The major emphasis in “consumer-directed healthcare” proposals for reforming consumers’ healthcare behavior – turning them into prudent and well-informed purchasers of sickness care when needed.  This would be in sharp contrast to the pattern of purchase behaviors where someone else is responsible for paying, and consumers feel entitled to as much care as they feel like getting, at least if they are insured well enough to cover the costs.

But there is an equal and potentially more valuable effect that may arise from shifting more costs, responsibility and information to consumers with respect to sickness care costs.  They may begin to seek, on their own, ways to manage their own health so as to reduce their risk of and thereby expenses for sickness care.  Already, employers, commercial insurers and government insurance programs have enrolled millions of people in free-to-participants health management (HM) programs, in any one or a mix of: general health and wellness promotion, risk behavior or condition prevention and correction, and chronic disease management.

While the costs of payor-sponsored HM programs tend to be lower than what consumers could purchase as individuals, this is not always the case, particularly when payors don’t get involved until consumers are patients with complex and expensive chronic diseases or multiple co-morbidities, where costs of disease management can run to over $5,000 a year per participant.  Consumers have access to a wide range of differently-priced options if they wish to take charge themselves, and are willing to pay out-of-pocket for that right.

Concierge Physician Practices

“Boutique”, “concierge”, “retainer”, “membership” or “patient-paid” practices were started primarily to offer premium access, availability, amenities, and advocacy relative to sickness care when they were introduced just over a decade ago.  But most of the later-introduced examples were started, or have chosen to include major proactive HM services along with sickness care, and a few specialize entirely in HM, offering no sickness care.

These practices charge as little as $50 a month, and as much as $100,000 a year, though most are in the $1,000-2,000 range.  The MDVIP practices, numbering over 150 in 16 states cite the fact that “VIP” means “value in prevention”, not merely “very important patient”.  And they have proven the value to payors, as well as patients, in their services, with dramatic reductions in hospital inpatient care utilization and expense among their patients, compared to average Medicare patients, and members in the best managed care plans. (www.mdvip.com)

Cash-Only Practices

Some physicians have offered health management services on a patient-paid fee for service basis, rather than annual retainers.  These are typically “opt–out” practices where physicians chose to reduce their overhead to a minimum by not dealing with insurance, though they normally provide the paperwork necessary for their patients to seek reimbursement for their payments from insurers.  I recall an early adopter of this approach was a practice called “HMNo” in Denver, though it has since changed its name and become a retainer practice.

At the “Beyond Care” practice in Branford, Connecticut, the physician offers packaged HM programs related to wellness, fitness, stress management, nutrition, diabetes/metabolic syndrome, etc. and lasting from three to six months.  These programs were offered at prices between $1800 and $2800 when I first encountered them, though a recent visit to the practices website found no prices mentioned. (www.beyondcare.net)  The Tempus Clinic in Los Gatos, California offers a wide range of HM programs, including its health club memberships, that were once priced at between $10,000 and $30,000, though a recent visit to its website also found no prices mentioned. (www.tempusclinic.com)

Retail Medical Clinics

The majority of these convenient, low-cost, nurse-practitioner-staffed clinics focus almost exclusively on routine sickness care, at convenient locations, affordable prices, and easily accessible hours.  But at least some have added significant proactive HM services to their offerings, in addition to the usual array of physicals and immunizations.  These are the RediClinic locations, of which there are seven in five states in the South.  These offer a “StayWell” set of services to complement their “GetWell” treatments.

These include extensive health risk screening packages, ranging in price from $39 to $89, as well as traditional physicals.  And the clinics also offer a four-visit “Stop Smoking for GoodSM” program priced at $128.  And they have recently added a variety of “Cholesterol Challenge” programs at some locations, ranging from $49 to $89 in price.  They also offer a “Heart Health” program at prices of $79 or $129. (www.rediclinic.com)

Low-End Options

HM programs that rely mainly on automated analysis of health risks and automated online communications, or website self-service can afford to charge highly affordable prices per participant for payor-sponsored population-focused HM programs.  The same options are available for individual consumers, as well.  Three physician practices in Colorado offer a fitness/weight management program called Physicians Fitness Coach, through incentaHEALTH, in Denver.  It includes physicians, along with e-mail communications, and is priced at only $19.95 per month.

Another Colorado practice, Family Physicians of Western Colorado was able to apply the Chronic Care Model of disease management for its diabetes patients at an additional cost to the practice of only $104 per patient per year.  It lost money in this effort, because it could only get one health plan to pay for this program, and that plan covered only a minority of its patients. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management 12:10 Nov/Dec 2005 50-56]  But had it chosen to offer it to self-paying patients, this would easily have represented an affordable option for most patients.

With growing numbers of consumers choosing, or being offered no other choice but high-deductible health plans, these self-paid options are becoming increasingly attractive to many of them.  Even the higher-end practices such as the MDVIP examples are attracting middle-income patients, some of whom find their annual retainer is a bargain compared to the deductibles and co-payment costs of their insurance plan.  And many such plans permit employees to use their health spending accounts to pay for the retainer.

With other options available at prices as low as $20 per month, the number of consumers who could afford to pay for their own, particularly if they lack insurance coverage, is sure to increase.  Whether the number who choose such programs will also increase is another question, however.  Many will no doubt prefer to try personal HM on their own, without help.  But most such efforts have failed, and in the long run, affordable self-paid options may become widely popular.