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An Apex physician has decided to skip billing to insurance. He has patients pay him directly.

By Jennifer Ferris

MedPage Today/ North Carolina Health News

On a rainy Wednesday morning in the thick of fall allergy season, Brian Forrest disappears into one of the plain yet cheerful exam rooms at Access Healthcare with longtime patient Winston Goodwin. Half an hour later, the primary care physician emerges, heads to his office and types up a detailed treatment plan that includes specific meal suggestions – leafy greens and salmon – and other health tips.

All told, Forrest spends around 40 minutes on the patient. Most primary care physicians would go bankrupt if they spent that kind of time on routine visits, yet Forrest said he’s making two to three times the income of his colleagues while seeing only 16 patients a day.

All Goodwin pays when he checks out is $64 for the visit, $10 for the flu shot. And even though he has Medicare, neither the patient nor the practice will file a claim.

Goodwin can’t afford the monthly charge that Forrest offers his patients in lieu of accepting insurance, instead paying full cost for his visits. Even though he has Medicare, which he uses for hospital visits, Goodwin would rather pay out of pocket.

Brian Forrest, MD, stands in an exam room in his Apex office. Photo credit: Jennifer Ferris

“It’s cheaper than going [to] them other places,” he said, comparing Forrest’s Apex office to one where he’d used his insurance in the past. “[And] you don’t have to go through all that mess.”

Despite the fact Goodwin often brings the office staff watermelons, yams and other produce, the third-generation farmer isn’t receiving any special treatment. Forrest delights in spending quality time with his patients.

How can a primary care physician make upwards of $400,000, spend that quality time with each patient and still make it home in time for dinner every night?

Forrest said he spends evenings and mornings at home composing music on his keyboard, and describes himself as “happy as a clam.”

Forrest’s business model

Forrest attributes his success to cutting out insurance claims, which allows him to staff only one medical assistant, and receiving cash payments daily.

About 10 years ago, Forrest designed his own brand of direct pay: Either patients can pay a $40-per-month subscription fee along with a $20-per-visit fee, with some tests – EKGs, for example – included, or $64 per visit outright and additional fees for tests, which are listed in the lobby. There for a test for blood lipids? $34. Need a wart removed? $64.

Although Forrest said his is an egalitarian practice, one that provides access to low-income, uninsured families, this model works best where community members can pay a yearly membership fee. With average annual household incomes of $90,000 in this Raleigh suburb, Forrest has 1,200 patients on the rolls and more than 1,500 who schedule visits when needed.

Goodwin’s nearby farm is a remnant of a prior, more rural age. Today’s Apex residents are increasingly wealthy couples for whom the $480 a year fee might not seem a burden.

The secret to both his happiness and his prosperity, Forrest said, is eliminating everything that doesn’t directly benefit patient care.

Billing departments can easily use up to a third of a practice’s financial resources – but Forrest doesn’t have one. Medical office staffs are often large and perform redundant tasks – but Forrest has a single assistant who weighs patients, prepares their charts and handles scheduling.

Brian Forrest stands in front of his fee chart in his Apex office. Prices include $29 for a sports physical and $64 for non-member exams. Photo credit: Jennifer Ferris

Forrest’s electronic medical records system is free and his web provider is low cost. Although his physical office is well appointed and in a nice neighborhood, it is small – not a bit bigger than is needed for Forrest and two other providers to see their daily roster of patients.

The result is a thriving practice with only 3,000 charts on the shelves and employees who are happy and fulfilled. The medical students and assistants even moved their break room into Forrest’s personal office, setting up a microwave and conference table just feet from their boss’s crowded desk.

“Our patients don’t care if we have marble countertops or leather chairs,” explained patient care coordinator Susan Bavisotto, who has been with the practice since it opened in 2002. “It’s about taking care of them.”

Dysfunctional medicine

During the late 1990s, as Forrest was finishing medical school at UNC-Chapel Hill, he became preoccupied with what he saw as a dysfunctional system that served neither doctors nor their patients. As a resident in family medicine, he questioned every doctor he encountered about what they thought was wrong with the health care system.

“The physicians were overwhelmed. It was treadmill medicine,” Forrest said. “They were having to see 35 patients a day and they felt really burned out and like they couldn’t take care of patients because they were so rushed.”

Forrest was also frustrated by the higher costs self-pay patients were charged, while the negotiated amounts insurance companies paid were often half the amount. He decided to invent a new practice model, one that gave doctors more time with patients while keeping costs both low and fair.

Although there were several doctors prior to Forrest who practiced various forms of concierge or direct-pay medicine, Forrest credits himself with the invention of the modern model, which integrates the monthly payment alongside fees for appointments.

Several different permutations of the model evolved during the early 2000s, but Forrest’s was the first that combined the concierge approach with the fee for services for those who couldn’t afford the membership.

“My aim was to have a practice that was 90 percent uninsured people,” Forrest said. “At the time, Wake County had 85,000 people [who] were uninsured. And I’m, like, there are plenty of people who need a physician they can afford.

“Initially, people [who] came were uninsured. But then they told their neighbors. And their neighbors who had insurance said, ‘Hey, I want to try this out.’”

The direct-pay movement

Direct-pay practices have been growing in popularity over the past decade. In 2002, when Forrest opened Access Healthcare, less than half of a percent of primary care offices were billing the consumer directly, and they were usually only accessible to very wealthy patients.

Today, according to the American Academy of Private Physicians, an organization of direct-pay doctors, more than 9,000 doctors now work in direct-pay practices, with hundreds more joining the fold each year.

The calendar in Brian Forrest’s office outlines all of the consulting work he does, helping other doctors launch a direct-pay practice model of care. Photo credit: Jennifer Ferris

Without a formal professional organization to advocate on their behalf, direct-pay providers such as Forrest worked alone, each forging the new territory in parallel. But as Forrest’s practice gained traction, he began to develop a strong network of contacts. He had labs that gave him and his patients discounts, prescription companies that provided drugs at cost and an increasing knowledge of the regulatory issues at play in this new model.

Then Forrest founded the Access Healthcare Direct Network, a group of physicians who take direct payment from their patients. They share resources and make deals collectively with drug companies, specialists and other providers. Forrest has 503 doctors in his network, with more signing by the day.

A map of the Unites States hangs in Forrest’s office, crowded with thumbtacks marking each practice in his network. A wall calendar notes upcoming visits from interested doctors and trips to potential practices.

Nearly half of the weekdays are filled with plans to visit with doctors ready to make the switch. Bavisotto once spent her days weighing patients and filing charts. She now manages his busy calendar and updates his consulting business’s website during many of her working hours.

“Doctors love this model because it allows you to focus on the patients instead of worrying about what the codes are,” Forrest said. “Who cares about the codes?”

Forrest earns a consulting fee for his visits to other practices, and he charges doctors to join his network; they pay a monthly fee for access to low-cost labs and prescriptions. He travels the country advising doctors on how to ditch insurance companies and change their entire business model.

The doctors also join the American Academy of Private Physicians, of which Forrest is an officer.

Large companies have also taken up the private pay model. Qliance is a Washington-based, Amazon-backed company that provides medical services to software company employees as well as private consumers. Instead of investing in insurance, companies such as Expedia pay a monthly fee for their employees to be seen in one of Qliance’s many locations.

Other companies are developing similar models.

Improving outcomes

Although Amazon founder Jeff Bezos and Michael Dell invested in direct primary care because they saw it as a sound business decision, another reason the model is gaining traction is because it leads to improved patient outcomes.

The Consortium for Southeast Hypertension Control in Winston-Salem evaluated several years’ worth of Forrest’s patients’ charts and data. Researchers found that the extra time spent with the patients led to 60 percent fewer ER visits as compared with traditional practices and a 65 percent lower rate of hospitalization among patients who rely on Forrest to manage their chronic conditions.

Access Healthcare was designated by COSECH as one of only 33 Cardiovascular Centers of Excellence due to the results of the extra time spent managing patients’ conditions.

Patients of Qliance and other direct pay practices have benefited as well. COSECH’s research shows that, especially among patients with multiple conditions, the more time a doctor spends with them, the more positive the long-term outcomes.

For patient Melanie Williams, a retired new-home sales agent from Apex, the extra time spent with Forrest, combined with a practice model she believes in, means she never worries about her health, despite experiencing a number of comorbid conditions.

“I love the fact you have time with the doctor and that he has time to listen to you,” Williams said. “Even though we have insurance, it’s worth it to me to stay here and stay healthy.”

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This story is part of a partnership between MedPage Today and North Carolina Health News. The collaboration will make it possible for us to publish regular profiles of health care professionals from North Carolina.[/box]

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