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In the fall of 2005, Erika Bliss, MD, was helping a friend install a hardwood floor and got a splinter—a big one, deep under her fingernail. "I can see why they use that as torture," said Dr. Bliss, sitting in an examining room last week. "It hurt so badly, I couldn't think straight." She couldn't remove the splinter, nor could her friend. It was Sunday and her doctor's office was closed. Dr. Bliss went to the emergency room.

"I knew the doctors there, and they got me treated quickly and that part was lovely," Dr. Bliss said. "They injected some lidocaine into my finger, pulled the splinter, and gave me a tetanus shot. Take a wild guess how much that cost." She paused. "Twelve hundred dollars."

If Qliance, Dr. Bliss's revolutionary new medical group, had existed back then, she could've come in on a Sunday, had her splinter pulled, and left without paying a penny.

For the past 14 months, Dr. Bliss and a few other doctors in downtown Seattle have been running a radical experiment in health care. They've sidestepped the entire health-insurance industry by opening a practice that gives direct primary care to their patients for a monthly fee ranging from $49 to $129. "Think of it like a gym," says member services associate Meg Tronquet. "You can use it as much or as little as you like."

Qliance keeps patients out of hospitals and costs down by having an on-site digital X-ray machine, a lab, and a dispensary that sells generic drugs at cost, so patients don't have to pay extreme pharmacy markup. They're open seven days a week, allowing people without health insurance to get reasonably priced primary care, preventing who knows how many catastrophically expensive visits to the emergency room.

That saves public money, too, since many people who can't afford insurance—and whose visits to the emergency room have to be written off as a public cost—can afford Qliance. Governor Christine Gregoire's proposed budget for 2009 eviscerates public-health spending, including a $252 million (or 42 percent) cut in the state's Basic Health plan and elimination of medical care for people on the General Assistance Unemployable program. Qliance may be exactly what many of those people need.

Even people with insurance are thrilled about Qliance. Dustin Johnson, who has health insurance through his job at the nonprofit Housing Resources Group, goes to Qliance for his primary care.

"The benefits are astounding," he says. "Qliance has the only doctors with a true doctor-patient relationship with an exchange of ideas, and the attention is really remarkable." Johnson's first appointment was an hour and a half long—Qliance prides itself on unhurried appointments—in which he described his chronic kidney issues, which had him going to the emergency room several times each year. (Johnson, who is 24, has had seven surgeries for kidney stones in the last 10 years.) His doctor, Erika Bliss, said she'd do some research and get back to him.

"I've heard that before," Johnson says. "It usually means the doctor will reference a book for a minute." At his second appointment, Dr. Bliss brought in a thick stack of research, which she had read and synopsized for Johnson, then described a new strategy to treat his kidney problems. He hasn't been back to the emergency room since. He's so excited about Qliance, he's nominated them for the annual Warren Featherstone Reid Award for Excellence in Healthcare.

Some other success stories from the last 14 months at the Qliance Medical Group:

A high-school student separated his shoulder and, instead of going to the emergency room, went to Qliance, where he was diagnosed, x-rayed, treated, and given exercises to do, all for $39.

Compare that with another patient (who asked to remain anonymous for privacy reasons), a real-estate agent in Seattle, who doesn't have comprehensive insurance, only has a high-deductible plan. He cut his finger and was told by his doctor at Swedish to go to the emergency room. Ultimately, he wound up paying $700 for six stitches. When the agent first heard about Qliance from a friend, and that stitches are included in the monthly benefits, he said "couldn't believe it." He's been a member for eight months and says he couldn't be happier.

"People get so trashed out there in the insurance system," says Dr. Garrison Bliss, a founder of Qliance. "It's amazing that people put up with it—it's a kind of learned helplessness."

Another high-school student, a teenager with depression, started coming to Qliance several times a month to meet with her doctor, discuss issues, set goals, and monitor medications. Because Qliance has no co-pay and no insurance, her appointments are completely confidential. Otherwise, she may not have come in for help.

Patients with hypertension and diabetes have been able to get their conditions under control by checking in with the doctor every week—previously, they hadn't been able to afford it—preventing emergency-room visits and the worsening of their own health.

Another patient with dangerously high blood pressure had stopped seeing doctors and taking her medication because (a) it was expensive and (b) she felt like doctors weren't listening to her. Through a slow process of building rapport, one of the Qliance doctors convinced her to take a regime of blood- pressure medication and teased a family medical history out of her. The history combined with a CAT scan showed the hereditary polycystic kidney disease, which can cause brain aneurysms. (The patient's mother had died of an aneurysm at 39.) Further investigation revealed two aneurysms in the patient that were repaired last summer. The patient, according to a report from her doctor, "is alive and well, without complications. I feel that having enough time to spend with patients in order to obtain a thorough family history is what allowed me to make this diagnosis." That diagnosis probably saved her life.

Because Qliance doesn't mess with insurance, even outside consultations can be radically cheap. They've negotiated a $20 consultation rate with a radiologists' group to look at X-rays taken in the Qliance office. "You can't find a $20 X-ray anywhere," says Dr. Erika Bliss. She talks about how happy she feels being able to make decisions about care and treatments directly with her patients, without the interference of an insurance company and what it will and won't cover.

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"I tell you," she says, shaking her head, "no matter what, I am never going back." recommended

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