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.

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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."

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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." recommended

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.

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