SOUTH PORTLAND, Maine — Roxanne Pettigrow has no health insurance. But the Gorham woman visits her doctor in South Portland every few weeks, paying $50 up front, once per month for regular checkups, office visits and preventive health screenings — care those lacking health coverage often skip.
With her $600 annual subscription, Pettigrow enjoys hourlong visits and email exchanges with her primary care physician, Dr. Michael Ciampi. The South Portland doctor attracted national media attention a year ago for his decision to stop accepting all forms of health insurance, and he began offering the subscription option in mid-January.
Pettigrow saw Ciampi on the news and became one of his first subscription patients, who number about two dozen.
“Dr. Ciampi never looks at his watch, which I find totally amazing,” Pettigrow said, sitting in an exam room after a recent appointment. “He’s the first doctor I’ve ever seen that doesn’t look at his watch.”
Ciampi’s patients can either pay the monthly subscription — which costs $95 per month for an adult couple and $140 per month for a family — or pay for individual services, based on prices Ciampi posts on the practice’s website. Some patients have health coverage, seeking reimbursement from insurers after the fact. Others find paying Ciampi costs less than accumulating high out-of-pocket costs under their health plan or believe he is worth the better care even if he costs more.
“The $50 a month that I pay, for the services I get, is really unbelieveable,” Pettigrow said. “It really is. I think more people should know what he’s offering because there’s so many of us out there that don’t have health care.”
Pettrigrow said she couldn’t afford the $200-plus per month it would have cost her to buy insurance under the Affordable Care Act. She saves about $75 a month by purchasing her prescriptions through Ciampi’s office, which sells many generic medications to its subscription patients at cost.
His office also provides vaccines at cost, or free for subscription patients. Lab work sent out for processing is offered at the practice’s cost, at a savings of 25 to 75 percent compared with local hospital and commercial labs, Ciampi said.
Included in the subscription are annual physicals; office visits for chronic conditions, illnesses, and injuries; some services related to diagnostic testing, such as EKGs and pregnancy tests; draining of abscesses and some joint injections, among other services.
“Anything that would normally happen in a family doctor’s office, it’s all part of the membership,” Ciampi said. “There are no co-payments, there are no deductibles.”
When patients need to visit a specialist, get an X-ray or MRI, or use other services outside Ciampi’s scope, he does his best to send them to doctors and facilities that offer discounts for paying cash.
Symptom of change
Ciampi’s among a small but growing number of physicians, faced with mountains of insurance forms and packed waiting rooms, who are rejecting the traditional health insurance model.
Independent physicians like him, who don’t work for hospitals with large billing departments to handle paperwork, appear particularly drawn to cutting out the insurance middleman. Freeing themselves of insurance overhead saves both time and money, as doctors can employ fewer people to handle billing. That savings allows them to lower fees, physicians say.
An estimated 1,500 to 3,000 physicians nationally are offering “direct primary care,” according to Garrison Bliss, co-founder of Qliance, a lower-cost concierge medicine firm based in the Seattle area. The umbrella term includes a variety of arrangements under which providers have direct financial arrangements with patients.
Bliss wrote in an email that at least the same number are pursuing “concierge practices,” a similar model in which patients pay up front for access to a doctor. Concierge medicine has developed a reputation for celebrity-style treatment at high prices, though some practices offer more affordable rates. More than 60 percent of concierge and direct primary care memberships cost less than $135 per month, according to the trade publication Concierge Medicine Today.
Some experts applaud the rise in direct-pay doctors, seeing patients getting better value for their health care dollars. Others worry the model isn’t sustainable or could lead to the rich receiving better care, while poor and working class Americans fight to be seen by a shrinking pool of doctors.
“It’s a much more affordable option than the standard concierge practice that people are starting to see pop up across the country,” Ciampi said.
In Maine, Ciampi knows of just one other physician attempting the direct primary care model, Dr. Jack Forbush in Bangor. The American Academy of Private Physicians, a professional association for such doctors, lists about 20 Maine doctors in its directory of physicians committed to eliminating dependence on insurers.
Forbush made the leap to a subscription option on Jan. 1, charging $1,250 for an individual membership, which includes all preventive care, plus a $99 enrollment fee. About 150 patients at his practice, the Osteopathic Center for Family Medicine, have signed up, including some with health insurance, he said.
Forbush, also president of the Maine Osteopathic Association, plans to stop taking all forms of insurance by the end of the year. He believes the American health care system has lost sight of its mission: to work in patients’ best interest.
Both he and Ciampi said the problems began years ago but were exacerbated more recently under the Affordable Care Act.
At Forbush’s practice, patients don’t have to worry if a treatment “is part of the third paragraph, fourth word on page 53 of my 600-page insurance manual,” he said. “They just get the care. It frees me from being a slave to the insurance industry. All I’ve got worry about is taking care of patients, and all patients have to worry about is getting care. It’s a no brainer.”
The average American medical practice spent nearly $83,000 per doctor dealing with insurers in 2011, according to the Commonwealth Fund. Meanwhile, the typical family doctor treats an average of more than 2,800 patients at any given time, according to the American Academy of Family Physicians.
By dropping insurance, doctors argue that more time can be spent with each patient, heading off chronic diseases, ER visits and other costly drains on the health care system, while it also leaves paperwork hassles behind.
“What we really love about this is that in most traditional medical practices, you only get paid if you have people come into see you,” Ciampi said. “So it puts you in the very uncomfortable position of waiting around and hoping for people to get sick so you can make a living. We really want to get away from this paradigm. The healthier I keep my patients, the less hard I work and the better I do financially.”
Patients at his practice can almost always schedule an appointment on the same day, he said. Patients also won’t see a computer screen in the exam room. Ciampi got rid of electronic medical records, deciding the technology was a barrier to patient care rather than a boon.
A model for the future?
Ciampi’s practice lost a few hundred patients after he ditched insurance, but it also gained a few hundred more under the new approach, he said. Financially, the last year’s been “lean,” but he expects the practice will become viable with far fewer patients than the typical patient roster of 2,000 for primary care doctors, Ciampi said.
Critics contend that by winnowing down patient loads, direct-care doctors leave consumers scrambling to find another primary care doctor, already in short supply in many areas.
Ciampi argues the model will attract more new doctors to primary care and keep many burned-out physicians from leaving the field.
While he sees a bright future with the new model, Ciampi said he misses many of the older patients who left because they could no longer use Medicare coverage. Some were also treated by his father, Dr. Louis Ciampi, who founded the practice.
“There were some tears on both sides,” he said.
Meanwhile, Ciampi’s seen an influx of uninsured and underinsured patients, many of them younger.
Mitchell Stein, an independent health policy consultant, said that those patients should know direct primary care doesn’t satisfy the requirement under the federal health reform law that all Americans have health insurance this year or pay a penalty. Those patients could wind up with mountains of debt if a serious illness or injury lands them in the hospital, he said.
“By saying that they’re going to take care of your needs up to a certain point, it leaves people very exposed,” Stein said of direct care practices.
Both Ciampi and Forbush encourage patients to consider purchasing a catastrophic health plan to cover at least some medical bills in the event of a costly hospitalization.
Some patients can’t afford direct care plus insurance, even a bare bones policy, Stein said. The direct care approach highlights the need for payment reform in health care, he said. Doctors aren’t paid for connecting with patients through lengthy visits, phone calls and email.
With America’s health system undergoing major changes, and providers merging into ever-larger businesses, the number of independent doctors in Maine has dwindled. About 80 to 90 percent work for hospitals or other large health systems. One-doctor shops will be increasingly hard-pressed to keep up in future years, as the health reform law focuses resources on big systems tasked with reducing costs and improving care, Stein said.
“I’m sympathetic to the idea that doctors want to be able to spend more time with their patients, but I think we need to figure out how to do that for the whole system, not on this piecemeal basis,” he said.
Health care dollars may also be more wisely spent employing providers at other levels, such as nurses and nurse practitioners, Stein said. A doctor with multiple years of graduate education, rather than answering questions about the flu, for example, could focus on medical problems more suited to his or her training, he said.
“These individual physicians who want to go back to the country doctor model, I don’t think it’s either practical from a cost perspective or appropriate from a care perspective, in terms of providing the best quality care at the lowest price,” Stein said.
But Ciampi and Forbush see a bright future for a model that allows patients to pay doctors much like they would a plumber or lawyer.
“If I can save someone one visit to the emergency room, it pays for the subscription for three years,” Ciampi said.
For Pettigrow, the comfortable atmosphere in Ciampi’s office makes all the difference.
“He really cares about the quality of the service that you’re getting from him,” she said. “It’s an experience I’ve never had with another doctor.”