Primary care doctors paid by patient monthly fees, not insurance, gaining traction

Oct. 27--The stuff that Dr. Kim Corba deals with every day ? colds, infections, back pain, anxiety, hypertension, skin rashes ? is part of the routine for a family doctor.

But the way her patients pay her is not.

Corba, whose office is in Upper Macungie Township, provides direct primary care to patients for a monthly fee, without involving health insurance.

"I felt like I couldn't practice my art anymore," Corba said of her decision, made more than three years ago, to offer her services separate from insurance. "Insurance has now gotten to the point where it dictates how I perform what I was trained to do."

Direct primary care is a growing trend in Pennsylvania and elsewhere, with more than 1,000 practices across the country and at least 30 in Pennsylvania. State Sen. Pat Browne, a Lehigh County Republican, said he intends to reintroduce a bill in Harrisburg that would remove obstacles to doctors who want to provide monthly-pay, direct primary care.

A strong supporter, incoming Pennsylvania Academy of Family Physicians CEO Brent Ennis, said the chief purpose of the bill is to keep government out of the relationship between family doctors and patients.

The signed contracts between patients and direct primary care doctors "should be a civil contract, as opposed to something governed by the state," Ennis said.

At the federal level, a measure that cleared the U.S. House of Representatives last year to address tax-related obstacles to direct primary care payments was not taken up in the Senate. But it has been reintroduced this session.

And the Trump administration issued an executive order in June that directed the U.S. Treasury secretary to propose new regulations within 180 days to treat expenses related to direct primary care as eligible tax-deductible medical expenses ? meaning they could be taken from a health savings account.

Corba went to Washington for Trump's signing of the executive order.

She and other Pennsylvania direct primary care doctors said in interviews that routine medical care paid for without insurance was attractive to many patients.

Some, Corba said, have been frustrated by insurers' challenging of payments for doctor-recommended treatment.

"That is what I am hearing from patients," she said. "'I am paying all this money and then I get stuff denied.'"

Dr. Michael Carnathan had worked for a hospital for about five years when he left the job in January. On Sept. 3, he opened a direct primary care practice in Bethlehem.

At 37, it is his first independently owned private practice.

A big plus for him is time with patients. Under insured or managed care, he said, primary care doctors often must see patients "in a rapid-fire rate" while in his direct-pay practice, Carnathan can take as long with patients as he deems necessary.

"I can honestly say that I love my job again, and I have not been able to say that since I left my residency program in 2012," Carnathan said.

Dr. Ricky Haug, who has a direct primary care practice in Kennett Square, Chester County, said his patients like greater access to their doctor.

"They have longer visit times, same day appointments. They can text and email," Haug said.

He equated his patients' visits to a car owner taking a vehicle in for an oil change. Auto insurance, he said, would not be involved.

He said, "Why do we use our health insurance for a cold?"

Dr. Patrick Rohal, who provides direct primary care in Lancaster and York, said insurance should be reserved for extraordinary medical situations.

"Things that are unlikely to happen," Rohal said.

Twenty-five states have passed laws that set up frameworks for direct primary care providers. Browne's original proposal, introduced during the last legislative session, was the subject of a 2017 hearing before the Senate Banking and Insurance Committee.

At the hearing, then-Acting Insurance Commissioner Jessica Altman expressed reservations about the proposal. But she also said she was wiling to work with lawmakers if it moved forward.

This week, a department spokesman said its position had not changed.

Among other things, Altman said at the hearing she believed some consumers might think the monthly fee would be all they needed to pay for health coverage, even though it would not cover things like emergency care and hospitalization.

"It is unclear what kinds of services physicians might offer under direct primary care agreements as envisioned by this bill," Altman testified.

She also wondered whether consumers would understand the monthly payments did not count toward their insurance deductibles. She asked what recourse they would have if the doctors did not provide services as promised.

Since the bill put the doctors outside Insurance Department jurisdiction, Altman said, it would hinder the department's authority to enforce the law against bad actors.

If the bill moved forward, Altman said, it should require a series of disclosures to consumers, including some of the concerns she described.

Insurance Federation of Pennsylvania President and CEO Sam Marshall testified at the 2017 hearing, "This sounds like magic. There is no magic. I wish there were."

If lawmakers formally recognize direct primary care, he said, the system should have the same safeguards and consumer protections applied to insurance policies.

In an email this week, Marshall said the federation's view remains the same. The main question, he said, was how to make sure direct primary care is responsibly offered and fulfilled.

At the hearing, Jay Keese, executive director of the Washington, D.C.-based Direct Primary Care Coalition, said doctors already were making disclosures in the contracts they signed with patients but he welcomed Altman's suggestion that disclosures be formalized.

Ennis, head of the doctors' group, said in an interview that contracts signed by direct primary care doctors and patients typically spell out exactly what is covered, as well as the benefits of having a high-deductible insurance plan to cover serious or catastrophic medical situations.

And, Ennis said, consumers of direct primary care already have protection via state government. If a doctor fails to provide good, professional care or violates the contract, Ennis said, the consumer can file a complaint with the Department of State's Board of Medicine or Board of Osteopathic Medicine.

He pointed out that the government of New Jersey already offers a "hybrid" health coverage arrangement to employees, consisting of access to direct primary care doctors and high-deductible health insurance.

Ennis said the number of direct primary care doctors across Pennsylvania is growing at a modest rate.

The urgency of the issue, Ennis said, is that some people are skipping primary care because of the expenses involved.

A bill similar to Browne's was approved in the House in 2017. It received no action after reaching the Senate committee that held the hearing.

Corba, the Lehigh Valley doctor, said she has 350 patients.

They pay monthly fees between $35 and $110 a month, based on age. For that price, she said, patients get unrestricted access to her office's services, extended visits during appointments, same- or next-day scheduling, and savings on lab and medication costs, among other things.

Direct primary care doctors are not against insurance, according to Corba. She said 75 percent of her patients have insurance, and she encourages the rest to get it.

But some of her patients have insurance deductibles of $10,000 or higher ? meaning they would pay out-of-pocket anyway when seeing primary care doctors who work with insurance companies.

Lehigh County Democrat Sen. Lisa Boscola, who was not associated with the bills last session, said she liked the concept put forth by Browne.

Boscola said she has heard of doctors who cannot practice medicine the way they would like because they are not given enough time to see patients.

Direct primary care, she said, could work in tandem with insurance.

Boscola said, "This is just like an enhancement, a supplement, but doctor-driven."

Morning Call reporter Ford Turner can be reached at 717-783-7305 or [email protected]

___

(c)2019 The Morning Call (Allentown, Pa.)

Visit The Morning Call (Allentown, Pa.) at www.mcall.com

Distributed by Tribune Content Agency, LLC.