Primary care, simplified
Dr. Ben Aiken founded Lantern Health in Asheville in May 2018 as a “small, independent practice trying to have a big impact.” It was a pilot project of Mission Health, which wanted to study direct primary care,” a medical option that cuts some of the traditional relationships between doctors, hospital systems and insurers.
Mission Health, which was still then locally controlled, “felt that primary care was dying a slow death. They were, as most hospital systems are, losing money on primary care and fee-for-service settings so they rely on downstream referrals to their hospital for specialty care and services to cover the loss on the primary care practice itself.
“And, physicians were burned out and frustrated, and their patient satisfaction was increasingly average at best.”
The majority of hospital revenue is linked to inpatient overnight stays, surgeries and specialty fees. But direct care programs typically charge a monthly fee and don’t require insurance or the need to file a claim for an office visit. Employers offer such programs as an option to provide coverage for employees’ basic doctor visits, with an insurance company connection for major medical circumstances.
“Most DPC clinics operate ‘outside’ of the health plan. That is to say that employees are provided traditional health insurance but then ‘opt-in’ to a DPC provider,” says Jordan Harris, an employee benefits consultant with Main Street Insurance Group, a benefits advisor with offices in Charlotte, Chapel Hill, Forest City and Tryon. “The employer pays an extra fee for those that opted in hopes that this DPC relationship will help keep them out of the hospital, out of the ER, away from unnecessary specialists and limit the amount of unnecessary services. Patient panels are much smaller and allow doctors to spend much more time with patients, truly understanding what is going on.”
When Nashville-based HCA Healthcare bought Mission Health in 2019, “They were intrigued,” Aiken says, “but it [Lantern] isn’t very hospital-focused, so they just weren’t interested. They said ‘you’re not breaking even yet, and the pilot is interesting, but we’ll close you down.’”
Aiken, 39, bought the practice in February 2020. “We didn’t lose anyone on our team, and we didn’t lose any patients,” he says. “We just said we’ll buy it and try to see the vision through.”
Lantern charges a monthly fee that’s $60 to $100 depending on age, and $50 per dependent child 17 and younger. There also are prenatal and pregnancy rates.
Aiken says it can cost about $50,000 to nearly $300,000 to launch a direct care practice. He paid for the equipment and the space and renamed his office Lantern Health to “create a new brand.”
Direct primary care operations remain very rare in North Carolina with only about 20 practices in the state, mostly in Asheville, Charlotte and the Outer Banks. Most have a couple of doctors and they typically limit their practices to 400 to 600 patients so visits can be longer and more focused. The national DPC Coalition reports an office visit averages about 40 minutes, whereas traditional primary care visits average 13 to 16 minutes.
“Since most DPCs are independent, they are all different from each other in one way or another,
says Christy Gupton, president of Morganton-based Custom Benefits Solutions. “Their practices are filling up fast. Many that I know of are looking to add more doctors to fill their increasing demand.”
She notes that about 85% of health care needs can be handled in primary care.
Aiken thinks the long-term outlook for direct care is strong. “People are looking for something different in health care, and DPCs are one of the things that continue to surprise people, because it makes so much sense,” he says. “Employers are increasingly looking at paying health benefits differently and are increasingly thinking about primary care and insurance plans. Like, let’s just have a [name brand] plan for the unexpected and let’s pay a DPC so our employees get high-level care, longer appointment times and built-in telemedicine.”
Companies with more than 50 employees are required to provide health coverage as part of the Affordable Care Act. Smaller businesses often add health care as a benefit, also.
Primary practices owned by hospitals, Gupton says, “are like a fox guarding the henhouse.”
“Let’s say a child hurts his knee and goes to the [hospital-employed] primary doctor,” she says. “That’s an automatic referral to an orthopedic specialist. They actually have quotas to meet, and if they refer out-of-system, they [the physician] will be penalized. So you see this practice with beautiful granite countertops and it’s pleasing to the eye, but behind the scenes is where the problem is. They’ve gotten into the big insurance abyss where they’re encouraged to see more patients in smaller windows of time.”
Small businesses are proving to be more willing to try direct care than larger businesses, Gupton says. “I always hope that big companies see the value in DPC, [however] most don’t because they can’t break away from their big BUCA Plan.” (BUCA is industry slang for giant insurers BlueCross, United Healthcare, Cigna and Aetna.)
Harris believes hospitals are putting a greater emphasis on building primary care practices. but mainly as a referral source for the rest of the health system. Primary care is such a small portion of hospital revenue so I don’t think DPC practices have that big of an impact on what hospitals do. Gnat on an elephant.”
More doctors are showing interest in direct care, Gupton says, partly because of concerns that more of their work is being performed by nurse practitioners or physician assistants.
For Aiken, “We look for any opportunity to tell the story about what we’re doing. The concept of a Lantern is leading people through darkness, and we wanted to illuminate them from the past into something different.”