Bill Lucks of Lewes had already landed in California when he realized he’d forgotten two medications back home. One of them required a new prescription, and a pharmacist there told him he’d need to get a fax from his doctor. 

It was a Friday, so Lucks probably wouldn’t get his medication until Tuesday or Wednesday, the pharmacist told him. He stepped away and called his doctor’s office. Minutes later, the fax arrived, stumping the pharmacist. “She said, ‘OK, I’m impressed. Who is your doctor?’ ”

Lucks received his medication that day not only because he had a good doctor — though her patients say she is — but because she was operating under a different health-care model. 

In traditional medicine, low insurance reimbursement rates may require family doctors to take 2,000 or more patients to run a profit. The consequences of this financial situation include rushed visits, physician burnout, long wait times and trouble getting an appointment.

Many patients and doctors feel trapped by a system that puts profits ahead of people. Lucks’ doctor, Christine Degnon, opened Coastal Direct Primary Care in Lewes in part to rebel against rushed doctor’s appointments.

“I felt like I couldn’t see patients and treat them well in a short seven- to 15-minute visit,” she said.

The solution was simple: Have fewer patients. She now has about 250 patients and plans to eventually double that, still far fewer than most doctors. 

To make it work financially, she charges each patient a monthly fee based on their age. The fee starts at $25 for children and rises to $100 for seniors. Most of her patients already have health insurance; they’re paying for the privilege of having the kind of doctor who can fax a pharmacy when they’re on vacation. 

Broadly, this model is called “retainer medicine” because patients pay a fee to secure a doctor’s services. There are several types of retainer medicine — including concierge medicine and direct primary care — that are mainly distinguished based on whether the physicians accept private insurance and what they charge.

At the core of this model is the idea that the health insurance system is undervaluing primary care. Paying more, they hope, will let doctors practice medicine at a slower pace and leave patients more satisfied.

But there are serious questions about whether retainer medicine can be a solution for most Delawareans. Will charging extra to provide better care create a two-tiered system, with house calls for those who can afford it and rushed visits for everyone else? 

Doctors who use this new model are sensitive to the complaint, but they share the conviction that the traditional, fee-for-service model is untenable. 

For Dr. Kimberly Nalda of Wilmington, the beginning of the end came when her practice was purchased by an insurer.

Breaking down the revolving door

Dr. Nalda was told that she wasn’t seeing enough patients or billing for enough services. Administrators gave her a report card based on how many patients with a given injury she had referred for X-rays or other services. These therapies and tests tend to be much more lucrative than office visits, so doctors are often judged based on how many their patients get.

She started to get burned out. “You’re not only unmotivated, but you start to get cynical and jaded and that’s not me at all, I’m an optimist,” Dr. Nalda said. Meanwhile, her patients’ wait times and frustration grew.

“All day long, I would spend the first few minutes of the appointment apologizing,” she said.

So she made a change. Three years ago, she opened her own practice along Kirkwood Highway called Rekindle Family Medicine.

“I wanted to rekindle a relationship with patients, an authentic, old-fashioned relationship where I know my patients and have time to spend with them,” she said. She doesn’t accept insurance payments at all, which makes hers a direct primary-care practice.

Her prices range from $20 a month for children to $100 a month for people older than 65. Not accepting insurance also helps her to keep costs low. 

“We don’t need billers, coders, schedulers, or other layers of administration,” she says.

Dr. Uday Jani of Lewes, who’s had his own practice for 20 years, watched as his independent colleagues had to see 25 patients per day just to keep their doors open. At some point, he said, it stops being medicine.

“After a while, you start churning numbers and not giving real care,” he says. “I went into medicine to help people, not work for insurance companies.”

He made the jump to retainer medicine. Because he practices in an area with a lot of retirees, it makes sense for Dr. Jani to bill Medicare and insurance companies. This makes him a concierge physician. 

His patients pay his $1,600 annual fee because he’s available on short notice and can give them time and attention. 

Robert Fischer, a Lewes retiree, has long had high cholesterol. But the medication to treat it gave him terrible muscle cramps, so he stopped taking it.

When he saw Jani, Fischer learned he has “large molecule” high cholesterol, which doesn’t cause as much plaque buildup in blood vessels. Now, he doesn’t worry about not taking medication.

“The man drills down, he has the time to spend a half-hour, three-quarters of an hour,” Fischer said. “He wants to know you as a whole patient.”

Doctors providing retainer medicine often estimate they can provide 80% to 90% of the care their patients need. But what about the final 10 or 20%? What if you need an ultrasound, or even surgery?

Paying with cash

Going outside of the insurance system often means paying cash instead of filing a claim.

Imagine you need a common test called a complete blood count, which requires the services of a lab. For most people with typical insurance, a doctor would write a referral and you’d get tested at a lab.

Instead, Dr. Nalda has negotiated cash prices for common blood tests, including this one, which costs $11.

What about more expensive services, like a computed tomography, or CT scan? Dr. Nalda’s website says her negotiated cash price is between $350 and $450. 

About a third of Dr. Nalda’s patients don’t have insurance at all, which makes these cash pay options critical. Even if you have health insurance but have a high deductible, you’d probably be better off paying cash and not even filing a claim.

Getting competitive cash prices for surgeries is more difficult. Even doctors have a difficult time getting hospitals and surgical centers to be transparent about their prices. But they try.

One of the most common surgeries in the United States involves patching a hernia, which is a hole in our muscles, usually in the groin or belly. A person with a hernia feels it as a bulge in their skin.

Dr. Degnan sends many of her patients to a hernia repair facility in Rockville, Maryland, where she and others have negotiated cash prices.

“I have colleagues in Idaho who send their patients to Rockville,” she says. For many people, it’s cheaper to fly to Maryland, stay in a hotel and pay for surgery with cash than it is to go through their own insurance.

This cash-pay system has its detractors. 

When people pay out of pocket, they may avoid care because they can’t afford it, says Dr. James Gill, who operates a fee-for-service Wilmington family medicine practice called Family Medicine At Greenhill.

“People are not good consumers or stewards of their own health-care dollars,” he says.

Gill has plenty of sympathy for his colleagues in retainer medicine, but he worries their prices may put them out of reach for too many.

Leaving people out?

Gill sees retainer medicine as a reasonable if imperfect response to a dysfunctional health-care system.

“We have a completely backward system where we pay enormous amounts of money for high technology, much of which has little value, and little money for primary care, which has very high value,” Dr. Gill says. In Delaware, he says, only 3% of health-care spending goes to primary care, the lowest in the nation.

The result is overworked doctors, shuffling from one appointment to the next. Very few doctors coming out of medical school — “virtually none,” he said — are going into primary care, and the doctors that remain are trying to get out. 

“So concierge medicine was one way to continue to do the noble thing, take care of your patients,” Gill says. “I don’t blame those people at all, they’ve found a way to make it work. Unfortunately, it leaves out people who can’t afford that concierge fee.”

It’s a criticism that doctors in retainer medicine feel keenly.

“A lot of people call me concierge and I don’t like that term,” says Nalda. “My goal is to keep health care affordable. We don’t try to cater [only] to wealthy people.”

Gill says the better solution to the primary-care crisis is to require insurance companies to pay more for primary care. In 2018, the governor signed a bill requiring commercial insurance companies to match Medicare reimbursements. In most states, Medicare rates are low but in Delaware, “the commercial payers were so bad that getting at least Medicare rates was something,” Gill said.

Diane Issel, a Lewes retiree who sees Dr. Jani, says she’s heard the criticisms that “only rich people are going to be able to do this.”

“To me, it’s what are your priorities, it’s that simple,” she says. 

By Dan Linehan
DBT Contributor