Program closes gap in members’ health coverage

Aiming to fill a critical gap in its members’ health care coverage, Health Access RI is now offering them short-term, high-deductible catastrophic health insurance from Assurant Health/John Alden, sold through the local office of broker USI.
Created by Dr. Michael Fine, the now-retired leader of Hillside Family and Community Medicine, and now offered by 10 primary care practices in the state, Access is a program that allows uninsured or underinsured people to become members of a practice, for a monthly fee, and get the same access to primary care that they would get if they were insured.
At Hillside, for example, which has offices in Pawtucket and Scituate, members pay an $80 enrollment fee, then $30 per month and can see a doctor for $10 – whether it’s a short visit, or an annual checkup. Hillside also offers weekend and evening hours and 24/7 phone access.
The idea is that most people’s medical needs can be covered entirely, or almost entirely, by primary care doctors. And by keeping third parties out of the equation, Access can actually be profitable for the doctors, because they get their money directly from the patients.
The program began in late 2007, and since then, it has grown to close to 600 members, said Kimberly A. McHale, executive director of the Rhode Island Academy of Family Physicians, which runs Access. Many members stay in the program long term, she said, while others leave when they get insurance, or if they have financial difficulties.
But while Access makes primary care affordable and accessible, it can’t cover all of its members’ needs, by a long shot. Some things are at least partly taken care of: Through partnerships with local providers, Access members can get imaging and lab work at steeply discounted rates – what Medicare pays. There’s also a deal for home care.
Should a person end up in the hospital, however, Access would be of no help, its leaders acknowledge, and that’s where the new offering comes in.
“What people worry about when they worry about their health is first, having somebody to take care of them, and then the cost,” Fine said. By offering catastrophic insurance Access is “just responding to what people were telling us. … They are looking for something to give them an extra sense of security.”
Pairing primary care access with catastrophic insurance is not a new idea for Fine. In his 2007 book, “The Nature of Health: How America Lost, and Can Regain, a Basic Human Value,” Fine argued for taking primary care out of the insurance system and replacing it with a new model in which people would have a “medical home” in their community that would meet most of their needs, and that would be paid for by patients or the community itself.
In Scituate, where he lives, Fine has actually tested the latter concept; a town program ensures that every resident has access to primary care.
But the second piece, providing for people’s more costly medical needs through high-deductible health insurance, is not really feasible in Rhode Island because low-cost major-medical insurance isn’t available. Even very high-deductible plans here offer comprehensive coverage after the deductible is met, and the premiums reflect that.
The Assurant/John Alden plans are available for six-month or 12-month terms, with rates that are much closer to Fine’s target of $100 per month. For a 35-year-old woman, for example, a six-month plan with a $1,000 deductible and 20 percent coinsurance would cost $118.81 per month; a $2,500 deductible would bring premiums down to $83.87.
The plans have major limitations, however, which the Access Web site warns about: They pay only the “usual and customary” cost of many expenses, so if you go to a facility that charges above-average fees, you will get stuck with the difference. People who have had cancer, diabetes, heart disease or HIV/AIDS may be denied. Pre-existing conditions aren’t covered. These are all limitations that Rhode Island doesn’t allow with standard health insurance, which is part of why there’s such a big price difference.
But given the low cost of Access, and the large and growing number of uninsured Rhode Islanders – more than 119,000 as of 2005, before the recession, according to state figures – why hasn’t the program enrolled thousands of people already?
“Most of us, when we think about health care, are used to thinking about our insurance card, and if we don’t have an insurance card, we think we don’t have health care,” Fine said.
Access has also been growing mostly on word of mouth, lacking the resources to advertise, Fine noted. By comparison, when Tufts Health Plan entered the market last year, it launched a major ad campaign – “and they’re selling something that people recognize.” &#8226