After parking her Subaru, physician Lauren Hedde grabs a bag containing her laptop and medical gear and cradles a digital scale in one arm before knocking on the front door of a boxy little house on a dead-end street in Coventry.
When Ashley Thomas opens the door, the first-time mom is holding Hedde’s newest and youngest patient — 3-week-old daughter Faith.
“Tell me how everything’s been going?” Hedde says as they sit down in the living room.
“Good,” says Thomas, adding, “We think she’s got a little bit of diaper rash.”
Hedde, wearing tall leather boots and black tights rather than medical garb, begins her examination. She dons a stethoscope to listen to Faith’s chest and weighs her on the scale.
Hedde’s willingness to make house calls — mostly for newborns and the disabled — is a throwback to the days when a family doctor would arrive at the front door with a black bag in hand. But what truly sets Hedde’s practice apart from modern medicine is an even more unusual approach: She doesn’t accept insurance.
Instead, Hedde charges a monthly fee for those who want to be her patient. They can make unlimited appointments to see her in her North Kingstown office, where she has no staff, or to request a house call. The fee varies based on a patient’s age and needs.
If that sounds familiar, it’s because so-called “concierge doctors” began appearing on the scene several years ago, devoting themselves to the care of patients who pay monthly or yearly fees. These practices, with lighter patient caseloads, were promoted as a way to see a physician with less wait and to have a more personal doctor-patient relationship.
Similarly, “micro-practices” and “ideal medical practices,” have been cropping up. In these, doctors practice solo — with no administrative staff, nurses or other doctors — to lower overhead and spend more time with fewer patients.
But Hedde’s practice, which she says is unique in Rhode Island though gaining in popularity elsewhere, differs from both of these in significant ways. Micro-practices rely upon payments from patients’ insurers while concierge doctors typically accept insurance in addition to collecting pricey fees befitting their name.
Hedde wants to be free of insurance — with its administrative burdens and costs and relatively low reimbursement for primary care — but remain affordable to the average person.
“Concierge medicine shouldn’t just be for wealthy people,” she says.
Ashley Thomas and her husband, Ryan, certainly aren’t wealthy. They rent their little house and have modest-income jobs. She’s a shoe store manager; he works for a heating and air conditioning business.
At 25, Ashley is still on her parents’ insurance. Her husband is covered through his job. Still, after meeting Hedde at a workshop for new parents, they were drawn to her practice. Hedde charges $50 per month for Ryan plus another $10 for Faith. The couple figures it’s worth it.
“As soon as I saw the home visits for newborns, that did it,” Ashley Thomas says.
It could also save them co-pays they might otherwise have to spend on some doctor visits, she says. Recently, for example, they were alarmed by how Faith’s belly button looked and how it was healing.
“We were about to go to the hospital,” Thomas says, knowing that could have meant many hours in the emergency room and an unwanted bill. Instead, she snapped a picture and sent it to Hedde. The doctor saw nothing unusual and didn’t schedule an appointment.
“I’m happy to save the ER from some of these things,” Hedde says.
Hedde, 32, who grew up in Medway, Mass., landed a Brown University family medicine residency at Memorial Hospital in Pawtucket. It included a stint at a primary care micro-practice before she finished up early last summer.
“That sort of piqued my interest,” she says, describing how in bigger practices, “I was feeling rushed…. I didn’t feel like I was getting to know patients well.”
So as she was finishing her residency, she began exploring options and learned about an emerging field in medicine called “direct primary care.”
Embraced by the American Academy of Family Physicians, some large national companies have adopted the model, including Expedia, which opened a clinic at its headquarters in Seattle. Seattle is where the movement was born, with a practice called Qliance that today reportedly has 35,000 patients.
Drawn to the movement, Hedde attended a national summit on direct primary care last year. In August, a week after completing her residency, she started her own practice. It’s called Direct Doctors.
Meanwhile, her husband, a fellow resident, joined another physician in a Massachusetts practice affiliated with a hospital.
“We sort of needed someone to make a steady income while I was taking a bigger risk,” says Hedde, who lives in West Greenwich.
Hedde is moving in a very different direction than her husband and most other primary care doctors. These days, efforts to improve the cost and quality of health care in the United States have focused on expanding access to preventive care to avoid costly visits to emergency rooms and hospital admissions.
While Hedde has the same goals, the industry trend is toward growing, not downscaling, primary care practices. One of the best-known of these new approaches, “patient-centered medical homes,” relies on electronic medical records and pulls together a team of medical experts. Together, they coordinate care for patients, especially those whose chronic conditions, such as diabetes and heart disease, can lead to complications and costly medical interventions
Blue Cross & Blue Shield of Rhode Island worked to establish the first such practice in the state in 2008, says Augustine Manocchia, senior vice president and chief medical officer. Since then, with the state health insurance commissioner requiring insurers to expand medical-home practices and insurers raising reimbursement rates for these doctors, nearly half of Rhode Island’s 950 primary care physicians now belong to one.
While not familiar with Hedde’s practice nor questioning the quality of care she delivers, Manocchia is critical of whether her skills are being efficiently used.
The demand for primary care physicians, who were already in short supply due to the allure of more lucrative specialties, is greater than ever with previously uninsured people now obtaining coverage through the Affordable Care Act, Manocchia says. While Hedde’s goal is to have about 500 patients, the typical caseload at other practices is about four times that.
“I get complaints every day from people who have difficulty finding a primary care doctor,” he says.
One of the thrusts of medical-home practices, Manocchia says, is to have doctors “practicing at the top of their license.” That means utilizing their expertise while leaving the rest of the medical team to handle other matters, such as nutritionists to address weight issues, nurse practitioners to offer guidance on managing diabetes and on-staff pharmacists to monitor prescriptions.
If Hedde is performing these and other administrative functions on her own, “I think it’s taking away from the more important things she could be doing,” says Manocchia.
Even a Rhode Island Foundation medical school loan forgiveness program to promote primary care discriminates against solo practitioners. It’s open only to doctors who join a practice of four or more.
These biases could give way as more is learned about direct care. In January, Qliance issued a report — not peer-reviewed research — that it says shows its direct primary care model is 20 percent less costly than traditional insurance. Proponents say that the monthly fee for such practices can be offset through savings in doctor visit fees and by choosing health plans with higher deductibles and tax-free health spending accounts.
Hedde says she’s yet to see convincing evidence that patient-centered medical homes are improving the delivery of health care. But she’s convinced she can reduce costs.
In East Greenwich, for example, she visits Judith Kinzie, a 65-year-old whose four-decade-long battle with multiple sclerosis has left her immobile. A health care aide wheels Kinzie into the living room and, with an electric lift, hoists her onto a recliner.
“You sound a little wheezy,” Hedde says.
They talk about the need to monitor whether it’s a passing cold or something more serious. Then Hedde turns her attention to the chronic swelling in Kinzie’s limbs. There’s a sore on her left heel and her right hand is unusually enlarged. Hedde suggests getting the hand elevated and applying dressings to the heel. She reviews her prescriptions and orders blood tests to check her kidney function.
Kinzie and her 75-year-old husband, Andy, who live in an addition to their son’s house, have Medicare. But both pay a monthly fee to see Hedde — $150 for her and $100 for him.
“I think I’m saving Medicare money. A patient like Judy could be in and out of the emergency room all of the time,” Hedde says. “Being able to see Judy in her home environment, helps me understand the reality of her situation and the needs she has.”