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Can Qliance Revive Primary Health Care?

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“I can’t figure out why primary care is dying, and I’d like to resuscitate it,” said Dr. Garrison Bliss, summing up his founding of a boutique medical clinic.

We were in a little café on the third floor of the Medical-Dental Building on Olive, below the Qliance offices on 16. Bliss had just taken me on a nickel tour of his clinic, from its peaceful waiting room to its lab, X-ray room ($17 per reading), and even the in-house laundry room, where a load of full-coverage gowns were cycling in warm suds. Now, we were getting coffee. Strike that. I was having coffee. Bliss got fruit juice.

I was down visiting Qliance after reading “How American Health Care Killed My Father” (Atlantic Magazine, September 2009). In it, David Goldhill wrote something startling to me: “The average insured American and the average uninsured American spend very similar amounts of their own money on health care each year–$654 and $583, respectively.” He also mentioned, approvingly, that “Qliance Medical Group, for instance, now operates clinics serving some 3,000 patients in the Seattle and Tacoma, Washington, areas, charging $49 to $79 a month for unlimited primary care.”

The Qliance fee scale is graduated for age–I’d be looking at $768 per year for primary care, which, other than an appendectomy back in high school, is all I’ve ever needed in life to this point. Last year I paid over $3,200 in health insurance premiums on Costco’s small business insurance plan. I saw my doctor once, for a physical.

This is the kind of story that makes Bliss’s eyes light up. He calls our health insurance dependency “learned helplessness,” and likes to reference Marcus Welby when talking about the Qliance difference. “You can design this so that 80 percent of American can pay for primary care out of pocket. And the other twenty percent could do it with some subsidy,” he argued. “I’d like to prove that.” His first point is that whether you’re insured or not, if you want or need quality primary care, you’re mostly out of luck.

“Primary care docs are living on a shoestring, they don’t have adequate support staff, they don’t have time–that’s the biggest thing, time. Today they get eight minutes a patient. We’re talking to someone right now who’s seeing 40 patients a day,” Bliss added, with a “What can you do?” expression.

“The only reason primary care docs are in a big clinic is so they can refer patients for all the expensive stuff. They can order MRI and CAT scans, and all the profit will be generated through those machines, and if you’re not using those machines enough, you’re a pariah in your clinic. You’re the ‘unproductive’ one. You’ll be getting a note from the clinic manager.”

Qliance, in contrast, is all primary care. Any time you have the cold or flu, wake up not feeling well, have a minor accident and need stitches, sprain your ankle, or pull a muscle, Qliance offers same- or next-day appointments (and 24/7 phone consultation). In the clinic, they do blood draws for lab work (lab work that is sent out is billed à la carte), “EKGs, joint injections, skin biopsies, wart removal, wound care, PAP smears, and spirometry.” Generic medication is provided onsite, and billed at cost.

Whether Marcus Welby really had that kind of time on his hands or not, the Qliance model stands in sharp contrast to the productivity-driven clinic: “The average doc or nurse practitioner here works about an 8-hour day,” Bliss explained. “The office visits are booked in 30-minute intervals. Physicals are given at least an hour–we have some patients we know are going to take two hours. We try to set up our day so we can deal with emergencies, so we’ll have two or three physical exams scheduled sometime during the day, and then everything else is filled in with 30-minute appointments.”

On any given day, there will be four to five empty half-hour slots so that people who come down with something–a cold, cough, fever, infection, sprain, headache, stomachache–can get in. People with chest pain might just walk in. “We try to mix up the cultures a bit,” Bliss said, with the idea that family practice doctors can consult with other practitioners at the clinic.

There are two levels of Qliance care, Q1 and Q2, with the higher level serving patients who have chronic illnesses, and who may require periodic hospitalization. While Q1 patients who need hospitalization are guided “remotely” (through Qliance phone coordination with the emergency room or admitting physician), hospitalized Q2 patients are included in their Qliance doctor’s daily rounds.

“We come by every day and check on you and talk to you,” said Bliss. His patient load of about 500 is made up largely of Q2 patients. Doctors with primarily Q1 patients max out at around 800. The lower patient load is tied directly to patient care. “With a third of the panel of patients, or a quarter of the patients, that most doctors have, we’re very busy,” said Bliss. Besides in-person consultation, his doctors are available by phone and email.

Part of the rationale behind the monthly fee system, besides its regular, stable cash generation, is to give patients peace of mind around medical costs. “When a patient leaves us, they should have a pretty good idea about what their adventure with us cost them. For most people, the adventure costs nothing,” Bliss said. “If it involves what we do, with our brains and our hands, it’s free [with the monthly fee]. If you need sutures, you get sutures. If you need a splint on your fracture until you can get to the orthopedist, we’ll splint you.”

Most other services are provided at cost: “If you need a boot because you fractured bones in your foot, we’ve got the boot, we’ll put the boot on, and we charge you our cost for the boot. There’s very little in the surprise category. If you want to know what your labs are going to cost you, we can compute that for the most part, even if we’re not doing them ourselves.”

Why would this extra-care model work? Bliss argues that it’s because most of us are starved for primary care, and getting thinner.

“The thing that is invisible to everybody is that the insurance world currently is expending only something around $10-$25 per month per patient on primary care. No one’s specifically told me that, but we’ve had conversations where we’ve asked, ‘If you didn’t have to insure primary care, how much would you lower your monthly charge?’ And they say, ‘Oh, ten bucks. Fifteen. We could go to $25.'”

Bliss leaned in to make his next point: “Most people have no idea how little, of that big pot of money, is actually being pushed toward the 80 percent of care that everybody wants and needs. They also don’t realize that you probably have to double or triple that number to make primary care effective again. A five-, ten-, twenty-percent increase, which is sort of what the federal government is thinking about, won’t work.”

And here is where Bliss separates from the pack on health care reform. While he agrees that health insurance is part of the problem, when it comes to primary care, he doesn’t want more coverage.

“All the policy people, with few exceptions, their idea of health care policy is health insurance policy. They can’t get escape from thinking that everything has to be fixed by tweaking insurance,” said Bliss. But for him, the inexpensive nature of primary care makes it a terrible candidate for insurance.

“The cheaper the event, the more distorted and disrupted it will be by our system of payment. At the primary care end of the scale, you actually asphyxiate the service altogether by paying for it with an insurance system. If doctors just work for the patients at that level, you spend less money and get better care. Plus, now the doctor is incented to take care of the patient in a way that feels like care to the patient. Service now matters.”

With the inexpensive 80 percent of health care–primary care–paid for on a monthly fee basis, the hugely expensive ten to twenty percent would remain to be covered by insurance. Then insurance companies, freed from the terabytes of primary care data, could focus on (and compete on) specializing in providing the best coverage for, say, bone marrow transplants.

People who couldn’t afford primary care, he suggested, could receive a subsidy. “Like food stamps?” I offered.

“Exactly,” Bliss said, launching into an extended analogy. “It would be hard to argue that eating is less important than medical care. We thought medical care was too important to let the marketplace function. But if you look at food, you realize that food is inexpensive for the most part, it’s widely available–what would happen if we insured food?”

“With food, the marketplace is controlled by the 80 percent of people who can afford to buy with cash. You have places that sell expensive, high-end food, places that sell fast food, places that sell farmer’s market stuff–the pricing models are highly evolved and the service levels are great. You put a food stamp in somebody’s hand and they become a consumer in that system–their money is as good as everybody else’s.

“If you did that in health care, so that primary care and chronic care were all managed with monthly fee systems and competed for patients, and patients decided where to spend their money, [you’d seem improvements in] services, quality of care, availability.

“In the insurance world, any customer’s ten minutes is worth the same as another ten minutes, and there’s an infinite supply of patients waiting. There’s no cost to not being open on the weekends. But there will be shortly. We plan to make it uncomfortable. If you run a clinic and you close weekends, and Qliance is down the block, you’re going to be losing market share.”

While Qliance represents a trend toward boutique health care becoming more affordable, it’s growing through a kind on pincer movement, attracting insured patients who can afford to pay for better service, and another group for whom any primary care at all is a step up. At Qliance’s new Kent clinic, Bliss said, they are working with companies that have never had health insurance, who tend to employ  minimum-wage workers.

Qliance is trying to negotiate cash prices with larger health care providers for out-of-house services, but it is difficult because these institutions would be in violation of their agreement with Medicare if they priced care lower than they charge Medicare.

“A reasonable ‘retail’ price isn’t possible if Medicare is willing to pay too much,” Bliss said. “And they are. That’s why we’re in the mess we’re in. The inertia of the system is very hard to overcome in that particular area. You know, we’re working on cash mammogram pricing. But it may be that we have to break away from the whole system in order for this to work. We may need to do mammography ourselves.

“Kaiser Permanente has figured this out. They’re an insurance company that owns their own treatment system. It’s to their advantage to get their procedures done inexpensively, and to not overdo them. They have nurse practitioners who are trained to do colonoscopy, do many of them a day, and I’m sure are not being paid $1,000 every time they push a scope.”

It’s a fascinating conversation to have, and one strikingly different in tone than much of the health care debate I’ve heard about over the summer. As a health care consumer, I have leaned toward the simplicity of a single-payer, government-run system. But there is no denying that right now–today–Qliance can offer me primary care at less than the cost of my iPhone bill. If decoupling primary care from specialized medicine can work in medical practice, why not in insurance billing practice?

I asked Bliss early on if there was an idealism requirement for work at Qliance–at a venture-funded start-up, salaries are often lower than market rate. He shrugged and countered with the lower Qliance patient load. But late in the conversation he added:

“It matters to me whether the Qliance model gets adopted nationally because I think it’s better care. I have a great-uncle who invented the iron lung and refused to patent it. His feeling was that it was really important for people to have access to this machine.” He didn’t elaborate beyond that. But it is clear that he imagines Qliance, with its Q1 and Q2 paddles, as capable of delivering a healthy shock to a primary care system in danger of shutting down entirely.

Health

Qliance Expands to Kent

In an Atlantic Magazine article–“How American Health Care Killed My Father“–making the rounds right now, a local health care provider gets a mention for its innovative business model and it isn’t Group Health:



Qliance Medical Group, for instance, now operates clinics serving some 3,000 patients in the Seattle and Tacoma, Washington, areas, charging $49 to $79 a month for unlimited primary care, defined expansively.

Last Thursday, September 10, Qliance held its ribbon-cutting ceremony for its new clinic at Kent Station (in Kent, which, for the benefit of our Seattle readers, is here–even farther away than Renton). If nothing else–though there is plenty else–Qliance illustrates the immense costs that the for-profit health insurance model adds to health care. (Qliance’s founder Dr. Garrison Bliss claims that about 40 cents of every health care dollar supports the insurance industry.)

For “direct primary care”–same day or next-day appointments for urgent care–clients pay a monthly fee of on average $50-$60 per month, depending on the level of service. That includes “30- to 60-minute office visits, 24-hour phone and email access to a physician,” and X-rays and lab work. 

Qliance provides, in other words, your health tune-ups, oil changes, tire rotation, and brake replacement all for that regular monthly fee. If you get in an accident or drop a transmission, well, then it’s off to the specialist. For that, Qliance recommends what’s called wraparound insurance–the high-deductible plans that cover more occasional health concerns.

In less automotive terms, Qliance CEO Norm Wu likes to call it “Marcus Welby” care. Kent Mayor Suzette Cooke said it’s “putting the patient first.” However you slice it, the regular, predictable monthly payment for help staying healthy is popular; Kent may be the site of clinic number two, but venture-capital-backed Qliance wants to go regional soon.

Health

Treating Flu the Chinese Way

Cold and flu season is on its way, and as you know Western medicine has pretty much retreated re: treating it. If the vaccine doesn’t work, you are S.O.L. Not like the old days, when they’d give you antibiotic and knock it right out. Now it’s “fluids and rest.” Health care reform can’t come soon enough, in my view.

So what about Eastern Medicine? To Ho’s Herbs & Massage Center on Jackson!

I didn’t have the flu, but my “girlfriend”–invented for the sake of this exercise–did. I walk in. It looks more like a doctor’s office than I expected. Rising from the floor, there’s a glass case full of plasti-wrapped boxes of herbal remedies. On the wall behind that case, another case bolted to the wall, this one with dozens of drawers. Further back, to the left of the cases, a middle-aged Chinese man with perfect skin sits surrounded by file folders.

“My girlfriend has the flu,” I tell him. “Do you have anything for that?”

“How long ago did it start,” he asks, though not in as perfect English as that. I wasn’t prepared for this inquisition. Thinking fast, I borrow the details from my last flu. He seems satisfied. He says he will sell me an herbal remedy that costs $7/day. He recommends taking it for five days.

Now, I love my fake girlfriend, but now we’re talking about real money. We agree that I’ll give one treatment to “her” and come back for more tomorrow if “she” thinks it’s helping.

My fake girlfriend’s doctor walks over to the case hanging from the wall. Each drawer is subdivided into about a dozen compartments, each with a roll of detachable herb packets, rather like how condoms are packaged. The doc begins rifling through the drawers, ripping off different packets–which are about the size of a pack of Orbit gum–and placing them on the table. By the time he’s done, he’s cracked off about ten of them.

He tells me to take them home to Fakeina, and empty them into hot water, into which I may add honey, which as its sticky smoothness anoints her full but delicate lips, and oozes to her needful tongue, stirring feelings inside of her she’d thought dormant, and his rough hands grip her thighs … sorry, wrong article. The honey is for taste. Also: I am not to use coffee as the liquid, that will mess things up in some unspecified way.

When I get home, I inspect the packets. All but one of them has an English-language label on them, naming which herb it contains. “Peppermint” I recognize. Not so much “Fineleaf Schizonepeta Herb” or “Weeping Forsythia Capsule.”

Time to try the concoction. I heat water, and, after aligning the packets together and scissoring them open simultaneously, let the herbs go for a swim. I stir. The color is about that of dark coffee. I smell. The odor is that of the underside of a rotting log. I taste. Yes, that’s underside of a rotting log for you. I add the honey, which has little effect.

If you actually had the flu, I imagine your sense of taste would be depressed and this wouldn’t be so bad. As for me, I’m not about to torture myself. I dump the most expensive hot beverage I’ve ever purchased down the drain. I’m sure, though, that my fake girlfriend would’ve finished it.

Health

H1N1 Flu Makes Forays into Seattle

With a suspected 2,600 cases of swine flu at Washington State University in Pullman (and no slowdown in students reporting sick), it’s no surprise that the University of Washington has reported two suspected cases of H1N1, too. Unofficially, last weekend’s PAX attendees have reported over 100 cases, renaming the virus H1Nerd1.

So far, #paxflu sufferers are tweeting what it’s worth remembering, despite the size of the outbreak: while it’s not pleasant, it’s not for most people a particularly terrible flu. If you get sick, stay home and don’t spread it. And please don’t drag yourself to a large conference or convention.

Health

West Nile Virus Comes to Laurelhurst

King County Public Health has announced that a dead crow found in Laurelhurst was infected with the West Nile Virus. It’s not the first time, but it is earlier than detected last year, and so there’s a longer risk of someone being bitten by a mosquito that fed from an infected bird. Use mosquito repellent if you see skeeters.

So far, West Nile virus is responsible for the deaths of six people across the whole country, out of 156 cases. Most of the time, people who become infected remain symptom-free, but a small proportion develop a fever, aches, and nausea. An even smaller number react severely and develop encephalitis. The CDC has a West Nile fact sheet if you want to know the particulars.

In the meantime, the health department–who hate to say “We told you so”–reminds you that their “program’s budget was severely cut back this year due county budget challenges and mosquito testing was eliminated. However, dead crows continue to be tested. The WNV-positive bird reported today is the 35th King County bird tested so far this year”–out of the over-1,000 dead birds reported.

Health, News

T. R. Reid Explains Health Care Reform for You

 

  • T. R. Reid talks at Town Hall at 7:30 p.m. Tuesday, September 8. Tickets are $5 at the door. The Washington Post correspondent and NPR commentator has a new book out, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.

T. R. Reid argues that lack of universal health care is primarily a moral question, not an economic one. It’s estimated that each year we do not offer universal health care, 20,000 U.S. citizens die who did not have to. To my ears, the debate sounds Abrahamic:

24What if there are fifty uninsured people in the country? Will You really let them fall ill and not spare the lives of the fifty uninsured people? 25Far be it from You to do such a thing–to kill the uninsured with the terminally ill, treating the uninsured and the terminally ill alike. Far be it from You! Will not the Judge of all the earth do right?”

I can’t pretend not to be biased here–I’ve been a proponent of health care reform since reading of Harry S Truman’s attempts at reform in the mid-1940s. Said Truman, “I do not understand a mind which sees a gracious beneficence in spending money to slay and maim human beings in almost unimaginable numbers and deprecates the expenditure of a smaller sum to patch up the ills of mankind.”

But that said, one thing we need to agree on is that we can’t afford not to reform health care. Even when throwing the poor and uninsurable under the wheels, even when allowing insurance companies to decide if they feel like paying or not, costs have ballooned out of control. Not because of runaway malpractice settlements (everything associated with malpractice adds only about one percent to our total health care bill) but because of runaway administrative overhead.

“Contrary to conventional American wisdom,” writes Reid, “most developed countries manage health care without resorting to ‘socialized medicine.'” And unlike many outraged shouters, he can speak with personal authority, having been a foreign correspondent dependent on the health care systems of other countries.

He goes on to explore the varying health care models at work in France, Germany, Japan, the United Kingdom, and Canada. It’s notable that every country on that list offers a form of universal coverage and spends less money on health care (as a proportion of GDP) than the U.S. All that spending gets the U.S. ranked 37th in the world in terms of health care quality by the World Health Organization.

“There are four basic arrangements,” instructs Reid. Under the Bismarck model (Germany, Japan, France), private insurers pay for private health care–the difference is simply that the insurers “are basically charities. They cover everyone and don’t make a profit.” If you’re a working person under 65, this is your model, except your insurance company makes a whopping profit. The NCHC says, “The cumulative increase in employer-sponsored health insurance premiums have raised at four times the rate of inflation and wage increases during last decade.”

Under the Beveridge model (the U.K.), taxes pay for government-run health care. “Medical treatment is a public service, like the fire department or public library.” There may still be private doctors and hospitals, but they have to accept what the government decides to pay. If you’re in the military or a veteran, this is your model.

The national health insurance model (Canada) is just what it sounds like: the government simply insures its whole population. The citizens pay a monthly fee. This is, essentially, Medicare–the “whole population” is those over 65. Medicare’s administrative costs run about three percent, compared to private insurers’ 20 percent.

The fourth and most widespread model, outside of wealthier countries, is no model at all. If you can afford health care, you get it. If you work part-time or are unemployed, this is your option.

Reid’s investigations of how this all works “on the ground” make for page-turning reading. Nothing about health care is simple in practice, it turns out. Some countries implement a minimal co-pay; some use co-pay, but then refund it when the bill is accepted and paid, on the theory that people don’t respect the worth of something that seems free.

All countries are struggling to contain costs, and all of course have their successes and failures. Reid is particularly taken with France’s “carte vitale,” which is an encrypted smart card that travels with each person, and keeps track of their whole medical history, allowing doctors to dispense with rooms full of file cabinets and even receptionists.

It is heartening to learn we are so tantalizingly close to universal health care–it wouldn’t require an enormous overhaul to establish a public insurance option, and exert some Wal-Mart-style downward pressure on private insurance premiums. Or, we could give health insurance non-profit status. But of course this has been true for some time. We have been “so close” since 1945, and have agreed to let the most vulnerable among us suffer and die for the sake of profit every year since.