential to the health of the community and helps prevent larger health issues that need hospital care and thus keeps costs down overall, and that there could be a place for direct primary care.
“I’m a strident believer in primary care, and the value of it and building a cost effective system, but you need more than primary care because some portion of the population are going to develop health issues no matter how robust primary care is,” he said. “The more people you get into primary care, the lower the health care cost of the community. That is the lesson of the last 40 years here.”
Room to grow
Whether direct primary care is the most effective model or best for doctors and patients, the practices in town continue to grow and there is room for expansion and new ideas.
Boyer expressed frustration with the system in place and feels the direct primary care model is the best way to rectify it at the moment.
“Our goal is to be the anti-medicine medical clinic. Right now, the medical system is broken. There’s terrible customer service, terrible patient experience and it’s because of the system that’s set up,” Boyer said.
For Gustafson, adding dieticians was a big move as patients can now have access to their expertise in leading healthier lives and with no change to their monthly fee.
Registered Dietician Vanessa Carter wasn’t familiar with direct primary care, but says it’s made her work easier — and busier.
Before, she said, she was tied up in issues of what would be covered by insurance and how often people could visit, but now she said any patient at Appleton can work with her.
“It removed the barriers and limitations of insurance and allows me to help patients, which is all I want to do,” she said. “If you’re a healthy person and don’t have any diagnosis and want to improve your diet, there’s no insurance company that will pay for it.”
Gustafson sees a chance for more growth and could add more specialists if the practice continues to grow and if any specialists want to make a change.
“In a lot of ways this is not a new thing,” he said. “This is kind of a throwback to a time when patients and doctor were a team. That’s resounded with patients here.”