By Tom Brown
Jeff Lourie juggled more than 1,000 patients when he worked for Gifford Health Care at its Berlin facility, which limited the amount of time he could spend with each person. The family nurse practitioner found it difficult to establish personal relationships and provide consistent outcomes for patients amid the hurried environment of a large group practice, which has become the standard in today’s consolidated healthcare system.
Now he serves about 100 patients at his North Branch Health practice in the former First in Fitness building in Montpelier under a new model of direct primary care that is spreading around the country. By eventually capping his practice at about 300 patients, Lourie hopes to build the kind of personal relationships that are reminiscent of Vermont’s old country doctor by spending more time with them during office visits and earning trust.
Under direct primary care (DPC), patients pay a flat fee for access to a provider, which advocates for the model say enhances patient experience, improves health outcomes, and adds a level of cost transparency compared with conventional primary care. Under direct primary care, insurance companies are not billed, and patients instead pay a monthly fee for unlimited office visits and consultations. Many consumers are finding DPC a useful alternative to conventional pay-per-visit primary care.
“I think everybody is starting to appreciate that the system is broken, and not just a little bit broken, but broken on every level,” he said. “Why not go back to the old model of you having a relationship with somebody and kind of have them on retainer.”
Lourie, who opened his office on Blanchard Court in September, offers three types of service:
• Direct primary care membership, in which the patient pays about $800 a year ($76 a month) for unlimited office visits without involving insurance. A five percent discount is offered for full-year prepayments;
• Concierge primary care membership, in which patients with health insurance pay about $300 a year ($25 a month) for the same service but with billing to Blue Cross and Blue Shield or Cigna;
• Traditional Medicaid, which works the same as with any primary care provider. He does not accept Medicare patients.
The concept is not for everyone, Lourie admits, but for a certain segment of the population it is a good fit, and he stresses that everyone should have health insurance for major healthcare needs.
What membership in North Branch Health offers is access to prompt, no-rush appointments (always within 48 hours and usually less), more time spent with the practitioner, telemedicine consults, and even house calls if necessary. Lourie allots one hour for each office visit, and it is that extra time spent with the patient that builds a rapport that can lead to better health outcomes. During a visit, Lourie takes the patient’s vital signs himself (he has no nurse) and does so slowly once the person is relaxed and the conversation is underway.
“Most of the visit is usually spent talking,” he said. “I firmly believe that most things that are going on you can get a pretty good idea about what it is by asking the right questions, so if you have time to sit and talk with people the right questions seem to present themselves.”
As a Family Nurse Practitioner (FPN), Lourie can prescribe any medications the patient might need and refer them to specialists just as any other primary care practitioner would. He can also perform routine in-office tests, such as for strep throat, but there is an additional charge for those tests, a cost he says that is usually lower than that charged by other primary care providers. The only thing he can’t do, he says, is prescribe diabetic shoes and admit patients to hospice care (both for regulatory reasons).
There were about 770 direct primary care practices in the U.S. as of February 2018, and there are three currently open in Vermont. Criticism of the concept centers on cost and whether the practice caters to the rich. In some areas of the country in which direct primary can cost $20,000 a year or more that might be true.
Lourie, who has nine years’ experience as a FPN, says the patients he sees are generally between the ages of 20 and 50 and in relatively good health with high insurance deductibles of about $2,000 a year. People with complex and chronic medical conditions might not be the best match.
But for those with high-deductible plans, Lourie says a direct primary care membership could save money. For example, he suggests that an average visit to the emergency room costs $1,200 to $1,500 and the average primary care visit costs $125 to $150. That means for about 75 percent of a single ER visit or six conventional office visits, a person could get a full year of unlimited office visits at North Branch. Remember that virtually all insurance plans offered on the Vermont Health Connect exchange carry deductibles that must be paid out-of-pocket before the plan pays any costs, and on top of that are the monthly premiums.
“I think this is the best model for primary care, but that said it’s not appropriate for every patient,” said Lourie, who supports a single payer healthcare model. “If people have a lot of medical needs it’s not probably the right thing for them. But for the average person, most people don’t need an entire army taking care of them, they just need somebody to listen and somebody to kind of guide them.”
Lourie offers a free consultation to explain the practice to new patients. To contact the office, call (802) 760-6288.
In light of the government shutdown, Lourie is offering to defer billing for federal employees until the dispute is resolved.