Retainer Medical Practices a Growing Trend in Oregon

September 8, 2011—Getting affordable primary care without insurance is almost unheard of. But that’s what a lot of Oregon primary care physicians are working to do.

Primary care physicians, frustrated by the reimbursement rates set by insurance companies have started to create “retainer medical practices.” In exchange for a monthly fee or an annual lump sum, they’re offering basic medical care.  

People receive a certain number of visits, an annual physical exam, the ability to correspond with a physician by email or phone, generic prescription drugs, and basic tests and labs that can be preformed in a doctor’s office. Specialty care and specialized procedures, such as MRIs, are not provided.

The motivation behind retainer practices is two-fold: provide access to primary care for uninsured or underinsured patients, as well as people with high deductible plans, and enable primary care physicians to have a financially viable practice with a steady stream of clients.

The practice of charging retainers is sometimes called “boutique” or “concierge” care. Those terms, said Doug Barber, the Oregon Academy of Family Physician’s lobbyist, usually refer to  medical practices catering to wealthy patients.

“This model is gaining considerable traction. We may end up needing to do something like this” if insurance carriers continue to drastically increase rates, said Dr. John Saultz, chair of Oregon Health & Science University’s Family Medicine Department.

Demand for retainer practices may be high

Saultz is interested in creating a retainer practice that’s financially viable for primary care physicians, allows them to provide care to people able to pay the retainer, as well as provide healthcare to those unable to afford the cost.  “I personally don’t think it is okay to train residents and students to deny care to uninsured people,” Saultz said.

In 2008, Saultz began a research project to determine the demand for such a retainer practice, and whether it could cover a primary care physician’s costs.

Under his model, patients, regardless of income, are charged a $150 six-month retainer fee (which equates to $25 per month). Then, on a sliding scale based on their income, they also pay the cost of their visit.

People who earn below 200 percent of the federal poverty level, or $40,000 for a family of four, paid nothing for the visit, while those earning more than 400 percent of the federal poverty level, or $80,000 for a family of four, paid the full cost, around $130, Saultz said.

People received care at OHSU’s Gabriel Park family medicine practice, or at the Community Center for Health and Healing. They had full access to physicians via email and phone, free prescription refills, “and all the visits” they wanted while enrolled, Saultz said.

Those unable to afford the enrollment fee and cost of an office visit were referred to the SW Community Health Center or the Richmond Clinic, safety net clinics both operated by OHSU. Whether patient demand has substantially increased is unclear—the SW Community Health Center did not return repeated calls from The Lund Report by press time.

Over half the patients in the program earned more than 400 percent of the federal poverty level. Many are “young, healthy college graduates sick and tired of high premiums,” Saultz said. What they’re looking for, he said, is primary care.

That should terrify the health insurance industry, Saultz thinks.

“There’s a huge demand for people who are sick to death of dealing with their health plans for ordinary things,” Saultz said. “I’m convinced that were we to market this, we’d be potentially doing nothing but this in our practice.”

It’s unclear if OHSU would market the program to a general population. But Teri Bunker, who owns Portland’s Bridge City Family Medical Clinic, is convinced.  

A family nurse practitioner since 1998, the majority of Bunker’s patients are on Medicaid. Bunker estimates that she’s reimbursed half of what a commercial insurer might pay, meaning she has to see twice as many patients to keep her practice financially viable. If patients don’t show up for an appointment, as they frequently do, she’s not paid for lost time.

“It’s been my passion to take care of Medicaid patients,” she said. “But I’m ready throw up my hands. It’s not the way I envisioned my practice going.”

She’s transitioning to a retainer-based practice that charges $49-$90 monthly based on a patient’s age, in addition to a $99 yearly fee, which will cover unlimited office visits, an annual physical, the ability to contact a primary care physician, generic medications and basic screening labs.

“It’s a way for me to take control back of how I practice,” she said, without having to worry about insurance practices.

Barber, the Oregon Academy of Family Physician’s lobbyist, believes more retainer practices will emerge that charge below $100 per month. “It’s going to be pretty individualized,” Barber thinks, based on what a physician is willing to provide.

There’s a lot of anecdotal information about retainer medical practices, Barber said, and “a real lack of information of what's happening in Oregon.” No one knows how many retainer practices exist in Oregon since they’re unregulated.

Insurance Division Will Scrutinize Practices

The Insurance Division has taken note. With passage of Senate Bill 86, retainer practices must register with the Division, which will allow officials to determine the success of these practices and know how many people are being served. “It’s this unknown,” Barber said and will be important to monitor whether retainer practices are “over promising.”

Bunker calls retainer medical practices “the future of primary care,” and doesn’t believe such practices will end up charging exorbitant rates and only appeal to the wealthy.

“Who would sign up for that?” she asked. “The idea is to put the power back in the patient’s hands and let them say, well, what am I paying for?”

To Saultz, retainer medical practices are a way to circle around an increasingly frustrating insurance industry that increases costs.

“How well we do financially is driven by who we take care of, not how we take care of them,” he said. “That is not remotely okay.”