Hi, thank you for reading! My name is Dr. Jeff O’Boyle. I am a board certified family medicine physician. My clinic, Beyond Primary Care is located in Ann Arbor, Michigan. In this post I am answering a common question that I receive, and that is does Direct Primary Care (DPC) work with your insurance? The answer for a vast majority of DPC clinics is yes, DPC works with your insurance, but not for your insurance. This is an important distinction.

DPC does not work FOR your insurance

This is the essence of DPC, that it works directly for you- the patient! We forgo insurance payments in order to save our patients from the arbitrary, intrusive decisions that inevitably follow with third-party payers (health insurance). Furthermore, since DPC practices are independent, we are free from hospital contractual agreements and can offer reduced prices on laboratory tests, imaging, and medications. As noted by this Wall Street Journal article, hospital systems are ignorant of their actual costs. Instead, they often increase prices to meet profit margins.

DPC works WITH your insurance

While DPC’s goal is to cover the vast majority of healthcare needed for all individuals, there are many instances in which a patient may need to utilize their insurance to see providers or utilize services outside the membership.

Specialist Referrals

This would be when a member needs to see a specialist for a condition that requires care past what could be offered in a family medicine clinic. Examples include physician specialist, psychiatrists, counselors, and physical therapists.

Say a member needs a referral to an oncologist- which is a doctor that specializes in the diagnosis and treatment of cancers. No one ever anticipates needing a such a doctor. But when called upon, a DPC doctor will work to find a doctor that accepts your insurance, help coordinate your care, while minimizing your financial impact. How do we minimize your financial impact? If that specialist requires imaging, medications, or blood work, DPC practices will work with you to find the lowest costs– often through our DPC clinics- that meet the needs of the health provider. 

Hospitalization Coordination

From time to time, accidents or serious medical conditions do occur and an elevated level of care is required where a member needs to be monitored 24/7 by a team of doctors and providers.

An example could be a member suffers a broken arm from falling and needs to be hospitalized for a major surgery. DPC will help communicate with your inpatient hospital team of providers making sure they know your current health status and working towards understanding your options for care upon discharge. While we may not be able to care for you in the hospital, we can certainly use virtual medicine (also known as telemedicine) to discuss your needs and questions. We can also give you helpful advice to make sure you won’t receive any unexpected bills from the hospital upon your discharge.

The following picture is a hospital bill from a patient who posted her hospital bill online. The patient was contemplating hurting themselves and walked into an Emergency Room seeking help. The patient states the “physician charges” are NOT shown that bring the grand total to over $18,000!

Here is some FREE Doctor Advice from Beyond Primary Care: In the hospital, ask to know the identity of every unfamiliar person who appears at your bedside. If you’re too ill, ask a companion to serve as gatekeeper. Write it down. What seems like a pleasantry may constitute a $700 consultation

Special Medications

One of the coolest features about DPC is many practices offer in-clinic dispensing of hundreds of generic medications, often at substantial price differences compared to retail pharmacies. Still, there are times a member needs or would benefit from a certain medication that is brand name only (very expensive) and would be best obtained through insurance that requires a prior-authorization from the insurance company.

In this scenario, we will work to fill out the necessary paperwork to get your needed medications at reduced costs or even reach out to the pharmaceutical companies seeking a reimbursement or free supplies on your behalf. A great example is we got one of our members Vivitrol, a vital medication for Medication Assisted Therapy in Addiction Medicine. This medication costs over $1,000 on the market, but we worked to get our member the medication FREE of charge with their insurance. Did I mention the office visit and the injection itself were included with the membership? So the patient literally paid $0. Saving money for our patients gets me so excited!

Hi, thank you for reading! My name is Dr. Jeff O’Boyle. I am a board certified family medicine physician. My clinic, Beyond Primary Care is located in Ann Arbor, Michigan. In this post I am answering a common question that I receive, and that is how does Direct Primary Care (DPC) take care of it’s members with virtual home medicine? Virtual home medicine, also referred to as telemedicine, is a where you connect with your doctor via phone or computer’s webcam without physically being in the doctor’s office.

The Exception rather than the Rule

Why is it nearly impossible to get a doctor to talk with you over the phone in a timely fashion? Because because certain services like virtual home medicine are typically not be reimbursed by private insurance carriers and government payers. Nearly 40% of what we do in medical offices the patient doesn’t actually have to be there. But why are you there? That is the only way for doctors in a fee-for-service system to get reimbursed for your care, is to actually make the patient physically come in to the brick-and-mortar office to be seen- no matter how routine (eg- common cold, urinary tract infection) or obscure (filling-out paperwork for FMLA or work) the visit seems.  

Standard of Care with DPC

Under the DPC model of care, we naturally provide such care – yet another freedom we enjoy together as a result of our independence from the restrictions of third-party payment. As noted by this Forbes article, telemedicine pairs well with DPC. Since DPC has opted out of insurance contracts altogether, and we contract directly with you, the patient. DPC offers our patients around-the-clock access to primary care medical needs in exchange for an average fee of $50-75 per month. Phone calls, emails, texts, FaceTime- are included in a patient’s membership. Patient are routinely connected with their doctors within minutes to hours when reaching out, versus days to weeks with fee-for-service doctors.

Benefits of Virtual Home Medicine

One of the defining characteristics of DPC is that we keep our practices small so we can spend more time with our patients. Because we have the increased time in our visits to know you well, we can streamline your care when you’re sick away from home or even at home. Many illnesses can be diagnosed and treated with a simple conversation by phone or computer webcam.

Say you are traveling out of state and feel sick. You have access to a conversation with your DPC doctor from your pocket. We will discuss your symptoms, discuss management, then we’ll locate the nearest pharmacy and order the medications most appropriate for your present circumstances.

As a doctor, there have been times where I have seen patients- with just the act of walking from the waiting room to the examination room- get winded or experience excruciating pain. Why would doctor offices allow this? Where is the concept ‘first, do no harm?’ If you are local, often times the DPC doctor may deliver the medications right to your address, saving you the hassle of a trip that may potentially worsen the condition.

Curbside Referral Consult

Adding more value the DPC membership at no additional cost to our patients is many DPC practices participate with electronic consults, or online consultations for speciality care. Primary care can handle nearly 80-90% of all medical conditions, but there are times when a condition may be past our scope of practice. Instead of rushing the patient to the nearest specialist, which will result in a bill likely through the patient’s insurance, many DPC practices seek medical advice on behalf of our patients through an online service call RubiconMD. Through this online service, many DPC practices pay a monthly fee where we can get medical advice on behalf of our patients from more than 100 medical specialities. The company guarantees a response time within twelve hours. The DPC physician fills out the necessary forms, get’s the response through the RubiconMD service, then will pass this medical information onto the patient- at no cost! 

In researching your diabetes care, you may have heard people say they have “a touch of diabetes” or that their “sugar is a little high.” These words suggest that diabetes is not a serious disease. That is not correct. Diabetes is serious, but you can learn to manage it. Most of the steps needed to take care of diabetes are things you do yourself. I will help outline some of these steps in this blog post.

Progression of Diabetes

Keeping your blood sugar (glucose) in your target range can delay the health problems caused by the progression of diabetes. Yes, you read that correctly, diabetes is a progressive condition. Pancreatic Beta Cells (These cells produce, store, and release insulin) function will typically decrease over time. All the strategies listed here and discussed by your health care provider can help delay/prolong this progression.

Exercise & Nutrition

The doctor’s axiom of ‘eat less and move more’ is quite possibly the worst advice any doctor can give, especially if done in a rushed/ inconsiderate manner. Yet, regular movement and diet modification has been shown to improve insulin resistance–the main issue in those with type II diabetes. Moving your body and diet modification can improve A1C levels alone by as much as 4 points! This is far better than any single diabetic medication.

Cholesterol Counts

Diabetics have a higher risk of heart attack and stroke. That’s why doctors treat cholesterol levels more aggressively in those with diabetes

Pay Attention to Blood Pressure

The blood pressure goal of the diabetic person is below 140/80, just like the general non-diabetic population. A side-effect of elevated blood pressure and diabetes is the risk for kidney disease. Damaged filters don’t do a good job.

Get Your Vaccines

Diabetics also have a higher risk of infection. That is likely because bacteria love to live in high sugar environments. For that reason, doctors recommend diabetics get an annual flu shot, in addition to the pneumonia shot once before age 65 and once after age 65 (with at least 5 years in between).

Eye Doctors Aren’t Just For People With Glasses

Every diabetic should also get a yearly eye check that includes being examined by an ophthalmologist (eye specialist) who takes a look at the retina, or the back of the eye, for changes produced by diabetes.

I recently met a doctor and self-proclaimed underserved medicine wonk who bellowed that DPC doctors ‘cherry pick’ healthier and wealthier patients, leaving the the vast majority of individuals without care and fewer doctors to choose from. Nothing is farther from the truth- Direct Primary Care is not concierge medicine. I wanted to scream (I didn’t) that this perception whereby accepting a patient’s insurance somehow improves access to health care. I wanted to point out how the health care services this doctor was providing relies so heavily on third-party reimbursement systems, costs for their medical care have likely gone up. But in the end, the before-mentioned doctor was so entrenched in the health care insurance matrix, I could only use their misconceptions to help educate others.

Direct Primary Care Doesn’t Cherry Pick Patients

Direct Primary Care doctors run their own business so that we can do what is right for a change in health care; Treat individuals the way everyone wants to be treated by giving patients the time and peace of mind they deserve. We have transparent pricing on the care for our memberships, and do not charge more for complicated patients, or management of difficult or chronic medical conditions that require more frequent trips to see the doctor. Our plans work great for anyone at any level of insurance or for individuals at any level of savings and income.

• No insurance? Whether you have a family, or are a single working mother whose employer doesn’t offer insurance, Direct Primary Care is a great option. We provide the vast amount of medical services needed, there are no surprise bills, and contacting or seeing your doctor doesn’t mean you will have to miss work or school.
• You have insurance but a high-deductible? Direct Primary care does offer excellent and affordable healthcare that can compliment a person’s insurance. I talked about a better plan- Direct Primary Care with Insurance earlier. Direct Primary Care focuses on decreasing their patient’s need for specialty care, ER visits, and hospitalizations by focusing on health and prevention. Doing so can (and does) reduce the need.
• Have good, or even great insurance? Direct Primary Care universally recommends all patients have insurance. But having insurance does not mean access or longitudinal care. Having insurance without proper access is tantamount to rationing. With Direct Primary Care, we will exceed your office expectations in getting you in for your appointment with the same provider who knows you and your health- every visit.

Direct Primary Care wants to work for you. 

Opening My Clinic, Beyond Primary Care

My goal with opening a direct primary care practice was to make healthcare more affordable and accessible to everyone in the community. I have worked in the fee-for-service system, up-billing every visit to maximize insurance reimbursement (remember, costs are passed down- ultimately to the patient). I remember the conversations about patient’s prescribed blood pressure medications that cost $100 a month, and how I felt powerless to offer alternative ways of obtaining more affordable medications. I know the gut-wrenching decisions I had to make in cutting short a conversation about a patient’s knee pain because I was already a half-hour behind, offering them to return for a subsequent visit two weeks away.

At some point, my job as a family doctor in the fee-for-service system felt more like just a title and salary. After spending the better part of a decade in medical school and post-graduate training, I wanted my role as a doctor to have value. Value for providing my patients with unparalleled access to care. Value for providing my patients with transparent pricing on health care services and helping them navigate the system when needed. Value for sitting down with my patients, spending the time with them that is needed, and being there. That is the value in Beyond Primary Care.

It is fairly easy in exceeding office expectations for the area of customer service, as people have an increasingly low expectation for the service they get at the doctor’s office. It’s normal in fee-for-service office systems to have to wait an hour or more to be seen, and then get only a few minutes of the doctor’s time (if a doctor is seen at all). Many patients often find they half-day off or work or activities, just to be seen. This has left people seeking alternative facilities, such as urgent-care type setting for their ailments. 

What Your Office Visit Looks Like In A Fee-For-Service Office

You likely scheduled a 15-minute time slot. When the doctor’s medical assistant calls you back, you are on the clock. 15 minutes includes everything: time to walk back from the waiting room to the exam room, time for the medical assistant to take vitals (eg- blood pressure, temperature), time for the medical assistant to do the office intake questions. All this, even with the best and fastest medical assistant takes 7 minutes at a minimum. That leaves 8 minutes. 8 minutes for the doctor to do any courtesy conversation (eg- how have things been, what have you been up to since we last spoke), time for the history of illness questions, time for the physical exam, time for discussing what the possible diagnosis is, and time to wrap up the visit by either dispensing medications, ordering laboratory studies, or helping to coordinate your care. By the way, the doctor is going to want to document that visit in your electronic health record. 8 minutes is NOT enough to discuss acute or chronic illness, let alone anything. This results in, at best, frustration. At worst, people avoid care they should be getting.

At Beyond Primary Care, the patient has a much different experience:

• All days begin with multiple slots open for same-day urgent visits.
• Patients seldom have to wait more than 10 minutes to be seen.
• Appointments are 30 minutes per patient but can be extended to meet the needs of the patient.
• More than one concern can be address at your visit. Come in to talk about your anxiety, but want to discuss that mysterious new rash? That is what we do.
• Care is often done via text message or phone, reducing the need for coming to the office at all.
• Late/early office days because health issues don’t always arrive between 9 am – 5 pm and you shouldn’t have to miss work/school/etc to be seen.

With Beyond Primary Care, a premium is placed on exceeding office expectations, and again this is done because it’s in the best interest of our clinic, but returning health care to what it once was- focused on patient care. 

Hello and thank you reading my blog at Beyond Primary Care and trying the BPC Good Eats recipes. This featured recipe is a Cheesy Skillet Pizza. These recipes are my attempt, in a way, to bridge that Doctor’s adage of “Eat Better & Exercise More.” In this post, I will showcase a healthy meal made on a budget, my pictures are pretty decent, and that is how I got into this food endeavor.

Cheesy Skillet Pizza Pasta
Prep Time: 15 minutes
Total Time: 40 minutes
Adapted from: The Comfort of Cooking

Ingredients:
1 tbsp olive oil
8 oz spicy or mild Italian sausage, casing removed
½ cup mini pepperoni, divided
2 (15oz) cans tomato sauce
½ tsp dried oregano
½ tsp dried basil
¼ tsp garlic powder
8 oz. rotini pasta
Salt and Pepper to taste
1 cup mozzarella cheese, shredded
½ cup parmesan cheese, shredded
2 tbsp fresh parsley, chopped

Instructions:
1) Preheat oven to boil
2) In a large cast iron skillet set to medium-high heat, add olive oil.
3) Once oil is hot, add Italian sausage and cook until browned. Drain excess fat.
4) Stir in ¼ cup pepperoni to skillet with sausage and cook 1 additional minute.
5) Stir in tomato sauce, oregano, basil, garlic powder, pasta, and 1 ½ cups water.
6) Bring to a boil. Cover and reduce heat simmering until pasta is cooked through, about 12-14 minutes.
7) Remove from heat, sprinkle with mozzarella, parmesan, and remaining ¼ cup pepperoni.
8) Place under broiler and cook until melted and golden brown, 1-2 minutes, watching to avoid burning.
9) Garnish with fresh parsley, serve

If you are in the process of open-enrollment, consider a better plan- Direct Primary Care (DPC) with Health Insurance. This post is the second of a two-part blog post where I detail how anyone, regardless of their coverage of insurance, would potentially stand to benefit from direct primary care services. Check my earlier blog postings for the first part (and other cool things too… like the recipe for a yummy Chicken Noodle Soup).

You read my first post and have looked at your own insurance or enrollment options, and say “I am paying a lot of money for health insurance.” Maybe you are left wondering how direct primary care can fit in or rather “What kind of health insurance should I purchase with DPC?” I went on a health insurance exchange to give everyone a better idea of what pairing insurance and a membership to Beyond Primary Care would be like.

Practical & Affordable
The following slide features a hypothetical family of four, that lives in Ann Arbor, MI. Let’s say the parents are in their 40s and they have two young children. Their household income is $65,600/year, which is the median. This family has a number of things happen in the course of their hypothetical 2017, listed in the left column.  A somewhat busy year medically, but not catastrophic.The family purchases either a gold (high premium, low deductible) plan, a bronze (low premium, high deductible) plan, or a bronze plan paired with Beyond Primary Care ($130 a month for family membership). Then let’s see what each of these occurrences “costs” out-of-pocket under each of the three scenarios, and then add up the total out-of-pocket expenses for 2019 in the last row.

Notice that in the last column, the family paid their bronze plan premium ($10,908 for the year) AND the monthly fee for Beyond Primary Care ($130/month, or $1,560 for the year). Despite the extra expense of Beyond Primary Care, they still came out way ahead compared to the gold and bronze plans. This is because Beyond Primary Care offers many types of out-of-pocket savings, including: no visit copays, no additional fee for stitches, and substantial discounts on labwork, medications, and radiology.  These savings help to hedge against using that high deductible.  

Tolerance & Values

At some point in your research of health insurance, it no longer becomes analytical but needs to revolve around a conversation about tolerances and values.

What is your risk tolerance? As example, if you pick plan ‘B,’ what monetary hit can your family afford to take if you get ‘run over by the bus?’ Health care in the US, is a service, and it is expensive. What do you value in your healthcare? As example, do you care about longitudinal care? This is where a doctor really knows you and your family. Do you value access to your doctor, or appointments that run on-time?

With Direct Primary Care, patients are paying the practice, so we are very conscious of trying to give a patient their money’s worth. If DPC can give them value (a concept that has become foreign to healthcare) and patients are happy with our care, they will continue to stay in the practice. It’s in DPC’s best interest to do this, so we do a number of things to save patients’ money:

• DPC offers very low-cost lab testing (using “client billing”), saving people 75 percent or more on labs.
• DPC clinics dispense medications in the office (legal in most states), also saving people 75 percent or more, and offering a huge convenience to the patient.
• DPC will find the lowest cost for procedures, X-rays, and specialist services. While many of these are covered by insurance, most people have higher deductibles. So the lower cash prices are very valuable to them (not to mention the value to the uninsured). 

Health Insurance can be Expensive.
Insurance is a hedge against financial disaster, not a prepaid healthcare. DPC is not meant to replace insurance, nor does the model in any way encourage patients to drop their insurance. People need a way to pay for the high-cost areas of care, such as surgery and hospitalizations. DPC doesn’t try to address paying those costs.

Direct Primary care does offer excellent and affordable healthcare that can compliment a person’s insurance. DPC focuses on decreasing their patient’s need for specialty care, ER visits, and hospitalizations by focusing on health and prevention. Doing so can (and does) reduce the need. With Direct Primary care we are delivering a higher level of care at a known price.

If you are in the process of open-enrollment, consider a better plan- Direct Primary Care (DPC) with Health Insurance. I often get the question, “How does direct primary care work with health insurance?” This post is the first of a two-part blog post where I detail how anyone, regardless of their coverage of insurance our level of income would potentially stand to benefit from direct primary care (DPC) services. Check my blog post regularly for the second part (and other cool things too… like the recipe for a Dorito Taco Salad, because why not?!).

Figure out your Monthly Costs: Known as a Premium
Premiums are what you pay on a monthly basis to be insured. Premiums vary on the type of plan you choose. As example, you’ve done your homework and picked a health plan that costs $150 per month. You are paying $1,800 for essentially an insurance retainer, a cost to keep your insurance active. You’ll need to pay your premium on time every month.

Direct Primary Care has most membership fees are between $50-$100. The pricing for membership fees at my clinic, Beyond Primary Care, can be found here. This gets you full access to your doctor, regardless how many times you need to be seen. You could pay around $600 a year. The cost of a DPC membership is often significantly less than just the cost of having the insurance, let alone using it.

Reaching your Deductible
Deductibles are what you have to pay out of pocket before your health care plan kicks in. You may also have different annual deductibles for different types of care (as example: hospital care, laboratory tests, medications, etc). As example, you pick a plan with a $1,000 deductible meaning you are on the hook for all medical bills up to that amount before insurance kicks in.

Direct Primary Care provides you with with primary care services without government or insurance involvement. Your membership to a DPC practice does not influence your deductible. As example, you see your DPC doctor because of a mysterious symptoms. That visit was covered by your membership. When a person goes to a traditional fee-for-service practice, they won’t know the cost of care upfront, and labs and medications are potentially much more expensive than we offer. The predictability and transparency of cost is what makes DPC appealing.

Understanding the Relationships between Premiums and Deductibles
If you are healthy, you may want to dish out as little money as possible on the monthly premiums (to keep more in your own pocket), but still have coverage in case of an accident, sudden illness, or life change. Be aware, the less you pay for that monthly premium, the higher your annual deductible. Some folks may want a low deductible, but your premium will be thousands of dollars a year.

Direct Primary Care offers these healthier people improved access to care. Just because you are assigned a doctor by your insurance doesn’t actually mean you get to see your doctor, let alone in a timely fashion. DPC does not charge more for complicated patients, or management of difficult or chronic medical conditions that require more frequent trips to see the doctor.

Co-Insurance
This is a fixed percentage of your medical bill you share with your insurance company once you have reached your deductible. As example, you have a 80/20 plan. This means if you have a doctor visit after you reached your deductible, and their fee is $150, you are on the hook for $30 while your insurance covers the rest. You still have your copayment though.

Out-of-Pocket Maximum
This feature is just as important as premiums and deductibles, and is a term for the total amount your insurance plan will require you to spend on medical care in a single year. If you reach this amount, your health insurance will cover the rest of your care. Note, you may have reached your deductible, but are below your out-of-pocket maximum, you will still be required to pay some of your health care costs.

Seeking Transparency in Health Care Costs
No wonder health insurance is so frustrating and confusing for most people. Using automobile insurance as a parallel, health insurance has done the equivalent of paying for gas, oil changes, windshield wipers, and other car repairs in addition to covering collision and liability. Using insurance would allow these things to have artificially set prices which are unreasonably high (since it’s covered by insurance). The cost of your routine maintenance would go up, and insurance could dictate what shop or gas station you could go to for service. But in reality, consumers are already motivated to do those things and will pay out of pocket to maintain their car so as to avoid needing to use their auto insurance at all.

Health insurance is suppose to be a hedge against financial disaster, but people are seemingly are using insurance to cover every ache, pain, anxiety, and pill resulting in artificially inflated prices. How can a outpatient clinic charge $600 for 1-hr procedure? Or $90 for a generic medication? Because unlike bananas, Americans and most doctors have NO idea what an one hour procedure or generic medication should cost- and ultimately how much they will be on the hook for- until they decide to get it done. For better or worse, this has created a demand for transparency among individuals. Direct Primary Care can help fill that void. Check back soon for part 2 of this blog post.

At Beyond Primary Care, we have a narrow focus- you and your family. Dr. O’Boyle is a dually board certified Family Medicine Doctor, and sees children of all ages, whether that is for the urgent needs, school physicals, check-ups, or that mysterious illness that you have questions about.

One of Dr. O’Boyle’s biggest annoyances of traditional physician offices are their limited hours and seemingly robotic answers from the on-call services. Does your child only get sick between 9 AM and 5 PM, Monday through Friday? If they do get sick during this time period, you have endless ability to take off time from your work (usually a half-day or more) to be seen at the office? Experience the on-call doctor reading the hospital script that if your child is sick you should take them to an urgent care or emergency room? Then the wait time at these locations!

At Beyond Primary Care, we will work with you to make time for convenient appointments, whether you need to be seen traditional working times or after-hours. Additionally, we because we know you so well, we offer our patients ‘virtual home visits,’ or ‘tele-medicine.’ Many illnesses can be diagnosed and treated with a simple conversation by phone or webcam. There is no corporate legalese with Dr. O’Boyle. When you enroll and call, you speak directly to Dr. O’Boyle and will get unabridged advice and care.

What are the benefits of having your family enroll in a direct primary care practice? According to this newspaper, DPC patients are 52 percent less likely to require hospitalization than patients under a traditional model. By providing the vast majority of care needed at the primary care level, a DPC doctor can allow a person to purchase the bare minimum insurance policy that is right for their family. The savings with this alone can be thousands of dollars each year.

Beyond Primary Care is hosting an open house this month and next month!

• Friday October 26th, 2018 @ Noon
  
• Friday November 2nd, 2018 @ Noon
• Friday November 9th, 2018 @ Noon

All open house events start approximately at noon. Dr. O’Boyle will discuss his clinic Beyond Primary Care, and the movement of Direct Primary Care, for approximately 10 minutes. Afterwards he will take questions from anyone. If your question is really good, it may end up on our FAQ page!

Can’t make these dates or times but still interested? Don’t worry, just contact us or call 734-395-2850. We will work with your schedule to arrange a time where you can visit the clinic and discuss your health care!

Hearing about Beyond Primary Care for the first time? Beyond Primary Care is a family medicine clinic and a part of a new way for patients to access medical care called ‘direct primary care.’ The model is membership based health care, where the patient pays a monthly fee directly to the clinic. The doctor provides the patient with primary medical care without insurance or government involvement. The patients get great access at a low, predictable cost, about the same as a cell phone or cable plan. This model allows the clinic to offer innovative services to further add value to the membership.