At a time when house calls are practically unheard of in medicine, one Bainbridge Island physician not only visits patients when their situation requires it, his office also gives some clients rides to appointments. Dr. Jared Hendler, MD, not only offers home visits , he offers them — along with a long list of other services — for a flat, reasonable monthly fee.
Hendler converted his practice in January to what is called direct patient-provider model. A law enacted in 2007 made Washington the first state in the country to allow this approach, which is sometimes referred to as “retainer medicine.” According to the Revised Washington Code that regulates this type of care, “Washington needs a multipronged approach to provide adequate health care to many citizens who lack adequate access to it. Direct patient-provider practices, in which patients enter into a direct relationship with medical practitioners and pay a fixed amount directly to the health care provider for primary care services, represent an innovative, affordable option which could improve access to medical care, reduce the number of people who now lack such access, and cut down on emergency room use for primary care purposes, thereby freeing up emergency room facilities to treat true emergencies.”
Hendler has been in practice for nearly four decades, including 29 years on Bainbridge. He says he has always been frustrated with the growing bureaucracy of providing health care, trying to find the perfect system. “There is no perfect system,” he says.
The direct patient-provider approach is as close as it gets. Essentially, it’s a contract between the practitioner and the patient, with no insurance involved. The patients pay the fee to the practice on a monthly basis, and neither the physician nor the patient can bill insurance for reimbursement. Patients can also pay in advance for a year or several months, but anything paid in advance beyond a month has to be in a trust fund, according to the law.
At Hendler’s family practice, the list of services covered by the retainer includes unlimited office visits , 24/7 on-call availability, in-office lab work and X-rays, EKG, vision screening, minor surgery, some vaccinations, coordination of care, phone consultations. The list goes on — it includes any in-house services available. All for $180 per month.
Hendler used to charge $174 for a routine office visit. Asked how he can afford to provide all these services for roughly the cost of one visit, he says, “It’s very tight. We’ve reduced our overhead a lot… We’re on a very skimpy budget.” Besides, he says, not only did insurance not reimburse at 100 percent, much of the overhead was created in order to deal with insurance paperwork. He says some private practices have as much as 65 percent overhead and when insurance only pays 50 cents on the dollar and Medicare only 30 percent of the costs, the only way for doctors to cope is through volume, which is why 15-minute visits are a norm. “It doesn’t matter how talented a doctor you are, you can’t do it well in that amount of time,” he says.
Hendler has tried to be innovative before, and about 10 years ago introduced a retainer system. At that time, he was investigated by the office of the insurance commissioner , and Hendler decided not to stand his ground. Who did defend the idea, however, was his own physician, Dr. Garrison Bliss of Seattle. Hendler credits Bliss with convincing insurance companies, lawmakers and the insurance commissioner to allow the direct patient-provider model. It took Bliss 14 years to do this, according to Hendler.
Although legally considered not an insurance program, the insurance commissioner’s office still has oversight over physicians opting for this type of practice. Beginning this December, the agency must report to the Legislature on an annul basis participation trends and complaints received. The state does not regulate the fees or set a cap, but physicians can only raise their fees once a year, and they cannot discriminate against patients based on their health and other factors.
Hendler has more than 70 patients currently and says he will close the practice to new patients when that number reaches 200. Some patients left after the switch, but he thinks many will be back once they realize the value of this type of care. Already, he says some who were skeptical initially are excited about the model after trying it out.
Hendler’s practice, which is located in a converted home on Madison Avenue, has four other support staff, including his wife, Gail, a nurse who is a Bainbridge native. He says they try to deliver “homey” and personal health care. “I really believe in quality care,” he says. “This is the best thing I’ve seen in my 35-plus years in practice.”
