A couple of years ago, Orange Cab driver Jagjit Singh, who lacked medical insurance, flew to his home country of India for a hernia operation, for which he paid $300 rather than the $16,000 he would have been charged in the U.S. Recently, Singh joined Qliance, a new boutique medical practice in downtown Seattle set to open on July 23. In fact, he says, so did roughly half of Orange Cab's drivers after hearing Qliance's pitch at the company's offices one day.
Singh is not your typical patient of a boutique medical practice; he earns about $50 or $60 a day—far less than the CEOs and other wealthy types who tend to pay the monthly, out-of-pocket fees that boutique (or concierge) practices charge for on-demand access to their doctors. That's because Qliance is not your typical boutique service. Indeed, it doesn't even like that term, which it says smacks of elitism.
Rather, Qliance's target demographic is the working poor and uninsured. It does not accept insurance, instead charging between $39 and $74 a month for an individual, depending on age. (The older you are, the more you pay.) That fee covers most of what encompasses primary care, including office visits, phone consultations, common X-rays, and some procedures and lab tests. Other tests, including those for cholesterol, diabetes, and blood count, will be offered at close to cost, for $7 to $17.50 each.
Qliance's monthly fees are a fraction of those charged by upscale boutique practices. For instance, MD², a Bellevue-based boutique practice that opened 11 years ago as the country's first, charges an average of $1,250 a month.
"I think this kind of care should be available to a substantial population of America," says Dr. Garrison Bliss, the guiding force behind Qliance. Ten years ago, Bliss helped convert his practice, Seattle Medical Associates, to a relatively affordable version of the boutique model, charging $95 a month. But he felt that wasn't low enough. He also wanted to create a larger practice from scratch that could be expanded. Hence, Qliance plans to quickly open a second practice in the suburbs south of Seattle, where many working poor live, and then expand throughout the state and possibly throughout the country.
"We're using Washington state to prove how effective this model can be," says Norm Wu, the company's CEO.
"Our purpose," adds Bliss, "is to reinvent the way medical care is practiced." He believes medicine has become a frustrating, joyless affair for both doctors and patients, who are squeezed by insurance companies into harried 15-minute visits. By getting insurance out of the picture, he contends, doctors can make more money, while at the same time serving patients better.
Critics, however, warn that Bliss is promising something he can't deliver. "I would urge a high degree of skepticism on this," says Stephen Tarnoff, associate medical director of Group Health Cooperative.
Bliss and Wu are seated in a small Qliance conference room, attempting to answer the question of how their practice will be able to offer rates that are so much lower than the average boutique firm. "It's magic," says Bliss, a wiry 57-year-old with a playful look in his eyes.
Wu, a genial, gray-haired businessman who has worked for a variety of high-tech companies, then sets out to explain the economics of the venture. For starters, he says, there's the saved expense of eliminating insurance from the picture, as doctors typically have to pay several staffers to handle the complex paperwork required by insurance companies. Secondly, Wu says, the clinic will be open seven days a week, 12 hours a day, from Monday through Friday. That should mean more visits—and thus more revenue per week—than the average doctor's office.
Qliance also counts among its providers not only doctors but nurse assistants and practitioners, who make less money than physicians. Each of an eventual four nurse assistants or practitioners is paired with a physician in a team that will be responsible for 1,400 patients. That's a lighter load than the typical primary care doctor, they say, who, because of increased productivity demands, is expected to carry 2,500 to 3,000 patients. Because Qliance providers have fewer patients, they can spend more time with each of them, booking 30-minute visits instead of 15, and offering same or next-day appointments.
Still, Qliance's practitioners will have far more patients that those of MD², whose doctors cater to just 50 families each. And Qliance won't offer the kind of perks, like house calls, 24/7 access, and hand-holding at the office of specialists, that MD² and other high-end boutique firms do.
"If you ask patients what they want, they don't necessarily want a silver tea set in the front room," Bliss says. "They want to get hold of providers when they need one; they want to be seen when they're sick."
But to Group Health's Tarnoff, Qliance represents more of a threat than other boutique firms because it has scaled back perks that are typical of higher-end outfits. It is nothing more, he believes, than a "basic primary care" service, but one for which patients have to pay out of pocket. "People who are going to get this are going to have to pay twice," predicts Tarnoff, once for their monthly primary care fee and once for the insurance they will still need for specialist visits and catastrophic care. If this model catches on, he says, many insurance companies might eventually stop covering primary care altogether.
In fact, Qliance's founders say they would welcome such a change. They compare primary care insurance to car insurance that would cover such routine work as an oil change. State Insurance Commissioner Mike Kreidler, among others, disagrees. "If we see a scenario in which primary care is abandoned by health insurers, then we would start to have second thoughts about what this is doing to the whole system," says Kreidler. "There are a lot of uncertainties as to what the effect of this is."
A few years ago, Kreidler cast doubt on the operation of boutique practices by telling them they were acting as insurance companies—by accepting prepaid money in exchange for medical services—without following regulations required of such companies. Yet a bill he supported, which passed this past legislative session, allows "direct patient-provider primary care practices" to run free of regulations on insurance companies. But the new law also imposes some safeguards. One that is crucial: Such practices cannot turn someone away on the basis of their health.
Group Health's Tarnoff contends nonetheless that low-cost boutique practices can only be financially viable if they shun certain patients. "They'll never say we're kicking you out because you're sick," says Tarnoff. "They'll say [we're] kicking you out because we don't have the expertise to take care of you."
"Word would get out very quickly that we're not taking care of people," counters Erika Bliss, a Qliance doctor who is a cousin of Garrison Bliss. "It would damage our reputation."
Qliance has started seeing patients on a trial basis, prior to its official launch later this month. After a physical exam on a recent day, Susan Lockwood explains that she found out about the service through the support organization Artist Trust. Lockwood, a willowy 44-year-old with long brown hair, is a painter who had previously paid out of pocket for medical services, often using naturopaths and other alternative medical providers, which wouldn't have been covered by many insurance plans anyway.
About four years ago, though, Lockwood developed cancer. With the help of hospital payment plans, she managed to pay the fees completely out of pocket. But she then wanted a plan that would offer her regular checkups with allopathic doctors; she found Qliance's fees "reasonable," and was particularly pleased with the team approach, which allows her to see the same personnel each time she comes. "It reminded me of the health care I had as a kid," she says.
Lockwood is now trying to sort out what she will do for specialist and catastrophic care. Qliance is currently suggesting a high-deductible plan offered through Blue Cross called LifeWise, whose rates range from about $50 to $350 a month, a fee that Lockwood expects to be able to afford.
But those fees are beyond the reach of Singh, who says he can only afford about $20 a month on top of his Qliance monthly fee. Says his fellow Orange cabbie Muler Ahmed, who's in similar straits, "For now, I am happy to see the basic doctor. At least you have some doctor you can talk to."
Ahmed says his doctor spent two hours with him at his recent physical, and was the first to ever talk him out of smoking. The doctor also found a problem with Ahmed's heart, for which she recommended seeing a cardiologist. Ahmed says he knows that's expensive, but that Qliance is trying to find someone who will charge less than the normal rate.
Ryan Allison wouldn't have that problem. He's an entrepreneur who owns a couple of hotels in Sun Valley, Idaho, and has just started a wine bar called Cellar 46 on Mercer Island, where he lives. He has full health insurance through his wife, who is a physician at the University of Washington, but still signed up with Qliance. An avid cyclist, he has periodic injuries related to the sport that require doctor visits. "I wanted immediate health care," he says.
"I've never been so close to a doctor," says Allison, who plans on offering it to his full-time employees at the wine bar, in addition to a higher-deductible insurance plan. While he currently offers no insurance to his hourly paid waitstaff, he is also thinking about covering half the cost of Qliance for them.
Allison's health care costs will go up a little, but in an industry where frequent turnover can put a strain on service and revenue, he's confident he'll save money in the end. "If turnover goes down just 1 percent," he says, "it will pay for itself."