Frustration With Insurance, Regulatory Paperwork Drives Physicians to Direct Care Model

  • Roger Roberts of NHVT Computer Services shows Dr. Ginny Alvord the functions of a computer system he installed in Alvord's new office in West Lebanon, N.H., on Nov. 13, 2017. After working at a family practice in Littleton, N.H., and at a clinic in Lebanon, Alvord is now taking a different path. She is opening a direct primary care practice later this month, where patients pay a monthly fee for care. (Valley News - Geoff Hansen) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • A temporary sign for Dr. Ginny Alvord's primary care practice in West Lebanon, N.H., is taped to the office door on Nov. 13, 2017. Patients will pay a monthly fee for care. "I’m not out there saying, ‘We have the answer,’ but I think It will probably be a better answer for a lot of people," she said. (Valley News - Geoff Hansen) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Speaking during an interview at her office in West Lebanon, N.H., on Nov. 8, 2017, Dr. Ginny Alvord is opening a new direct primary care practice later this month, where patients pay a monthly fee for care. “The one thing that people don't seem willing to change or innovate on is how individuals pay for their health care," she said. (Valley News - Geoff Hansen) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

Valley News Staff Writer
Sunday, November 19, 2017

West Lebanon — Fed up with mounting paperwork from insurers and regulators, some primary care providers are opting to stop billing insurance companies and instead charge patients or employers a fixed monthly fee for their services.

While there are limitations to this model, including the fact that some people may not be able to pay the fee and therefore will not be able to participate, providers such as Dr. Ginny Alvord, a former Dartmouth-Hitchcock family practice doctor, are ready to try something different.

While she could have joined a federally qualified health center or an already established Upper Valley private practice after she left D-H in September, Alvord, a Hanover resident who had previously considered a direct-pay model while she was in private practice at Summit Medical Group in Littleton, N.H., decided “maybe it was time to take a risk. It was kind of now or never.”

So, after four years as a family practitioner and administrator at D-H’s Heater Road clinic, the 52-year-old University of Connecticut School of Medicine graduate is poised to open a new direct primary care practice in West Lebanon on Monday.

Though the Heater Road clinic made great strides in ensuring that patients were getting the checkups they needed — colon cancer screening, pap smears, mammograms and immunizations, etc. — to ensure they stayed healthy, it wasn’t doing well financially, Alvord said. Communicating with patients via email or any other way aside from an office visit isn’t a reimbursable expense, she said.

“When it came down to it, all of those innovative things that we did to reach out to patients without having them see us in the office weren’t reimbursed,” she said, in a recent interview in the waiting room of her new office on Oak Ridge Road, across Route 10 from Sachem Fields. “In my mind, it just got to feel like it was a shell game that we couldn’t quite make work regardless of the effort.”

Primary care providers are often patients’ first stop when they need medical care. As such, these clinicians are responsible for providing regular care to help curb chronic health conditions and catch serious illnesses before they progress too far. Curbing conditions such as childhood obesity, diabetes and high blood pressure can help prevent more costly forms of care including emergency room visits, hospitalizations and trips to specialists.

Though important, primary care is not well reimbursed generally and, as health reform efforts aim to shift the focus to preventing more costly forms of care, primary care providers are being asked to do more to monitor chronic illnesses. The failure of the money to follow the quality successes at the Heater Road clinic is not unique to that clinic, or to any one health system, Alvord emphasized.

D-H spokesman Mike Barwell did not respond to questions about whether primary care makes money for D-H, but Susan Barrett, the executive director of Vermont’s Green Mountain Care Board, said her state’s health reform efforts are aimed precisely at fixing this problem.

“This is why we want to move away from a model that is based on procedures and fee for service,” Barrett said. “It isn’t happening fast enough.”

Despite efforts to reward providers for their patients’ wellness, the predominate reimbursement system is still fee for service, which encourages providers to order more procedures, Barrett said.

“The one thing that people don’t seem willing to change or innovate on is how individuals pay for their health care,” Alvord said. Direct primary care is “another thing to try. I’m not out there saying, ‘We have the answer,’ but I think it will probably be a better answer for a lot of people.”

Her goals for the new practice, to be named Monarch Family Medicine and which she will run with administrative assistance from her husband, Doug Caulfield, include reducing the number of patients for whom she is responsible. Though Alvord’s patient load at D-H was limited because she spent half her time in an administrative role, in general, a provider in a traditional practice cares for about 2,000 patients, while a direct primary care provider has about 800, she said.

She plans to charge a monthly fee of $75 for adults and $25 for children 18 and under (with an adult membership), plus a one-time registration fee of $100. That translates to $2,400 a year for a couple with two children, or $900 annually for a single person, not counting the one-time fee.

With the reduced patient load, Alvord hopes to be able to spend more time with each patient during office visits and also have time to respond to questions via email or otherwise.

“In this model, it just feels like the incentives line up,” she said.

Alvord is not the first provider to try this in the Upper Valley. Two practices using this model, Sugar River Family Practice and Montague Family Medicine, operated in Claremont for a time, but have since closed. One direct primary care office still in operation in the Upper Valley is Dartmouth Health Connect on Allen Street in Hanover, which provides primary care to employees and their adult dependents of Dartmouth College, the New England Carpenters Health Benefits Fund, some employees and their dependents of King Arthur Flour, and, as of recently, Medicare beneficiaries.

At Dartmouth Health Connect, which opened in March 2012, the employer pays a per patient fee to Iora Health, a Boston-based health care organization that operates practices across the country. The offerings include same-day access to a provider, shorter wait times for appointments, longer appointments, as well as the services of a health coach and behavioral health care providers.

The practice now has more than 1,600 patients who seem satisfied with the care they receive and with the quality of their health, according to Melissa Miner, Dartmouth College’s director of benefits and wellness.

“This has been a commitment that we’ve been able to deliver on improving access to high quality health care,” Miner said.

Dartmouth College spokeswoman Diana Lawrence, in an email, declined to say how much Dartmouth pays Iora per patient, but in 2011, when the new clinic was announced, college officials told the Valley News that the price per patient would vary depending on the health of the patient — sicker patients and those with chronic conditions would cost more than healthy ones.

The approach, however, differs from Alvord’s in that Iora Health employs the physicians at Dartmouth Health Connect and it is restricted to people insured by participating companies or organizations.

Right now, there are just a few provider-owned direct primary care practices operating in New England. Those who have adopted the model say it works well for them. They are, however, still seeking patients, at least in part due to some patients being unable or unwilling to pay a monthly fee in addition to an insurance premium.

Dr. Eric Kropp, a family practice doctor based in Concord who before opening a direct primary care practice in early 2016, worked for a Concord Hospital practice based in Penacook, N.H., said that he was motivated to make the change because he became frustrated that he spent more time checking boxes than interacting directly with patients and that he was responsible for so many patients that they couldn’t get in to see him when they needed to.

“There was a real frustration with the way it was being run,” he said.

Rather than relying on insurance companies to fix the health care system, Kropp said, direct primary care emphasizes the relationship between a doctor and his or her patients. “Homeowners’ insurance doesn’t pay to repaint the walls,” Kropp said. You “don’t need your third-party payers involved for all the expenses.”

Patients of direct primary care practices do, however, need to retain catastrophic coverage for specialty care, provided outside of the primary care clinic.

You “need insurance to cover you for catastrophic loss,” he said. “That’s what your homeowner insurance does.”

Though direct primary care isn’t perfect, and Kropp sometimes has trouble making referrals for patients whose insurance plans require that the referring physician be in-network, he has found that the lifestyle benefits are worth it.

“This was a cure for burnout,” he said. “I love my job. I love my patients. I love that I have time for my family.”

Both Kropp and Dr. Teresa Leverett, a family practitioner operating a direct primary care practice in Exeter, N.H., said they are still accepting new patients. They’ve noticed resistance to the direct-pay model.

“A lot of people just have this thing, ‘Why should I pay extra every month for something that is otherwise covered by insurance?’ ” Leverett said. “It’s just a frugality issue.”

Direct primary care is not for everyone. Part of the point of this care model is to move away from billing insurance companies, including Medicare and Medicaid. People who cannot afford Alvord’s fees are unlikely to be able to participate. Alvord’s fees will not count toward an insurance deductible and cannot be paid for using a health savings account.

But, given that many people currently are paying thousands of dollars out of pocket before they hit their deductible, they may benefit from this form of care financially, as well as qualitatively, she said.

Dr. Melanie Lawrence, who has a family practice in Newbury, Vt., said she certainly can understand the frustrations that led to Alvord’s decision.

“It is to me yet another attempt to sustain primary care in an unsustainable, hostile environment for both patient and primary care physicians,” Lawrence said.

Like Alvord, Lawrence spoke of the frustrating amount of time she and other providers are required to spend reporting information to insurance companies and regulators, including accountable care organizations. She also spends time interacting with patients through her cellphone outside of office hours, which helps prevent unnecessary trips to the emergency room, but cuts into her own free time and cannot be reimbursed.

To serve the Newbury Health Clinic’s 500 patients, Lawrence said, she employs three people — a medical assistant, a finance manager and a dual medical assistant and front desk coordinator — in addition to herself. Without the insurance reporting requirements, Lawrence said, she would need just one and a half full-time equivalents.

“To me, direct primary care is actually one more very thoughtful attempt to provide health care to those able to pay for it,” Lawrence said.

Though elements of a direct primary care model appeal to Lawrence, she said, she would not consider making the switch herself for fear she wouldn’t be able to provide care to her poorest patients.

“I am so concerned that our underserved populations are yet made more and more vulnerable and that we don’t have a system that’s addressing our public health needs,” she said.

Some private practices are already restricting the new Medicaid patients they take, due to low reimbursement rates, said Dr. Paul Reiss, the chief medical officer for HealthFirst, a Vermont independent practice association.

Reiss is not accepting new Medicaid patients at his Williston, Vt.-based family practice, Evergreen Family Health, a decision he said is necessary in order to keep the practice financially viable. He noted that his practice can make that choice because it is located in Chittenden County, where there are a sufficient number of patients who are not covered by Medicaid.

In Vermont at least, Reiss said, he’s hopeful state lawmakers will move forward with an effort to implement universal primary care, which would mean everyone would have access to a primary care provider.

“I’m supporting it very significantly,” Reiss said. We “should have direct primary care for all.”

Bills proposed in both the House and Senate last session, S.53 and H.248, however, got tied up at least in part because of unanswered funding and administrative questions, as state Sen. Claire Ayer, the chairwoman of the Vermont Senate’s Committee on Health and Welfare outlined in an April letter to advocates. “We had hoped to move the bill this year,” Ayer wrote. “But as many of you know, there are many specifics still to be resolved in order to create a workable universal primary care program.”

Though she’s not optimistic that a move to universal health care will be forthcoming in the current political environment, Lawrence said, universal coverage is the only way to address providers’ concerns about the burdens of complying with different requirements from different insurers and different ACOs.

“I applaud (Alvord) for trying something, but I’m devastated that we continue to have such a dysfunctional system,” she said.

Editor’s note: More information about direct primary care can be found online at the website of the New England Direct Primary Care Alliance, nedpca.org, or that of DPC Frontier, which offers a U.S. locator map of such practices, dpcfrontier.com. Valley News Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.