Direct primary care doctors don’t take health insurance. Instead, patients pay a monthly membership fee for access to their doctor. The number of doctors with direct primary care practices is growing in the Kansas City area. And the onset of the Trump administration could mean a new market opening up for these physicians: Medicaid. From the Kansas News Service, Andy Marso has more.
Medicine by Monthly Fee Expanding in Kansas: Is KanCare Next?
By Andy Marso
Dr. Damon Heybrock’s office doesn’t look like a traditional medical clinic.
Heybrock finished converting a two-story row house into a medical practice in September, putting exam tables in the bedrooms and a centrifuge for lab tests next to the kitchen sink. The look isn’t the only thing that’s different about his practice — so is the payment method.
Heybrock is part of a growing group of Kansas doctors who accept no insurance. Instead, they charge a monthly membership fee — in Heybrock’s case $60 for an adult — for unlimited office visits, phone calls and some lab tests.
They call it direct primary care, or DPC. Heybrock said he chose it because he didn’t want to spend time worrying about insurer coding and billing or become part of a hospital group in which doctors largely oversee the work of lower-level providers. “I didn’t get into medicine to manage,” Heybrock said. “I got into medicine to see patients.”
As DPC practices grow, patient advocacy groups warn that they’re no substitute for comprehensive medical insurance and patients who treat it that way risk large out-of-pocket bills.
But the doctors say they’re filling a customer service niche that patients aren’t finding in practices that depend on insurance reimbursement. They are collaborating and clearing regulatory hurdles and, if President Donald Trump fulfills one of his campaign pledges, they could soon move into a new arena: Kansas Medicaid.
An Alliance Forms
Heybrock’s previous job was at Cerner, where he worked for almost 10 years in the on-site employee clinic. The Kansas City-based health information technology company is self-insured, so Heybrock didn’t have to bother with insurance. “I liked how we were doing medicine,” Heybrock said. “The longer appointment times; we built a team care model, lot of integration and all that, so I loved that. But it was time for me to move on.” Heybrock wanted to practice that way, but in his community, so he turned to DPC.
Two years earlier he would have had few resources to look to for help in setting up his practice. But now Heybrock is part of the Midwest DPC Alliance, a group of 17 direct primary care doctors at nine locations in the Kansas City metropolitan area (eight in Kansas and one in Platte City, Mo.). The group’s leader, Kylie Vannaman, said it started with a dinner party in October 2015.
“We met informally and found it to be really great,” Vannaman said. “Just good camaraderie, good social support, and it just has kind of grown and manifested into this loose organization.” Vannaman, who has a direct primary care clinic in Johnson County with her colleague Haseeb Ahmed, said the group now meets quarterly. Vannaman said the group’s focus is largely educational right now: explaining to the public that DPC is having a doctor essentially on retainer. It’s what used to be known as “concierge medicine,” but she and her colleagues are trying to do it at prices accessible to people who aren’t wealthy.
Their organization also adds political clout to direct primary care practitioners in Kansas, a group that has thus far been led by Josh Umbehr, a Wichita physician and Libertarian candidate for lieutenant governor.
Umbehr, who owns AtlasMD, has long been an advocate of DPC and worked with the Kansas Medical Society this year to draft a bill that would allow doctors to negotiate prices with medical testing labs on behalf of their patients.
Since 2007 Kansas law has required that labs bill patients or their insurers directly, because of fears that doctors would mark up prices if they acted as middlemen. But DPC doctors say they actually want to do the opposite: haggle for lower prices. “We’re the middleman helping bring the cost down,” Umbehr said in a phone interview. House Bill 2027, which exempts DPC doctors from the lab billing restrictions, passed the Kansas House 119-1 this week. It requires DPC doctors to show patients in writing what lab they used and what the costs were. “The consumer protection side of that would still be if a doctor didn’t describe what their prices are, they would get in trouble,” Umbehr said.
The Trump Effect
Removing regulations for DPC doctors makes some patient advocacy groups nervous.
Most DPC physicians recommend that their patients at least couple their primary care membership with a low-premium, high-deductible health insurance plan to help cover catastrophic medical emergencies. But Andrea Callow, a senior policy analyst with the group Families USA, said that still leaves gaps in coverage that could lead to big out-of-pocket expenses. “For low-income people, all of those risks just get further amplified,” Callow said.
For years Umbehr has pushed for a pilot program to include DPC in KanCare, the Kansas Medicaid program that mainly serves low-income children and pregnant women and people with disabilities. He’s proposed allowing Kansans in Medicaid to get a voucher or debit card to purchase their primary care from a DPC provider. “We need a variety of care providers and a variety of options, and I think that’s an interesting one to explore.”
According to the national Direct Primary Care Coalition, several states have tried to incorporate DPC into their Medicaid programs.
Lt. Governor Jeff Colyer, a plastic surgeon from Overland Park who has had extensive input on KanCare, said federal rules make it difficult. But that could change under Trump, who has said he wants to shift Medicaid to a block grant system that gives states more administrative flexibility. If that happens, Colyer said Kansas will look at making DPC an option for the state’s 425,000 KanCare beneficiaries. “I’m interested in all options on the table,” Colyer said. “We need good-quality care and we need a variety of care providers and a variety of options, and I think that’s an interesting one to explore.”
Callow said it’s hard to evaluate the risks and benefits without knowing exactly how the state would use DPC in KanCare. But her group generally opposes shifting the costs of health care to individual consumers and would advise treading carefully with changes to Medicaid. The federal rules are there for a reason, she said. For example, they require early childhood screening for mental illness as part of primary care. “Everything that makes Medicaid Medicaid right now would potentially sort of be shifted in this kind of environment,” Callow said.
Andy Marso is a reporter for the Kansas News Service, a collaboration of KCUR Radio, Kansas Public Radio and KMUW Radio covering health, education and politics in Kansas. You can reach him on Twitter @andymarso.