Long before Grey’s Anatomy, there was Marcus
Welby, M.D. From 1969 to 1976, ABC’s popular television series
epitomized the glory days of health care. Dr. Welby was accessible and
caring. He knew every one of his patients. If you got sick, he took
care of you right away, always spending whatever time necessary.
Fast-forward to 2008. You’ve got a cough and high fever. Maybe it’s
the flu. Worse yet, it could be pneumonia. You call your family doctor
or internist. “We can get you in a week from Thursday,” says the
receptionist.
You arrive for your appointment, wait 45 minutes in the crowded
waiting room, wait again in the exam room, and then get 10 minutes with
your doctor, 15 if you’re lucky. Of course, he doesn’t remember much
about you except for those few notes he scribbled last time. How could
he? He’s got 3,000 other patients and will have to see 25 to 30 of them
before the day is over. You just hope he got the diagnosis right before
rushing to his next appointment. Sound familiar?
What happened to the old family doctor so wonderfully represented by
Marcus Welby? Insurance killed him.
Today’s insurance reimbursement process is an impediment to the
delivery of affordable, patient-centered primary care. To get paid,
your doctor has to meticulously track everything he does—and
why—then navigate an incredibly complex system of billing codes
that is prone to error. He’ll have to negotiate and resubmit charges
when the insurance carrier denies payment, which it often does. And
when he finally gets paid for your visit, he’ll get a low contract
rate—about $50–$70 in Seattle. It’s no wonder that today’s
primary-care doctor has to see so many patients each day just to make
ends meet.
Repeat this same reimbursement process for lab tests, X-rays, and
prescriptions. You’ll see why insurance-related administrative costs
consume over 40 cents of every dollar spent on primary care, money that
isn’t being spent on care itself.
Does one really need insurance for routine primary and preventive
care? No. But somehow health care has become synonymous with health
insurance. “Insuring primary care is like insuring lunch,” says Nick
Hanauer of Second Avenue Partners, a Seattle venture-capital fund. “You
know you’re going to need it. You know you can afford it. Why on earth
would you pay a third party to pay the restaurant on your behalf,
adding overhead and taking a big chunk out of the money you
pay—and because of the process, have to wait a week to get a
table and then have only 10 minutes to eat?”
Without the costs and profit that insurance reimbursement adds,
primary-care doctors could spend more time with fewer patients and
still charge low fees. More importantly, doctors could once again focus
exclusively on patient care the way Marcus Welby did. And more medical
students would choose to enter primary care, reversing a disturbing
10-year decline.
A new Seattle-based primary-care practice called Qliance, which
Hanauer is on the board of, wants to bring back the Marcus Welby
doctor. By forming a direct financial and professional relationship
with each patient—as in the days before insurance—Qliance
takes the 40 cents of each dollar that would have otherwise gone into
insurance reimbursement processes and puts it into more medical
providers, longer office hours, the latest diagnostic equipment, and
lower fees. No insurance is required or accepted.
The practice offers members same- or next-day appointments seven
days a week, plus 24/7 phone access to a physician. Visits are
typically scheduled for an unhurried 30 minutes so that health-care
providers can spend the necessary time and conduct the necessary tests
to accurately diagnose an illness or provide appropriate wellness
counseling. Comprehensive physical exams, included in the monthly fee,
typically last an hour or more. “Since coming to Qliance, I’ve been
really pleased. Everyone has taken lots of time with me. I get
complete access to my nurse practitioner and doctor. It’s been a
fabulous experience,” says Nathan Palmer, a patient.
Qliance members choose a personal care team of both a physician and
a nurse practitioner who get to know each patient very well, since they
see only one-fourth the patients that a typical insurance-based
physician does. Members pay only $39 to $74 per month for as much
primary and preventive care as they need. On-site digital X-rays and
many common lab tests are included in the monthly care fee.
Qliance’s goal is to make the highest quality primary and preventive
care affordable and accessible to all, rich or poor, insured or
uninsured. Unlike insurance, Qliance does not prescreen members on the
basis of health.
Qliance does recommend health insurance to its
patients—but not traditional low-deductible insurance. “Insurance
should be used for catastrophic illnesses, not routine care,” explains
internist Dr. Garrison Bliss, a national pioneer in direct primary-care
practices and Qliance’s cofounder. “A high-deductible health-insurance
plan combined with Qliance can save 30 percent to 50 percent off the
total cost of comprehensive care. It provides better access and service
at the primary-care level while maintaining financial protection for
serious illnesses.”
At a Qliance launch event on November 1, Governor Christine Gregoire
told an audience of patients and others: “I see someone like Dr. Bliss
and I say many of our physicians in this country and in this state went
to school
because they wanted to practice medicine, not because
they wanted to deal with insurance. Not because they wanted to deal
with bureaucracy. In fact, they don’t want to deal with any of that;
they want to deal with their patients and that’s what they are really
good at. And what Qliance has as a vision and a model is to allow
doctors to do what they love and what they feel passionate about, to
give patients… what they so richly deserve at an affordable cost and
with high quality. It is patient safety. It is driving down costs…
This is exactly what we and the patients in the state of Washington
need.” 
Norm Wu is CEO of Qliance Medical Management, the company
helping the providers at Qliance Medical Group and elsewhere set up
direct primary-care offices throughout Washington. Contact him at
thestranger@qliance.com.
Thank you for your excellent article. Garrison Bliss, the founder of Qliance, was also the second president of SIMPD, the national society of direct practice doctors that I now head.
Many of the problems of high cost and poor access have to do with the virtual destruction of primary care over the past forty years. That resulted from well intentioned but misguided activities of government, employers and some insurance companies hoping to “fix” health care without ever asking doctors and patients in the trenches how that might be done. The beginning of a solution is the restoration of adequate primary care. The question is how to do this.
Most now agree that patient centered primary care medical homes for all Americans are indeed the solution, but how do we pay for them? Thousands of doctors have learned the way to do just that. By limiting our practice size to 1000 patients or less and charging a periodic fee around $100 per month to each of these patients directly (direct practice) the patient centered primary care medical home becomes a vibrant reality. I know. I run one and have the honor of heading a national organization of doctors who run such direct practices.
In these practices patients are seen immediately when ill, on time and at length. They stop going to emergency rooms because they can find their doctor and get care from him or her directly at any time 24/7/365. Our data demonstrates up to 80% reductions in hospitalizations, which if applied to all Americans would mean our hospitals would work again without having to build more ER rooms and inpatient beds. This results in huge savings
Most patients today with multiple medical problems have multiple doctors, one for each problem. Direct practice primary care medical homes take care of most of these problems in one place and all at once, eliminating the need for many of these consultants entirely and reducing the frequency of visits to many more, resulting again in more huge savings.
Students who see how cheerful, well paid and professionally fulfilled are such direct practice doctors gain hope that they too can have such a practice. We need 400,000 such practices if we are to care for our population properly. Currently the numbers of primary care doctors are rapidly dwindling and only eight percent of medical students elect any primary care pathway. Not long ago that figure was 50%. Short of coercion no system except direct practice primary care medical homes will draw the students we need.
My national organization SIMPD is having its annual meeting at the Marina Marriott Hotel in San Diego May 6-9 and I invite you to come to discuss these ideas. One of our board members Steven Knope, MD recently authored an excellent book titled “Concierge Medicine–The New System to Get the Best Healthcare” and I recommend it to you highly.
Sincerely,
Thomas W. LaGrelius, MD, FAAFP
President SIMPD, The Society for Innovative Medical Practice Design, http://www.simpd.org
Owner, Skypark Preferred Family Care, Torrance , CA http://www.skyparkpfc.com
Thx to Garrison for his vision and mentoring. The time has come for physicians to change their practices to a business model where Docs have a direct financial relationship with their patients. “Direct practices” are emerging across the US as the solution to our primary care systems problem.
It’s fun to practice again…
Chris Ewin, MD, FAAFP
Past President, SIMPD
http://www.simpd.org
http://www.121md.net
cewin@121md.net
Drs LaGrelius, Ewin , and Bliss are pioneers with the courage to swim upstream to improve health care in our great nation. Good job good doctors!
Gary Price MD FACP
Is a reality that patient is not the most important thing, neither for the Govermment, nor for the health insurance agencies. This situation makes you feel like a number or that your value is established in dollars and cents. Is not your condition, what guides the physicians actions, is how much you have to pay the fees. It’s that humanity?
Dr. Pura J. Cruz-Oliver (Puerto Rico)
I joined Qliance a few months ago and LOVE their service. I came down with the flu yesterday, called my doctors and got same day care. They assured me it wasn’t swine flu, I went home and went to bed. All without paying a co-pay, I just pay $54 bucks a month. If for some reason I had to see my doctor every day, the payments don’t go up. So much better than paying a huge fee for insurance each month, just to have the option to then go pay my doctor for each visit.
I recommend this type of service whole-heartedly.