Hapless with Highmark (and the Hope of Direct Primary Care)

Photo by OcusFocus/iStock / Getty Images
Photo by OcusFocus/iStock / Getty Images

We caught our first glimpse of storm clouds in October with this article in LNP.  Highmark, the health insurer with the largest proportion of plans purchased by Pennsylvanians on healthcare.gov, would be dropping it’s most popular plans for 2016.  

As the December 15 deadline to sign up for a plan to start on January 1 looms, individuals and families are realizing that not only are their insurance premiums increasing, but they’ll have a higher deductible to boot.  Why?  Highmark found that people who purchase their insurance on the exchange are more likely to use medical care.  Said a Highmark official:  “Diabetes is 19 percent more common on the ACA [Affordable Care Act] marketplace.  ACA members consume about 58% more hospital days.”  How will Highmark address this discrepancy?  “We're going to interact with [patients] more regarding the things they need help with.  Examples include regular health coaching through calls, emails or texts, and embedding Highmark employees at hospitals to help with follow-up care planning when a member is discharged.” (1)

Health coaches.  Proactive phone calls.  And if you’re admitted to a hospital, expect a visit from a Highmark employee.  Let me offer a much better idea — Direct Primary Care (DPC).  Where Highmark wants you to stop utilizing healthcare, DPC invites you to utilize.

My new DPC practice, CovenantMD, opens January 4.  Direct Primary Care is gaining traction in America as way for families to reduce out-of-pocket health care spending, while revitalizing one of the big casualties in the current payment environment — the doctor/patient relationship.  I’m busy these days with crisscrossing the county, meeting with families that are interested in CovenantMD.  What drives them to reach out ?  I think one reason is the lingering buzz from CovenantMD being featured in an LNP article on November 1.  The other reason is that there are thousands of Lancasterites staring down the hit to their 2016 bottom line, and they are looking for “out of the box” solutions.  Direct Primary Care is one of those solutions.  

In Direct Primary Care, your doctor contracts directly with you, and not your insurance company, via a low monthly fee.  The intent is to “carve out” the common, less expensive stuff from health insurance, so you can reserve it for the less common, more expensive stuff.  The monthly fee to CovenantMD buys you visits with no additional fees, home and worksite visits at no extra charge, same and next day appointments, extended visit times, after-hours access to your doctor via cell-phone, text, and email, after-hours visits, and discounted medications, lab work, and radiology.  It’s Marcus Welby for the 21st century!

But how is Direct Primary Care an answer, particularly, for the woes of Highmark?  Three ways:
1) Better access to your primary care doctor.  All of us know the fear of that bill that might come weeks after you visit your doctor, with charges for things you never even thought you could be charged for.  That's a real barrier to any of us engaging with your doctor.  In CovenantMD, that barrier is removed.  And the costs are predictable.
2) Value.  This is the answer to the question of why anyone would "pay twice" for health care (see my last blog post).  Sure, you'll pay a low monthly payment for CovenantMD, but I bet this will be even less than what you pay for cable.  And the cost savings DPC brings is a "hedge" against using your deductible (see my Cost Benefits page on my website).
3) Better chronic disease management.  The DPC model returns the critical factor, TIME, to the doctor/patient relationship.  At CovenantMD, you'll enjoy visits of 30-60 minutes with your doctor, ample time to discuss lifestyle, medication management, and a game plan for acute exacerbations of your chronic disease so that it doesn't land you in the hospital.

So what are ways that you can mitigate your Highmark (or other health insurance) blues?  One is to consider a lower-premium, higher-deductible insurance plan, and pair that with Direct Primary Care through CovenantMD.  Again, DPC can function as a hedge against using that high deductible, so that your insurance is reserved for the expensive, less common stuff.  (Hence, "insurance!")  One other thing families are considering are sharing plans, like MediShare, Samaritan Ministries, Christian Health Ministries, and Liberty Healthshare.  With such a plan, you would pay a monthly premium (usually much lower than an standard insurance premium), and members then share with you when a medical expense exceeds a certain threshold, say $300.  

I often introduce CovenantMD with the statement, “This is an exciting time in healthcare!”  The reaction I get (understandably) is usually groans.  But what I mean is that as more individuals, families, and businesses face the ever increasing pressure of rising insurance costs, innovative ideas come to the forefront.  Consider CovenantMD!  Shoot me an email or give me a ring at 717-287-1983.   I would love to meet with you (or your employer!) and give you a chance to kick the tires of this whole Direct Primary Care thing!

Patrick Rohal, M.D., is a family doctor and the founder of CovenantMD.
1. Stauffer, H. (2015, October 6). Highmark announces big health insurance changes for 2016. LNP. Retrieved from lancasteronline.com.