Bill could clear the way for doctors who sign up patients by subscription

Yahoo

17-02-2025

Dr. Wendy Molaska of Fitchburg testifies on Feb. 12 in support of legislation to clarify that doctors charging patients under a monthly subscription program are not in the insurance business. (Screenshot/WisEye)
Dr. Wendy Molaska is a Wisconsin family practice doctor, but her patients don't use their health insurance — if they have it — when under her care.
Instead, Molaska's patients have a subscription for her services, paying $70 a month. They go to Molaska's office when they feel sick, need a checkup, or have some other routine medical concern. She'll see them as often as they need, she says — no extra charge.
Molaska is a direct primary care practitioner. Direct primary care, DPC for short, is prepaid outpatient health care. While both the doctors who practice it and their patients are just a drop in the health care ocean, their numbers are growing.
In back-to-back meetings last week, the health committees in both the Assembly and the Senate considered legislation to make it legally explicit that the subscription programs used by DPC doctors are not insurance plans and don't have to be regulated like insurance.
The identical bills, AB-8 and SB-4, spell out some definitions, along with rights and standards, for direct primary care agreements and state that they are exempt from insurance law. More than half of states in the U.S. have similar laws.
The concept won bipartisan support in the 2023-24 session of the Legislature but failed to make it to the governor's desk.
'In insurance, you risk-share,' said Dr. Nicole Hemkes, owner of a group of direct primary care clinics, Advocate MD, testifying at the Assembly hearing Wednesday. 'You're paying a bunch of money into a [pool] and then the insurance is paying out on claims.'
Direct primary care is 'basically a transactional relationship where you're paying a monthly membership,' Hemkes said.
'This is the old school medicine of being able to actually take care of your patients the way they need to be taken care of,' Molaska told the Assembly Committee on Health, Aging and Long-Term Care.
She testified that neither she nor patients have to deal with the question of what insurance covers and what it doesn't. The $70 monthly fee covers a broad range of in-office procedures and visits as frequent as a patient requires, she said.
Prescriptions, which she can dispense, and lab tests are extra, but Molaska said in an interview that they are often much less expensive when paid for out of pocket rather than as part of an insurance plan.
Molaska said there are about 100 direct primary care providers in Wisconsin, a number that has grown markedly starting in the first years of the COVID-19 pandemic. If each provider has 500 patients, a typical DPC caseload, that would mean 50,000 Wisconsin people have joined the trend from the patient side.
In an interview, Molaska said that removing the uncertainty over whether regulators would try to apply the state's insurance law to their operation could help motivate more doctors to provide direct primary care.
DPC practitioners say their approach is both cost-effective and patient-friendly.
Hemkes said patients with high-deductible health insurance plans might forgo a routine visit to the doctor to avoid an out-of-pocket expense they can't afford.
'We are not trying to replace insurance,' Hemkes told Assembly members. Direct primary care '[is] meant to make health care more accessible to more people.'
Some people opt for DPC as an alternative to a more expensive, comprehensive health plan, however. Molaska testified that in the Madison suburb of Fitchburg, where she practices, 'the number of people without health insurance is 7.4%. At my clinic, 41.3% don't have other health insurance.'
Many low-wage service workers have employers who don't cover health care, and their own incomes are too high for Medicaid but not high enough for them to buy their own insurance, Molaska told the Wisconsin Examiner. With a direct primary care subscription, 'at least they're able to access primary care,' she said.
For specialty care and hospitalization, patients are still likely to need health insurance or alternative forms of coverage of some kind. Nevertheless, Molaska said, her fixed fee covers as many non-specialist visits to her office as a patient might need to make, as well as being able to call or text for consultation.
Molaska said the system has allowed her to limit the number of patients to about 500 people, in contrast to conventional medical groups where a single doctor's caseload can be two, three or even four times that many.
Molaska said she calculated her monthly fee based on what existing DPC doctors were charging, the size that she chose for her caseload and her overhead costs and staff: two nurses, a certified medical interpreter and an office assistant. With direct care she doesn't have to hire someone for coding insurance claims or billing for visits, she observed.
Some patients have health insurance that covers primary care, but choose a DPC provider instead, paying the monthly fee themselves — valuing the short wait time to get in and the longer and less-hurried visits, Molaska said.
Evan Danells, a Madison chef and restaurant owner who also testified at the Assembly hearing, told lawmakers that many restaurant operators have profit margins too small to allow them to buy insurance for employees. Direct primary care made it possible for him to cover his employees for basic health care, he said.
Danells is one of Molaska's patients. He said her much smaller caseload allowed for more personal care rather than rushed appointments with a doctor who would 'look at me like they're seeing me for the first time over and over again . . . because they just had 2,500 patients last year.'
Hemkes said direct primary care doctors aim to make their services broadly affordable — not like medical practitioners who provide 'concierge medicine,' charging wealthy patients five-figure sums for special access.
Another misconception, Hemkes said, is that direct primary care 'selects out healthy patients.'
The legislation guards against that possibility with a provision stating the direct primary care providers 'may not decline to enter into or terminate a direct primary care agreement with a patient solely because of the patient's health status.'
At Advocate MD, which has three clinics in the greater Madison area and one in Janesville, 'our patients in our practice run the spectrum from young, healthy people to older people with multiple chronic medical issues,' Hemkes testified. 'Having an hour-long visit with that patient is very useful to be able to provide comprehensive care to them, to help them navigate all their specialists.'
The last time a direct primary care bill was before the state Legislature, in the 2023-24 session, it won unanimous support from Republicans and Democrats and cleared the Assembly on a voice vote.
The legislation died in mid-2024, however, when the state Senate adjourned in the spring without taking it up.
The 2023-24 session bill included a list of civil-rights protections for patients of DPC providers — one of them forbidding discrimination on the basis of 'gender identity.'
Those words led two organizations to lobby against the legislation in 2024 and submit public hearing testimony opposing it.
'We have no objection to the effort to make direct primary care more accessible to Wisconsin residents. We do, however, object to the inclusion of gender identity in the non-discrimination clause,' stated Jack Hoogendyk of Wisconsin Family Action. The organization routinely opposes legislation guaranteeing the rights of transgender and gender nonconforming people and LGBTQ+ rights.
The Wisconsin Catholic Conference also opposed the bill on the same grounds.
In place of enumerating specific civil rights protections, the 2025 version of the legislation's nondiscrimination section states, 'Nothing in this section shall be construed to limit the application of s.106.52 to a health care provider's practice.'
The clause refers to Wisconsin's civil rights statute, which does not include specific language protecting gender identity.
SUBSCRIBE: GET THE MORNING HEADLINES DELIVERED TO YOUR INBOX