In South Portland, Maine — Roxanne Pettigrow chooses not to buy health insurance. She visits her doctor in South Portland every few weeks, though, paying $50 up front, once per month for regular checkups, office visits and preventive health screenings. It’s care that those who lack health coverage often skip.
Her $600 annual subscription provides Pettigrow with hourlong visits and email exchanges with her primary care physician, Dr. Michael Ciampi. He switched over to an Atlas MD-style subscription model back in mid-January.
Pettigrow saw Ciampi on the news and became one of his first subscribers.
“Dr. Ciampi never looks at his watch, which I find totally amazing,” Pettigrow said, sitting in an exam room after a recent appointment. “He’s the first doctor I’ve ever seen that doesn’t look at his watch.”
Ciampi’s patients can either pay the monthly subscription — which costs $95 per month for an adult couple and $140 per month for a family — or pay for individual services. Some of his patients do have health coverage, seeking reimbursement from insurers after the fact. And others find that paying Ciampi costs less than accumulating high out-of-pocket costs under their health plan.
“The $50 a month that I pay, for the services I get, is really unbelievable,” Pettigrow said. “It really is. I think more people should know what he’s offering because there’s so many of us out there that don’t have health care.”
Pettrigrow said she couldn’t afford the $200-plus per month it would have cost her to buy insurance under the Affordable Care Act. She saves about $75 a month by purchasing her prescriptions through Ciampi’s office, which sells many generic medications to its subscription patients at cost.
His office also provides vaccines at cost, or free for subscription patients. Lab work sent out for processing is offered at the practice’s cost, at a savings of 25 to 75 percent compared with local hospital and commercial labs, Ciampi said.
Included in the subscription are annual physicals; office visits for chronic conditions, illnesses, and injuries; some services related to diagnostic testing, such as EKGs and pregnancy tests; draining of abscesses and some joint injections, among other services.
“Anything that would normally happen in a family doctor’s office, it’s all part of the membership,” Ciampi said. “There are no co-payments, there are no deductibles.”
When patients need to visit a specialist, get an X-ray or MRI, or use other services outside Ciampi’s scope, he does his best to send them to doctors and facilities that offer discounts for paying cash.
Some experts applaud the rise in direct-pay doctors, seeing patients getting better value for their health care dollars. We have numerous Direct Care clients who pay less per month in premiums and copays — this includes all their prescriptions, all their labs, all their vaccines — than they did as fee-for-service patients with “full coverage” healthcare plans.
Although, some opponents worry that our Direct Care model isn’t sustainable or could lead to the rich receiving better care, while poor and working class Americans fight to be seen by a shrinking pool of doctors.
Critics contend that by winnowing down patient loads, direct-care doctors leave consumers scrambling to find another primary care doctor, already in short supply in many areas.
Ciampi argues the model will attract more new doctors to primary care and keep many burned-out physicians from leaving the field. It’s true. Giving doctors the power to be entrepreneurs, and make money for doing good work, is what will make students want to enter into the field.
Although, Mitchell Stein, an independent health policy consultant, said that those patients should know direct primary care doesn’t satisfy the requirement under the federal health reform law that all Americans have health insurance this year or pay a penalty. Those patients could wind up with mountains of debt if a serious illness or injury lands them in the hospital, he said.
“By saying that they’re going to take care of your needs up to a certain point, it leaves people very exposed,” Stein said of direct care practices.
Wait, why are Direct Primary Care critics sounding an alarm about “exposure”? Obviously, the problem is that they are improperly communicating (or understanding) the value of a wrap-around insurance plan, something we encourage all subscribers, at minimum, carry.
What Is Wrap-Around Insurance?
It is complete protection from worst-case scenarios. A catastrophic plan generally requires you to pay all of your medical costs up to a certain amount, usually several thousand dollars. (Some plans pay for a portion of before you reach this limit, if they include a deductible.)
However, after you reach your deductible, costs for essential health benefits are paid for by the plan.
And yes, it might be scary to owe $5,000 if you’re in a serious accident. But, what about the people who are paying $200, $300, $400 per month for “full coverage” healthcare that requires them to pay $45 additional dollars every time they see a family doctor? Their paying up to $4800 for effectively nothing, except the security that if things went wrong, they’d be well covered. Also, they’re paying to be able to pay $50 to see a family doctor.
However, at an individual level, catastrophic things aren’t likely to happen. That’s why they are called catastrophes. And that’s how insurance companies profit, by careful analysis of actuary tables.
Catastrophic plans have lower monthly premiums than a comprehensive plan, but only cover you if you need a lot of care. They basically protect you from worst-case scenarios like serious accidents or illnesses. This is where Direct Care comes in. We take care of the routine maintenance, we negotiate for any mid-level (and less likely) tests or exams, and then the wrap-around plan covers you in case of a disaster.
Simply stated, you now pay around what you were paying before, except you get access to your own doctor 24-hours-per-day.
We sell you generic prescriptions at pennies per pill, meaning you don’t need to bother with the copay you were accustomed to using.
And for anyone who says we’re in defiance of the ACA, that’s not true. We visited the Marketplace website and found out that they offer wrap-around plans. Yes, individuals may now need to prove a “Hardship Exemption” (we’re going to investigate this exemption later this week). This is of course what we have labeled “red tape” and it’s kind of a nuisance. But, this proves critics like Stein outright incorrect: Direct Care does not “expose” people, it opens them up to more affordable insurance options.
In fact, we found on the government’s own website that “Catastrophic plans… [in certain cases] cover free preventive services.”
Not that you would need these services if you’re a DC subscriber. But still, there’s prospective value, and more reasons to make the jump to cash-only medicine.
Healthcare.gov also states that, “If you buy a catastrophic plan in the Marketplace, you can’t get lower costs on your monthly premiums or lower out-of-pocket costs based on your income. Regardless of your income, you pay the standard price for the catastrophic plan.”
That didn’t stop Stein from griping, “These individual physicians who want to go back to the country doctor model, I don’t think it’s either practical from a cost perspective or appropriate from a care perspective, in terms of providing the best quality care at the lowest price,” Stein said.
But Atlas MD and physicians like Dr. Ciampi see a bright future for a model that allows patients to pay doctors much like they would a plumber or lawyer.
“If I can save someone one visit to the emergency room, it pays for the subscription for three years,” Ciampi said.
For Pettigrow, the comfortable atmosphere in Ciampi’s office makes all the difference.
“He really cares about the quality of the service that you’re getting from him,” she said. “It’s an experience I’ve never had with another doctor.”