By Pete Shaw
“When’s the last time you had burgers and beer with your health insurance company?”
Morgan Butler, just finishing his afternoon workout at the gym, asks me that question while nursing some drink whose primary component appears to be cranberry juice. He’s not eating a hamburger, but even had he asked me when was the last time I had salads and spritzers with my health insurance company, the answer would be the same: never. Butler is the Member Services Community Organizer for the Patient/Physician Cooperative (PPC) of Portland. In insurance speak, this would be an agent.
But the PPC is not an insurance company, and Butler is not an agent. PPC is a non-profit cooperative currently set up to provide members with direct access to basic health needs. It was founded in Texas about seven years ago, and the Portland permutation has existed for 8 months, already gathering more than 120 members and over 40 providers.
“My message is simple,” says Butler. “We got cheap healthcare. You want some?”
Currently PPC of Portland offers two plans. The first, Plan A, requires a $10 one-time enrollment fee and then an $18 per month membership fee. For that, members receive a prescription drug card that can reduce costs by up to 54%, access to all providers, licensed specialists and wellness providers (practitioners who do not need a license, such a nutrition coach); patient advocacy; and doctor visits at a discounted price. Plan B offers all the benefits of Plan A and also allows members to choose their own primary care provider or providers for a monthly fee that includes a series of no-copay scheduled primary care visits for annual physical and preventative care, and management of chronic conditions. Most importantly for some, PPC will not turn away people because of pre-existing conditions.
Patient advocacy strikes me as one of the more interesting and useful aspects of the co-op. Ever get a medical bill and realize that not only do the prices seem grossly inflated, but that you don’t understand for what you are being charged? Spend some time in a hospital and the list of charges will be long and often times, mind boggling. That aspirin that costs more than the whole bottle you can buy at the drugstore? What about the enormous charge for the neck stability device more commonly known as a pillow? Call the hospital, call the insurance, get back on the phone with the hospital: it can feel the stuff of a Stephen King novel or some ancient Greek play about arrogant humans, vengeful gods, and divine retribution. Butler noted how quickly these costs diminish, or in some cases disappear– “funny how a patient could somehow not remember ever getting his stomach pumped”–by just his saying, “I’m from Patient/Physician Cooperatives of Portland and one of our members has a problem with her bill…”
Sonya Brookins is also a Member Services Community Organizer. She met Butler at a health fair and found PPC just made sense because of the breadth and scope of its mission. “It’s a total health package. People in the PPC care and want to make a difference for total health. We want to provide other options than just seeing a doctor when you are sick.”
Providers benefit as well. The logic behind PPC is similar to that of another popular program in Portland, Community Supported Agriculture (CSA). In a CSA members pay an upfront fee and in return receive a share of the farm’s produce. This approach helps farmers who know they will receive payment regardless of what Mother Nature may throw their way, and members know their farmer, where their food comes from, and how it is produced.
Likewise, when a PPC member registers for Plan B and selects a doctor, that doctor will be paid for the member’s covered visits regardless of whether the member uses her allotment. “It seems paradoxical,” said Butler, “but through our system, the provider makes more money and it’s cheaper for the patient.” Of course, it is not paradoxical at all. Health insurance companies are no different than any other corporation: they exist to maximize profits. PPC reduces clinic costs by saving doctors the costs, both in money and time, of billing and collecting from insurance companies, and in turn, for those members in Plan B, providers have a guaranteed income from the patient, currently anywhere from 33 to 77 dollars a month depending on which provider a member chooses. It’s an efficient model, but one that defines efficiency in 180 degree contrast to corporate dogma, valuing people over profit.
There is a hitch… sort of. Let’s say I am in Plan B, and I choose Doctor X as my primary provider. Doctor X costs me $40 a month, so at the end of the year, regardless of how many times I see Doctor X, I will pay $480 plus $216 in membership fees, totaling $696. However, as Brookins noted, part of the idea of the PPC is getting patients to see providers as caregivers members see on a regular basis as part of maintaining good health. “Instead of seeing a provider when you or your child is already sick, PPC encourages you to regularly see your doctor so you can take steps to lessen your chances of being sick. You can head off the problem instead of waiting to get sick. You want to see your provider the allotted number of visits; you want to nip health problems in the bud. It’s easy to do. It just makes sense.”
And that is a lot cheaper than walking in off the street. When I called a handful of the providers who work with PPC, their off-the-street with no insurance fees were between three and six times the cost to members. In the case of one $40 per month provider, that $480 would amount to two visits if not a member of PPC. On the cheaper end, with a similar $40 per month provider, it would come to 3 visits and thirty dollars in change–enough to buy you about three weeks of nifedipine to manage your high blood pressure should you not have PPC’s prescription card or any insurance covering pharmaceuticals.
Tack on knowing that you can afford to see your provider because you have already laid down the money, and as such you at the least are not as likely to let yourself get really sick before you see a provider, the saving can seem immense. After all, what price can you put on peace of mind?
This leads to what Butler describes as one of the things he finds most distasteful about insurance companies. “More than anything I’m disturbed by medical people being told by non-medical people what to do. Nobody in the co-op has that kind of influence on providers. It’s between you and and your provider.” The systemic logic is not lost on Butler: “You can’t expect a for-profit insurance company to care about your personal health.”
Most importantly, PPC allows more time for the patient-provider relationship–a personal and confidential relationship, Butler emphasized. And with the time for filling out insurance company paperwork as well as negotiating with insurance companies for payment negated, providers and patients have more time for discussing health issues, which is why their relationship exists in the first place.
But how does PPC stack up when you get sick beyond the realm of primary care? I have a close acquaintance–I’ll call her Kris–with scleroderma, a rare autoimmune disease with no cure that results in a hardening of the skin and , in her case, attacks the lungs. Other systems such as renal and digestive may also one day be affected, but, as she is nearing age 42, this seems unlikely. Nonetheless, Kris osmotizes a little less than 60% of the air she breathes, when compared with a normal person of her age, height, and weight, and that ratio is slowly diminishing. While Kris does well for someone with this disease, in the future she will likely need a lung transplant to continue living.
What can PPC do for her?
On the lung transplant, not much. But Kris has other needs. Among the major ones, she takes four different medicines daily, has pulmonary function tests once a year, and gets an echocardiogram every two years. She has seen a podiatrist about the erosion of tissue in her feet that has required orthotic inserts. Occasionally, calcinosis appears on her fingertips, causing severe pain from just a light touch.
And so on.
Kris is fortunate. She has pretty good insurance through her spouse. A few years ago, when she ruptured a lung and spent nine days in hospital, including an operation to seal the lung, her bills amounted to about $70,000. What has now become the privilege of having good insurance paid for about 85% of the costs.
Her prescriptions run about $2,000 a year, a steep cut from the $10,000 they would cost without prescription coverage. The pulmonary function tests and echocardiogram cost $4,000, but the insurance covers 75% of that. The orthotics, fully covered, were a little over $300. Specialist copays, such as for the podiatrist who prescribed the orthotics, are $45; $30 for regular office visits. The calcinosis is simply dealt with day to day with bandages and the like.
If Kris’ spouse lost her job and could not find another with health insurance, Kris would end up with the other nearly 45 million people in the United States without health insurance. No insurance company would take her on due to her preexisting condition. PPC, however, does not discriminate against people with preexisting conditions.
PPC’s prescription plan would cover 50% of Kris’ labs and about 25% of her prescriptions (PPC members pay about 50% off retail price for generic drugs and 10-20% for name-brand ones). Obviously the cost is more than Kris would pay under her spouse’s insurance, but far less than without it. And as PPC’s membership increases, it will have greater leverage in negotiating lower costs. Eventually, this will lead to negotiating lower costs with hospitals.
There is a classic trope in stories about a person who sees her doctor and talks of the problems of “a friend” in place of herself. We all know the story or the joke, depending upon the context of the scene. And the same is true here. Kris is me. I am lucky my wife has excellent health insurance, something becoming rarer every day in a country where more and more people are being forced to pay higher premiums and copays, or just flat out losing their insurance. There are people with my condition, and obviously people with far worse conditions, who do not have such good health insurance or health insurance at all. Their choices, if they can be called choices, are grim: die or go bankrupt trying to live. While the PPC model is hardly perfect–it is not single payer based upon a progressive system of taxation, insuring all are covered for all their medical costs–it is an alternative, one based on the belief that humans and their health are not commodities to be exploited for maximum profit.
PPC has set a goal of having 500 members by the end of the year. In between now and then, the co-op will be rolling out further benefits. Dental and vision will soon be available for $12 a month, and in two months, as part of Plan A, there will be 24/7 free consultation. As membership increases, the co-op will have more buying power and more access to specialists.
There is a bigger principle at work here. Why do we even live in a society, particularly in the richest country in the world, where people are not guaranteed healthcare? This question has been a hot topic the past few years, resulting in “Obamacare”, the tepid healthcare reform bill passed through Congress, signed by President Obama, and now being examined by the Supreme Court. If it is struck down, what will rise from the ashes? Medicare for All? Or will Paul Ryan’s austerity budget take the day, perhaps even getting rid of Medicare and setting healthcare reform back to the Dark Ages? And if the law is sustained, will it then become the springboard to single payer healthcare?
Despite Butler’s claim that PPC is not political, it clearly embodies an understanding of politics as the capacity to control your environment. In Portland, land of the sustainable and the home of the co-op, PPC is a snug fit. Indeed, the idea is all about creating a sustainable relationship. By breaking down the multiple barriers set up by insurance companies, PPC encourages a healthier relationship between patient and provider, one more resembling a community of those who need healthcare and those who have the expertise to provide it, instead of those who either have poor insurance or none at all and only see doctors when all other options have been exhausted; those doctors, because of the structure of our healthcare system, can do little more than see their patients as“production”, in insurance company parlance.
Butler seems a bit bemused by Occupy Portland, at least as it relates to PPC. “With so much excitement in the Occupy Movement and the Single Payer Movement, it can be easy to overlook opportunities that are available right now that could profoundly affect people and their personal health in a very fundamental way. Best of all, they don’t have to wait: they can have it now.” Portland, being a youth driven city both in its culture and activism, has presented some challenges to PPC in getting its message across. Younger people, while being aware of the inadequacies of the healthcare system, are largely young, healthy, and less likely to take practical steps in acquiring viable healthcare. However, Butler says PPC is seeing an uptick in young people becoming members, something that may be related to the Occupy Movement’s call for getting active and not being a bystander in life. Another reason may be that PPC offers alternative and naturopathic primary care providers, as well as more traditional MD primary care providers.
Tony McCormick, PPC’s Director of Information, after a lengthy discussion of bluegrass (he is a player, teacher, and aficionado) another thing I have never experienced with my insurance agent, told me, “We have an ethos of radical inclusion.” He and Butler emphasized that “being a member of a co-op is a form of activism. It’s not just about taking a personal stand for more affordable and proactive healthcare. It’s also about spreading this to others, to getting out the word. It’s hanging posters, making presentations, and doing much of the work necessary to expand the pool of members. Whether we’re saints or bastards, everybody should be hooked up with healthcare.”
For more information about the Portland Patient/Physician Cooperative, visit its webpage at http://www.ppcpdxcoop.org/ and attend the next information meeting on Wednesday April 18th at 7 PM at the Red and Black Cafe, located at 400 SE 12th Avenue.