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Insurance coverage (or lack thereof) got you down?

Alternative pay medical models offer a local option for healthcare woes

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Keeping current on changes in healthcare can be overwhelming.

Like an irrational tweeter, the fluctuations over coverage concerning preexisting conditions, who qualifies for Medicaid and Medicare, and possible tax credits or subsidies seems to zig-zag faster than can be searched on a smartphone.  

Some argue that the problem's origins can be traced to the 1960s, when the Medicare fee-for-service system forced a shift in healthcare from patient-driven to provider-oriented, rewarding volume rather than value of service and focusing on sickness rather than preventative care.  

As a result of the FFS shift, many have found themselves in a modern healthcare purgatory, including Bend resident Rachel Wilson.* As a full time mechanic's apprentice, Wilson's employer option is a healthcare package that covers 10 yearly visits, each with a co-pay. This coverage has no allotment for emergencies, specialist treatment, dental or eye care and includes a $7,000 deductible. The monthly cost is just under 10 percent of her take-home pay. Because of the gaps in coverage and the high cost, Wilson has opted not to pay for that plan, and instead pays the yearly tax penalty of $600—nearly 3 percent of her take-home pay.

"Since my employer offers coverage, I don't qualify for the federal and state reimbursements people get when their job doesn't offer healthcare," the avid skier and climber says. "I pretty much have no choices with conventional coverage and am definitely looking for alternatives. The reason I moved to Bend was to recreate in my free time. This puts me at greater risk for needing coverage."

In Irvine's pediatrics clinic, the fee includes all well visits, sick visits, follow-ups and appointments for chronic conditions.

Alternatives to the Typical Insurance Models

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mid the mire of the traditional health coverage models are alternative payment medical models, or alternative payment models. As former Utah governor Michael Leavitt (R) explained, "APMs are designed to move away from the perverse incentives inherent in the current FFS system and toward patient-centered healthcare."  

Local pediatrician Erika Beard-Irvine, MD has been offering APM services in Central Oregon since her separation from the Navy in 2014. When she began working in the civilian world, Irvine says she was torn about continuing to practice, because generally, patients are only allotted a 20-minute appointment window.

"I love taking care of kids," Irvine says. "I don't love having to compress my relationship with kids and their parents. I want to have time with my patients to get to know them. I want to tailor care to specific situations."

Irvine accomplishes longer visits and tailored patient care through direct primary care. With DPC, patients pay a monthly fee, much like a gym membership, that covers all services provided by the doctor. In Irvine's pediatrics clinic, the fee includes all well visits, sick visits, follow-ups and appointments for chronic conditions. In most clinics, patients typically have direct access to the doctor by phone, email and (often) text. Some DPC facilities also offer appointments via video chat, and discounted rates for testing and medications.

Costs of Direct Primary Care

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n addition to the monthly membership option, Irvine can bill patients' insurance plans as an out-of-network or nonparticipating provider, but recommends patients check with their insurance plan to determine coverage.  

Some DPC clinics offer a discount for paying the entire bill during the visit, and will give patients the paperwork to submit to their health insurance plan. Sliding scale payments are sometimes an option.

Mark E. Gonsky, DO of Deschutes Family Care, a facility offering DPC memberships, says he charges $60 per month ($10 a month for children of members) and that discounted rates are available for certain situations. He notes, "With DPC models, the patient gets to have YourCare rather than ObamaCare or TrumpCare."

In Oregon, DPC clinics are not considered insurance, so patients are still required to carry health insurance if they don't want to pay a federal tax penalty—problematic for folks who can't afford to pay for both. In addition, the IRS doesn't permit health savings accounts to be used to pay for DPC fees—although a bill has been introduced to change that. DPC clinics also sometimes offer contracts directly with employers.

The models can also be attractive for people on high deductible insurance plans, becoming more like car insurance: available for high-expense emergencies but not for routine expenses.  

For DPC patient and mother Eirinn Ames, access and costs have been the main selling points. "DPC allows direct access to your doctor without a third party having a stakehold in how your health care is administered. And, most people don't know the price of an actual office visit or any of the services that you go to see a doctor for because there is very little transparency in price. Most of the information on cost comes after it's been processed by the insurance companies. I can't think of going out to get something done on my car or house without first knowing how much I'm going to pay for it."

Direct Primary Care and Alternative Pay Model options in Central Oregon

Erika Beard-Irvine, MD

325 NW Vermont Pl, Suite 105, Bend

541-241-6371

bendkidshealth.com


Wendy Heath-Wirtz, MS, NCC, QMHP

Juniper Mountain Counseling

1569 SW Nancy Way, Bend

541-617-0377

JuniperMountainCounseling.com


OSU Cascades Free Counseling for Community Members

Graduate & Research Center

650 SW Columbia, Suite 7100, Bend

541-322-2047

osucascades.edu/free-counseling-community-members


Deschutes Family Care

1345 NW Wall St #302, Bend

541-323-3960

DeschutesFamilyCare.com


West Bend Family Medicine

2855 NW Crossing Dr. #102, Bend

541-383-8066

WestBendFamilyMedicine.com


Cascade Direct Care

198 NE Combs Flat Rd, Prineville

541-362-8688

CascadeDirectCare.com

 

*Name was changed to protect privacy.


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