I going to provide two examples in two posts about the cost of primary care. First, I want to highlight what the true cost of ordinary primary care visits can be even for those with insurance. Second, I hope to show how difficult it is to determine the cost of care before a visit occurs. Lastly, I want to show how a Direct Primary Care program helps stabilize and lower the cost of ordinary care.
Steve is a 55 year old truck driver who is married and has two daughters in high school. He drives a local route so he’s home every night to help with home work. He works hard and never seems to have the time or energy to eat as healthy as he knows he should. Steve started developing high blood pressure years ago and was started on medication. After several years of watching his blood sugar climb and pant size grow he was diagnosed with diabetes and high cholesterol. Medications were prescribed for both disorders. His doctor has talked to him about “diet and exercise” and even offered to set up an appointment with Medical Nutrition Management but that hasn’t happened yet.
Here’s Steve’s problem. The best medical care available recommends regular visits with his doctor to discuss how to eat healthy, how to incorporate exercise, and to make sure his medications are doing a good job without any side effects. That seems like a tall order for the routine 15 minute visit. Steve wants to make every dollar count so he asks what the price of all this care is going to cost.
He knows that he will need at least four moderately complex office visits (billed as a 99214 for those in the know) this year to properly work on his health problems. He might need more depending on unexpected illnesses and complications that develop. At each visit it is recommended he get a few routine laboratory tests done including a HgbA1c, a lipid profile, a chemistry panel, a urine microalbumin (twice a year usually is good enough), and since his doctor is very proactive at managing diabetes an insulin level.
Let’s consider four possible scenarios Steve might have depending on the insurance he carries.
If Steve comes to Trinity Medical Associates and has a High Deductible Health Plan (HDHP) then
Four 99214 office visits charged at $133 each = $532
Charges for all the labs for the year are $232
Total charged price for the year = $764
His insurance has already negotiated a lower price that typically runs about 80% of charges.
So Steve pays $611.20 per year out of pocket with a HDHP for four visits and the associated blood work.
Steve needs to be commended for coming in four times in a year to get his health issues under control. The average adult in the United States only sees their doctor about 2.5 times a year. That’s not enough time to work on medical issues and that is why many patients see their health decline year after year. Additionally, Steve knows that any other visits will result in more medical bills so he might try to ignore the worsening heart burn and the nagging chest pain a little while longer.
If Steve comes to Trinity Medical Associates and has no insurance then you might think he will get charged a crazy high bill. In fact, Trinity’s administrative team diligently spent 2014 leveling the playing field for all un-insured patients. We jokingly call it The Fairness Act of 2014. The total charged price for the year is still $764 and, if Steve pays for each visit at the time of service, he is given the same 20% discounted rate that the insurance companies negotiated. As a cash payor, he receives the same benefit as anyone with insurance.
So Steve still only pays $611.20 per year out of pocket without insurance for four visits and the associated blood work.
Still though, any other visits will cost extra, and there’s good evidence to suggest people don’t come to the doctor as often as they should due to the fear of high cost. Maybe he’ll try another heartburn pill over-the-counter and see what happens.
If Steve seeks out care from a retail health care provider, urgent treatment center, or doc-in-the-box then there really is no telling what the prices will be. I’ve spent some considerable time researching prices in the community and most everyone doesn’t fully post prices online (in fairness, neither does Trinity for now but it is available if a patient needs to know). For instance, the Little Clinic in Kroger’s posts lab prices of $54 for the lipid profile alone with a consultation about the results costing extra. They don’t offer the other necessary labs for diabetes management. AnyLabTest Now! offers a Diabetes Panel for $99 which is a good start but doesn’t include the other recommended tests. Other labs would cost extra and, of course, there is no consultation, management, or discussion about the medical problems either.
So Steve doesn’t know how much it’s going to cost to get care from these facilities. In fact, no one knows until the bill comes. That’s part of the problem with our current system. Would you go buy a family meal or a buggy full of groceries without knowing the price first? Imagine the waiter saying “Just leave your credit card number with me and you’ll see the price in a couple days when the charge clears the bank.”
If Steve comes to one of Trinity’s new Direct Primary Care offices in Hardin Valley or Maryville then he knows the cost of his care before he ever steps foot in the office. We actually have posted these prices already. His monthly price would be $60. This would include all his visits that he needs to have his diabetes, high blood pressure, and cholesterol managed. It would also include all the blood work needed to understand how he was doing and measure his progress. We already saw that this would have cost him at least $611.20. On top of all that though he would be able to call or email the office to ask questions or come in an additional 21 times that year for no extra cost. We include 25 visits per year with the membership and offer further visits at $25 a piece. These visits would typically last 30mins each and allow for more time to cover any topic he needed not just his diabetes, hypertension, and cholesterol disorder. Maybe he could finally talk about that heartburn and chest pain too. So Steve pays $60 a month for an ongoing conversation about his health care that includes his office visits, phone calls, and emails as well as all the routine labs used to help him succeed. He has further access to discounted pricing on other labs and services as needed including the Medical Nutrition Management and Wellness Coaching. He could even get a package that includes VitalSigns gym membership and a subscription to VitalMeals which offers weekly recipes and grocery list delivered via email. These tools are just what he needs to fully engage his health problems and maybe even cure them. Perhaps he could even come off his medications and save even more money?
At the end of the analysis we have wonder in which scenario Steve would spend less money and get more time to talk about the health issues most pressing to him. Which scenario benefits Steve as the patient the most? Now, is this scenario true for everyone? Is every patient a Steve? Of course not, but for many patients they feel very much like Steve. They are stuck in a system of high premiums and low coverage with health concerns going undiscussed. Maybe we should reorient our healthcare system to focus on the patient first and build a healthcare delivery model with that in mind. It’s definitely something to think about.