New Montana laws enshrine health care alternatives, for better or worse

When Paul Rana's primary care physician left the VA clinic in Kalispell to open her own practice, he followed her. But instead of picking up a new health insurance policy, Rana and his partner agreed to pay a monthly fee that came with the promise of better access.

Their provider, Dr. Lexi Tabor-Manaker, opened Glacier Direct Primary Care clinic in 2018. The model known as DPC, which can also stand for direct patient care, furnishes basic health care to patients for a set fee, often billed monthly like a subscription. The arrangement offers patients unlimited access to their doctors and allows them to communicate by phone or email. But the costs are all out-of-pocket.

"We have been pleased to be able to communicate with her instantly without going through an administrative gauntlet," as he might with the Department of Veterans Affairs, Rana said.

Direct primary care practices have been emerging around the country, but they are often criticized for not offering the patient safeguards of traditional insurance. State legislators this year, however, sought to preserve the approach and passed two new laws that prohibit direct primary care practices or health care sharing ministries — religious or ethical groups whose members pool money to cover medical costs — from being regulated as insurance.

Such arrangements, according to supporters, afford greater flexibility and lower costs for health care compared with traditional health insurance. Without these laws, "a future commissioner of insurance may deem them to be insurance and require them to come under the health insurance regulatory scheme, thus destroying their value and defining characteristics," said Sen. Tom McGillvray, R-Billings, sponsor of the bill on health care sharing ministries.

Lack of regulation comes with risks. Patients in direct primary care and health care sharing ministries mostly miss out on consumer protections mandated by the Affordable Care Act, such as coverage of preexisting conditions and prohibitions against charging more based on gender.

Some health care sharing ministries have developed into large nationwide organizations, such as Medi-Share and Trinity HealthShare. Critics of that model say the unregulated ministries aren't required to cap out-of-pocket costs or pay claims and can refuse coverage for certain treatments. They can also have annual and lifetime benefit caps.

In Montana, a pastor filed a lawsuit in 2007 after Medi-Share refused to pay for expenses for a member's heart condition. A state judge ruled the group was selling insurance without registering in the state, effectively banning health care sharing ministries. That changed in 2017 when Matthew Rosendale, then insurance commissioner, declared the programs weren't health insurance and could operate in the state.

McGillvray's bill cements Rosendale's ruling into state law.

Eight direct primary care facilities operate in Montana with out-of-pocket fees that typically range from $70 to $120 per month for an adult, according to DPC Frontier.

Supporters of direct primary care said the model lets doctors spend more time with patients. Physicians told lawmakers that when working with traditional insurance plans they might spend a significant chunk of their days on administrative tasks instead of patient care, according to Sen. Cary Smith (R-Billings), sponsor of the direct primary care bill.

That bill allows for any form of health care practice — therapists, dentists, physical therapists, etc. — to operate under the direct primary care model.

Direct primary care agreements don't cover hospital visits, prescription drugs, surgery or specialized care, such as cancer treatment. Providers and supporters recommend people sign up for health insurance to cover those costs.

Another criticism, one leveled by traditional health insurers, is that the monthly fee often doesn't save people money. Patients would have to go to the doctor several times a year to make the direct primary care monthly payments worthwhile, and people usually don't make that many visits, said Richard Miltenberger, CEO of Mountain Health Co-Op, a nonprofit health insurance cooperative that sells health insurance in Montana, Idaho and Wyoming.

"So, it's actually often, for many consumers, more cost-effective to just pay for the service [that isn't covered by insurance] when you utilize it, as you utilize it, as opposed to paying a monthly membership fee," Miltenberger said.

Rana, a retired Army veteran who lives in Woods Bay, doesn't fully depend on direct primary care for his health care. He still uses the VA clinic for regular checkups. He also has Medicare and Tricare — a health program for military members and their families — for larger procedures he gets outside of the VA, such as when he had knee surgery in 2020.

But his first stop when he noticed something wrong with his knee was with Tabor-Manaker, who saw him quickly and referred him to a specialist. That makes the expense worth it, he said.

"I knew going in that this was all out-of-pocket for me, and I accepted that because the quality of service is far greater in its value to me than the hundred bucks a month," Rana said.