In a white paper released last spring written for the Physicians Foundation, healthcare industry analyst Jeff Goldsmith argued for a subscription model in which patients would pay a monthly fee to their doctor. It’s a proposal that set the foundation talking and is sure to result in strong opinions from payers, providers and patients.
In “A Blueprint for a More Effective, Physician-Directed Health System,” Goldsmith, an associate professor of public health sciences at the University of Virginia, argues that instead of paying their primary care physician for visits and tests, patients should pay a monthly subscription fee for the relationship with their physician. That monthly fee would be in addition to what patients pay for their health insurance plans, but is not concierge medicine.
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The Physicians Foundation commissioned and released the white paper but hasn’t endorsed it, said Lou Goodman, PhD, the foundation’s president. “We’ve had a lot of debate on this and there are many elements of it that we wouldn’t disagree with,” he said. However, there were concerns about how patients and doctors would react, in particular to the subscription model recommendation.
Acknowledging that there are barriers to overcome, Goodman feels strongly that this model has merit.
“What I guess I’m arguing is that I think this is a good idea because it lowers the transaction costs associated with being a primary care provider and it lowers the overhead associated with maintaining the relationship, if you do it properly,” Goldsmith said.
“You’re paying for the relationship. You’re not paying for the practice.”
In exchange, patients get 24/7 connectivity and same-day access.
It’s a deal Goldsmith thinks won’t be a tough sell with patients. “I don’t think it’s going to be very difficult to sell a product where they can see their doctor on demand, where they can email them, where they can text them,” he said. “I think the difficult sell is to the health insurers who are wedded to an incredibly high-maintenance, expensive fee-for-service model for paying for a lot of physician care. That’s the hard sell.”
But Josh Trutt, a board certified emergency room physician who practices age management at PhysioAge Medical Group in New York City, thinks it won’t be that easy to sell this model to patients.
Patients pay a monthly subscription fee at PhysioAge Medical Group, and that model works well for the group, said Trutt. The monthly fee pays for things not covered by reimbursements such as responding to emails from patients. However, PhysioAge Medical Group is not strictly a primary care practice, and its patients are highly engaged and proactive about their health. Most patients, he said, are not proactive about their health, and furthermore, consider the emergency room same-day access.
“They’re not worried on the weekend that they can’t see their doctor,” he said. “… they’ll go to an urgent care or (the ER) and not only won’t they pay a monthly fee, sometimes they won’t even pay the ER fee because by law if you go to the ER and can’t give them your identifying information they still have to see you.”
The monthly subscription model as imagined by Goldsmith is not as revolutionary as it seems at first. There are institutions in the U.S. that already do it, including GreenField Health in Portland, Ore.
GreenField opened 12 years ago, born out of the idealized primary care design collaborative devised by the Institute of Healthcare Improvement, said Steve Rallison, GreenField’s administrator.
GreenField has always been subscription based. Monthly fees, based on age ranges, run from $12 a month to $65 a month. Medicare and Medicaid patients are accepted, but GreenField caps the number to 50 Medicaid patients per panel and 30 percent of the practice for Medicare patients.
The idea was to reject the visit-centric model built around maximizing a physician’s time to generate as much revenue as possible to cover compensation and the practice’s expenses, Rallison said.
Instead, the model allows patients to have contact with their physician beyond the annual exam (which lasts at least an hour). Patients can call any time (a real person answers the phone) to get their problem resolved without having to go into the office for a face-to-face visit (unless warranted).
“Since we’re not billing the insurance company for having you come in for a problem-focused visit, we’re saving the insurance company money,” Rallison said. “They’re the ones that should be paying for this, but you’re paying for it through the subscription service.”
The subscription model’s biggest vulnerability is healthy people, Rallison said, because they don’t usually need follow-up health services. These folks sign up because they want out of the traditional system and are excited about the model. They have their annual exam and then nothing more.
“And then we send them the bill for their annual fee 12 months later and they go ‘huh.’ They go, ‘350 bucks on top of what I’m paying for health insurance, my copayment? I can’t justify the added expense,’” said Rallison. “For people over 50, they go ‘this is the greatest deal. You should charge us more money.’”
In order to counteract this vulnerability, GreenField is looking at ways to offer value-added services, Rallison said. Things like making available nutrition specialists or offering discounts to fitness centers.
While the subscription model works for GreenField – it has grown to include 13 clinicians and 4,500 patients – GreenField is small scale. Rallison is not sure this model could work on a national scale, as Goldsmith suggests, but it could, he said, have an influence on the way the payment practices are designed by the health plans.
“I don’t think we have all the answers yet, but I think it’s clearly going in the right direction,” he said. “We need to find a way to replicate what we do here … because it’s hitting the right things: relationships, service and reliability at all levels.”