LA CONNER — Throughout her time as an intensive care unit nurse in Seattle, La Conner resident Brianna Wilson said she was struck by the lack of access patients had to primary care.
“Most people just wouldn’t go to their primary care doctor regularly, so by the time I saw them they were too sick,” Wilson said.
Hoping to help meet this need, Wilson left her work as an ICU nurse to become a family nurse practitioner.
But with back-to-back 15-minute appointment slots and prohibitive costs for patients, Wilson said she felt the traditional health care system prevented her from providing top-quality care and developing trusted relationships with patients.
“Our health care system is just so out of sorts,” Wilson said. “It’s just drowning people, and they can’t get out because they need it.”
Now, she’s hoping to sidestep the system by opening a direct primary care clinic, Thrive Healthcare, in La Conner.
Direct primary care is a membership-based model that Wilson said increases the affordability of care, the time clinicians can spend with patients and the quality of care. Insurance is not billed for services.
While the clinic won’t have a physician, Washington is one of 17 states where nurse practitioners such as Wilson are legally allowed to prescribe medications, diagnose and treat illnesses and administer physical exams without physician oversight.
In 2017, there were 40 direct primary clinics in Washington, according to a report by the state insurance commissioner. Thrive Healthcare will be the only direct primary care clinic north of Mukilteo, according to the report.
Nurse practitioners have a master’s degree or a doctorate rather than medical degrees, according to the American Association of Nurse Practitioners.
“In Washington state we are lucky to have no restrictions as a nurse practitioner in prescribing or owning a practice,” Wilson said in an email. “I also do not have to work under a physician as physician assistants do.”
Wilson’s clinic runs on monthly membership fees — $25 to $80. Her services can be paired with a lower-cost form of insurance to cover major medical issues.
“If you can make your premium less expensive for your family by having a high-deductible catastrophic plan as your cushion, then paired with this you can get all your primary care needs ... as a part of your membership,” Wilson said.
In this model, Wilson said she works for the patient, rather than the insurance companies.
“I no longer work for your insurance company, so I have your best interests in mind,” she said.
Wilson said she will offer same-day and next-day scheduling, unlimited clinic visits, house calls, after-hours calls and 24/7 digital consultations. All in-clinic diagnostics and procedures are included in the monthly membership fees as well as annual labs such as standard blood count and cholesterol.
However, patients will still want some level of insurance because the clinic can’t provide services such as specialized lab work and inpatient care, though Wilson has arrangements with specialists to get some discounts for her patients.
Wilson said her clinic is designed to work in tandem with a high-deductible plan.
“Membership does not replace the need for catastrophic insurance plans for the unplanned life events leading to surgeries, hospitalizations and serious medical diseases with expensive treatment,” Wilson said on her website.
According to the Washington Academy of Family Physicians, the availability and accessibility provided by direct primary care clinicians translates into better clinical outcomes — including reductions in the number of ER visits, the length of inpatient hospital stays, the number of specialist visits and the use of advanced radiology (such as MRI, CT and PET scans).
When clinicians aren’t constrained by the standard 15-minute appointments of traditional health care, Wilson said the quality of care increases.
Thrive Healthcare also accepts Medicare patients. Although Wilson can’t bill insurance, she said patients with standard insurance plans such as Medicaid and state insurance could potentially save money with a membership.
Dr. Philip Eskew, a state and federal adviser for direct primary care legislation, said Washington was the second state to adopt laws permitting the model in 2007.
The state Legislature describes direct primary care as “an innovative, affordable option which could improve access to medical care, reduce the number of people who now lack such access, and cut down on emergency room use for primary care purposes.”
Eskew said the direct primary care model can be a good option for for low-income patients.
“Any patient that cares about the cost of care will benefit from (direct primary care). This could be a wealthy patient with a high deductible plan, an uninsured patient, an (undocumented) immigrant, or a Medicare patient that cannot get any other physician in town to see them for more than five minutes in an assembly line operation,” Eskew said in an email.
Wilson’s membership fees are based on age, with a non-member walk-in fee of $50 or a televisit for $30. She offers discounts for veterans, college students and others.
For a patient between age 46 and 65, the $60 monthly membership fee works out to $720 per year.
In her business plan, Wilson cites a 2010 study by the American Journal of Managed Care that demonstrated decreases in preventable hospital visits for patients utilizing direct primary care, resulting in savings of $2,551 per person (the majority of them Medicare patients) in 2010.
Eskew said one argument against the direct primary care model is that it diverts primary care clinicians away from traditional health care facilities.
If the direct primary care model were to become popular in the United States, Eskew said demand for primary care clinicians may briefly raise the price for primary care, but the market would soon balance out.
Bob Perna, director of health care economics and practice support at the Washington State Medical Association, said the association doesn’t oppose nurse practitioners opening their own practices as long as they operate within the scope of their license.
“We certainly look at the comparison of expertise in physicians and the length and breadth of their experience (in comparison to nurse practitioners),” Perna said. “But it’s nothing we directly oppose.”
Patients should be aware that nurse practitioners have different training than physicians, said Jane Orient, executive director of the Association of American Physicians and Surgeons.
“It’s really up to the patient,” Orient said. “The thing is for a patient to educate himself and to be aware of the training on which he’s relying.”
Wilson said she plans to focus on the overall health of her patients, not just treating symptoms.
“The patient success is going to come down to how hard they work on it, not just me.” Wilson said. “I give them the tools and the information and help them help themselves because in order to be healthy, you have to be in charge of your own health.”