Dr. Todd Johnson of Lincoln is a modern-day pioneer, starting the first membership-based, insurance-free medical practice in Nebraska.
Access Family Medicine opened in mid-July and provides what is called direct primary care.
His patients pay a monthly membership fee for an old-fashioned relationship with their family doctor -- undiluted by insurance rules and paperwork.
Many of his patients have insurance, but Johnson does not do the paperwork or collect payments from insurance companies.
That gives him the freedom to focus on his clients, he said.
So patients get a minimum 30-minute office visit rather than the seven to 15 minutes primary care doctors often allocate per patient. They get access to the doctor, any day of the week, even when he's at home.
On a recent Sunday, Johnson got an email from a dad who discovered his kids needed physicals for sports -- soon. Johnson was able to schedule an appointment for a few days later.
Clients can often get same-day or next-day appointments, annual physical exams at no extra cost, wholesale costs for some diagnostic and in-house procedures and some common prescription drugs at very low prices.
And Johnson can do what he believes is best for his clients.
Several weeks ago, a patient with a history of blood clots called his home, worried about pain and swelling in his legs.
Johnson quickly ordered imaging studies, although the client wasn’t due for his annual tests. And the doctor met with him a few hours after those were finished. The client was fine, no blood clots.
“I knew his history. Doing the tests sounded like a reasonable thing to do,” he said.
Johnson gave up his practice at Autumn Ridge Family Medicine to start one that's free from all the rules and paperwork that go with health insurance.
“Ninety-nine percent of other doctors said, ‘I don’t blame you,'" he said. “One hundred percent said, 'You are crazy.'”
But Johnson, a doctor of osteopathic medicine, gave up the financial security of a bigger practice for a chance to have the kind of relationship with patients that he believes allows for the best care.
By focusing on that, he said, he is doing what he knows is right.
Generally, 40 percent of a physician’s overhead costs are insurance-related, which pushes doctors see more patients to help cover these costs.
But Johnson said he can spend 35 or 40 minutes with his patients without the nagging thought in the back of his mind that he’s losing money. Patients can get all of their questions answered in one visit and not have to schedule more, he said.
Johnson learned about the model while working on the quality committee for a larger health system. The committee explored questions like how to provide better care and increase efficiency.
Last summer, he went to a conference on membership-based, insurance-free health care in Kansas City.
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“It floored me. I couldn’t believe how much sense it made.”
He started digging and looking for the problems.
The biggest hurdle was getting affordable access to immunizations for children, but he’s found a pharmacy willing to work with him.
Otherwise, he said, he discovered very few flaws, while the flaws of the insurance-dominated system are many.
There is pressure to increase patient numbers. Too often, doctors see patients all day, then spend another three to four hours doing paperwork, leading to physician burnout, Johnson said.
The shift of focus from patient to documentation is chipping away at the sanctity of the doctor-patient relationship and disrupting the care patients get, he said.
Direct primary care is a growing trend that is making its way to the Midwest, said Dr. Bob Rauner, Lancaster County Medical Society board member.
It's an interesting way to try things out and see how they work, and it could become part of a future health care system, he said.
It offers a lot more freedom and one way of getting around the byzantine rules of the billing system, Rauner said, and it could lead to a happier practice for all involved.
Some doctors get retainer fees, on top of accepting insurance, primarily to give wealthier patients better access, longer appointments and more personal care. This is often called concierge medicine.
That’s not what Johnson is doing. Direct primary care doesn’t take insurance and offers that personalized care to everyone.
A few doctors in Nebraska don’t accept insurance, but are fee-based -- patients pay for specific services.
Johnson's is the only membership-based, insurance-free practice in the state. Like many direct primary care practices his fees are age-based -- $50 a month for younger adults, $75 for middle-aged adults and $100 for seniors.
There are no co-pays, no deductibles and unlimited consultations and office visits at Access Family Medicine, said Johnson.
Insurance itself isn’t bad, said Johnson. About 99 percent of his clients have it.
He can help them navigate the insurance world to try to take advantage of deductibles and health savings accounts.
The most economical model for his clients are high-deductible plans.
The very best model for direct primary care is a wraparound insurance plan, where a company offers catastrophic health coverage but the insured person finds his or her own primary care.
These plans can work for small businesses under the Affordable Care Act, Johnson said.
High-deductible plans can also fit in with his kind of practice.
And some patients keep traditional insurance and use his membership-based care because they value that kind of relationship with a doctor, Johnson said.