Bill could clear the way for doctors who sign up patients by subscription
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
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Miami Herald
21 hours ago
- Miami Herald
Why Florida is missing out on $200 million a year in Medicaid funding for schools
Florida lawmakers reached a rare consensus after the deadly Parkland school shooting: More money was needed for mental health counseling at schools. 'We haven't put enough resources into mental health issues,' said then-Sen. Kathleen Passidomo, R-Naples. 'And look what happens.' Two years later, lawmakers passed a bill allowing Medicaid dollars assigned to school districts to be used for more types of care for kids, including counseling. But state officials didn't adopt the changes. And they have refused to comply with federal guidelines that would help school districts provide that care. Florida schools have missed out on about $200 million a year in Medicaid funding — a total of $2.2 billion since 2014 — to support children's mental health counseling, physical therapy and other services, advocates say. Their calls to recoup funding come as schools face multimillion-dollar shortfalls in the budget year that began July 1 — and as kids struggle with the fallout from the COVID-19 pandemic. They say the problems lie with the Florida Agency for Health Care Administration, which oversees Medicaid in the state and reports to Gov. Ron DeSantis. Documents show that for more than a decade, the agency hasn't followed federal reimbursement guidelines for school-based services — one of the few areas of Medicaid the Trump administration and Congress have not targeted for reductions. The federal program provides in-school medical care and instruction for school-age children with physical or developmental disabilities who qualify for Medicaid. About 2 million children in Florida are on Medicaid, which provides free or low-cost health care to people who qualify. Without the money, school districts have struggled to find therapists, nurses and others to treat children. Some kids experienced lower-quality care or had that care delayed during critical periods of their lives, observers say. The state agency strayed from federal guidelines in 2014, when the U.S. government changed its rules regarding the reimbursements. Experts consulted by the Times said Florida is one of the few states, and perhaps the only one, that is using the outdated payment method. The federal Center for Medicaid and Children's Health Insurance Program Services warned the agency in 2020 that it was 'not in compliance with current financing rules,' but no substantial action followed. Over that time, instead of collecting $2.2 billion from federal coffers to cover school-based expenses, the state received about $250 million. With money tight, school officials want the agency to make the necessary fixes. 'This is a significant agency failure,' said Ken Kniepmann, former state assistant deputy secretary for Medicaid Policy and Quality at the agency. He was hired in part to improve the system but said he was later instructed to stop. 'It's really unconscionable. Nobody should be OK with this.' A spokesperson for the agency said it did not have sufficient funding to update its reimbursement method until this year's legislative session, and it is committed to getting it done next year. Kniepmann said the agency had not asked the Legislature for permission to draw down the federal dollars needed to enact the changes until this year. The Hillsborough County school board held a workshop in April to address the Medicaid funding gap. Hillsborough received about $6 million in Medicaid reimbursements a year ago for the services it provided, specialist Deneen Gorassini told her board, but would have gotten about $10 million more if the state agency followed federal guidelines. It's money that could have expanded medical and mental health services in schools. Other districts experienced similar-sized gaps, according to Kniepmann's calculations. 'If we can get (the agency) to do their job and submit a (state plan amendment), we could start getting reimbursed based on our expenses, which are way more than what we are getting reimbursed now,' Gorassini told the board. Since 1997, the state has been reimbursing school districts for services — such as counseling or speech therapy — based on a flat rate. In 2014, the federal government required states to reimburse school districts based on the actual costs of those services, which is much higher. Five years ago, federal officials wrote Florida telling them it hadn't adopted the change, and the state had 90 days to comply. 'Please note that you may not pay a rate from a fee schedule and use this as a certification of cost,' Center for Medicaid and CHIP Services acting director Todd McMillion wrote Florida officials in March 2020. The center said it is working with the state to resolve the concerns listed in that letter. Florida is still paying schools a flat rate that has changed little since 1997. Karen Thomas, a Medicaid specialist for Leon County schools for more than 20 years, said that while the formulas are complex, the solution should be 'extremely simple.' 'We're 90% there, maybe 95% already, in the way we are doing things,' Thomas said of districts' processes for collecting receipts and monitoring providers' time. 'They have everything they need to be in compliance with federal payment methodology. They just need to change the invoice, one line on the invoice. ... The fault is squarely in the agency's failure to come into compliance.' The state has shown it can make the switch, Thomas said. She pointed out that when federal authorities ordered county health departments to start billing for actual costs instead of flat rates in 2020, the state quickly shifted. She noted that school-based services are 'a very niche portion' of the state's Medicaid budget — somewhere in the neighborhood of 1% — and that over time agency officials have paid less attention to them, decreasing communication with school districts and reducing staff dedicated to the service. The issue shouldn't be a side note, as it affects the lives of some of Florida's neediest children, she said. And the pandemic made kids' mental health a national crisis. 'Kids used to miss school because of asthma,' Thomas said. 'Now they're missing school because of anxiety and depression.' After the 2018 Parkland attack, state lawmakers wanted to make sure students were getting proper mental health assistance in schools. In 2020, they passed legislation allowing schools to use Medicaid dollars for other types of care. DeSantis signed it into law. But his Agency for Health Care Administration never rewrote the agency's rules to allow school districts to use the new law. 'The law was very clear,' said retired Sen. Bill Montford, D-Tallahassee, who sponsored the 2020 bill. 'Why they didn't do it I don't know.' Rep. Christine Hunchofsky, a Democrat who represents Parkland in the House, repeatedly has asked agency officials if the state is doing all it can to leverage federal money for student services. The issue comes up frequently on the Commission on Mental Health and Substance Use Disorder, to which Hunchofsky was appointed by the Republican House speaker. She said the agency has provided few clear answers. Meanwhile, she's heard plenty from the school districts, and said she plans to pursue the questions further. Montford, also executive director of the state's superintendents association, said agency officials have told his group that they are preparing a rule revision to go into effect in mid-2026. That's when states are supposed to comply with an updated 2023 federal guidance on school-based services. But Kniepmann, who worked as associate director for health at the Florida Conference for Catholic Bishops before moving to the health agency, argued the state is stalling for reasons that remain unclear to him. He said the 2023 guidance was not intended to be a way for Florida to further delay implementing rules put in place more than a decade ago. Every holdup, he and others said, means less money available to pay for medical and related services. 'Eleven years and $2.2 billion is not a little thing,' he said. Hillsborough district officials, also leery of the state's ability to pull off a new rule by mid-2026, said they are looking into a different approach to bring in more Medicaid money. Gorassini told the board that her department would conduct a rate study for each service it provides and submit the updated amounts to the state for inclusion on the existing reimbursement schedule. Kniepmann said it's a long-shot effort that requires a lot of work at the district level, adding that the agency has discouraged such an approach. It's worth a shot, though, Gorassini told the Hillsborough school board. 'We'll never get what we spend,' she said. 'But in the meantime we're going to try to maximize our reimbursement.' What's really at stake is student health, said Thomas, the Leon County Medicaid specialist who also serves on the National Alliance for Medicaid in Education leadership team. Her district stands to reap about $2 million more per year if the change is made. 'That is the difference between being able to hire actual medical professionals who have the ability to recognize actual medical issues, and purchase medical equipment, actual things that could help the children that are most medically needy in this county,' she said. 'When I can't afford to pay for a nurse, all kids suffer.'
San Francisco Chronicle
a day ago
- San Francisco Chronicle
David Nabarro, British physician who led UN response to Ebola and COVID-19, dies
GENEVA (AP) — Dr. David Nabarro, a British physician who led the U.N. response to some of the biggest health crises in recent years, including bird flu, Ebola and the coronavirus pandemic, has died. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, confirmed Nabarro's death on social media platform X. 'David was a great champion of global health and health equity, and a wise, generous mentor to countless individuals,' Tedros wrote Saturday. 'His work touched and impacted so many lives across the world.' King Charles knighted Nabarro in 2023 for his contributions to global health after he served as one of six special envoys to the WHO on COVID-19. He won the 2018 World Food Prize for his work on health and hunger issues. He also was a candidate for the top job at the WHO in 2017 but lost out to Tedros in the final round of voting. Nabarro left the U.N. later that year. The 4SD Foundation, a social enterprise in Switzerland focused on mentoring the next generation of leaders in global sustainable development, said its strategic director died at his home Friday in a 'sudden passing.' Other details were not immediately available. 'David's generosity and unwavering commitment to improve the lives of others will be sorely missed,' the foundation wrote on its website Saturday.
Hamilton Spectator
a day ago
- Hamilton Spectator
David Nabarro, British physician who led UN response to Ebola and COVID-19, dies
GENEVA (AP) — Dr. David Nabarro, a British physician who led the U.N. response to some of the biggest health crises in recent years, including bird flu, Ebola and the coronavirus pandemic, has died. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, confirmed Nabarro's death on social media platform X. 'David was a great champion of global health and health equity, and a wise, generous mentor to countless individuals,' Tedros wrote Saturday. 'His work touched and impacted so many lives across the world.' King Charles knighted Nabarro in 2023 for his contributions to global health after he served as one of six special envoys to the WHO on COVID-19. He won the 2018 World Food Prize for his work on health and hunger issues. He also was a candidate for the top job at the WHO in 2017 but lost out to Tedros in the final round of voting. Nabarro left the U.N. later that year. The 4SD Foundation, a social enterprise in Switzerland focused on mentoring the next generation of leaders in global sustainable development, said its strategic director died at his home Friday in a 'sudden passing.' Other details were not immediately available. 'David's generosity and unwavering commitment to improve the lives of others will be sorely missed,' the foundation wrote on its website Saturday. Survivors include his wife, Flo, as well as his five children and seven grandchildren.
