Dr. Brandon Bilyeu knew when he was in a high school class in Red Lodge what he wanted to do. He wasn’t going to be a surgeon. He wasn’t going to invent a cure for cancer — nice as that would be.
He told the Senate Business, Labor and Economic Affairs Committee on Wednesday that he knew he wanted to be a part of people’s lives — he wanted to be their family doctor.
That all went according to plan until about six months from the end of his residency in family medicine. He saw himself working on weekends, nights — even vacations — to complete the paperwork and the administrative duties of a doctor. He spent time with patients measured in minutes, while paperwork stretched into hours. He was anxious, depressed and burned out.
“Even suicidal,” the Helena-based physician shared with the committee.
He took a break and did some soul searching. What he wanted to do, he thought, was impossible. He couldn’t seem to spend enough time with his patients. Then, he said he discovered “direct patient care” — a model where patients pay a monthly subscription fee for anytime access to a doctor. In lieu of insurance, doctors have upfront pricing on basic procedures in return for no insurance and no administrative hoops to jump through.
The model has been pioneered in other states, expanding from primary care doctors to dentists, chiropractors and even some specialties, for example, dermatology. In Montana, the growth of direct patient care has started with doctors like Bilyeu, but twice, legislation that would give clear legal guidelines and sanctions to the growing model was passed by the Legislature and vetoed by former Gov. Steve Bullock, a Democrat.
“This is freedom to grow the market,” said Frontier Institute chief executive Kendall Cotton. The Frontier Institute is a nonprofit think tank focusing on the free market. He gave the example of a fee-provider service in Oklahoma, which charged just $12,000 for a knee replacement as opposed to the $35,000 average cost in Helena.
“Let’s consider what is driving up the cost. The bureaucracy and middlemen are who is driving it up,” Cotton said. He previously worked for former Auditor Matt Rosendale, who now represents Montana in the U.S. House of Representatives.
“This doesn’t need regulation,” Cotton said. “It’s something outside insurance.”
Dr. Darcy Bryan, an obstetrician-gynecologist with the Mercatus Center at George Mason University, testified that by freeing providers, it increases the time they spend with patients and contributes to higher job satisfaction. She told the committee that 30% of the physicians’ work is administrative, and 40% of the cost of running a medical practice is administrative overhead.
“The current system places doctors and patients at odds with each other,” said Dr. Todd Bergland, an Iraq War veteran and family physician in Whitefish. “I’m directly responsible to my patients.”
He described the work as harder in some ways than traditional medicine — patients contact him by phone, text or email, days, nights and weekend. However, he also said it allows him to judge how much time each patient needs.
“Here’s my office,” Bergland said, holding up a tablet computer of his office. “Note the absence of a computer.”
No one during testimony spoke against the medical care or the providers, and most agreed giving patients a choice was a good thing. However, Senate Bill 101 would spell out specifically that these providers were not subject to the State Auditor and Commissioner of Insurance. That would clarify what is now a legally gray area, and require the providers to notify patients upfront that direct provider care is not insurance.
For example, if a person contracts with a primary medical provider through a DPC model, and that person had no other insurance but had to go to an emergency room, the patient might be liable for expensive medical treatment.
One patient who spoke in favor of the bill was Paula Sweeney, a civil malpractice attorney, who also loves the experience of direct provider care.
“I can tell you as a lawyer that one of the overwhelming causes leading to malpractice is because physicians only have seven minutes to get what they need to know about a patient,” she said. “That means that patients fall through the cracks and have awful outcomes. This (legislation) mitigates that.”
Two of the largest insurers in Montana spoke during the opposition portion of the hearing. However, they did so saying they expected an amendment to the bill by sponsor, Sen. Cary Smith, R-Billings, to be attached that would make it illegal for providers to bill both the patient and insurance for the same procedures, meaning patients would be on the hook for any services provided at them.
They testified that if the amendment was adopted, they would not stand opposed to the legislation.
John Doran, vice president of external affairs for Montana Blue Cross-Blue Shield, said the he was worried about the duplication of services or patients even paying more out of pocket, but ultimately his organization, which covers more than 300,000 state residents, didn’t object to the bill and supported cost transparency and patient choice.
“We tell consumers to be careful about what you buy,” Doran said, sharing an example that while having a direct-provider relationship may be beneficial for some things, it will not cover high-priced care like an air ambulance transport or cancer, which may require a healthcare plan.
“If you try to piecemeal these together — $100 for a primary care provider and then dentist fees and then pharmacy, which could run $400 month which is the driver of health care costs, you’re going to exceed the cost of what a traditional insurance plan would cost,” Doran said.
He said he shares the concern about a fee-for-service model, and that’s why the insurance giant, along with others, are looking at quality outcomes rather than number of tests ordered, for example.
“We in no way want to insinuate we are against choice for Montanans,” Doran said. “But there are inherent risks, and we need to be careful of those risks.”
Dr. Cara Harrop, a family doctor in Polson, said that after nearly 20 years of working as a practitioner, she’s only become the doctor she’s wanted to be in the past three years as she’s set up a direct patient care clinic.
She said spending $75 per month on a doctor for access is cheaper than many other conveniences, like cable or cell phone.
“I want to be that doctor who takes care of you from birth to death — the kind that you run into at the grocery store,” Harrop said. “We still need to have insurance for other things, like appendectomies, knee replacements or, God forbid, cancer. But this puts the relationship front-and-center.”