New model: Insurers hire the doctors

Leaders of a new east-side Des Moines clinic say they can help patients stay healthy while saving money for the insurance company that owns the place.

The CareMore clinic is the most extensive Iowa example of a new health care model: Health insurance companies that pay medical bills also employ the doctors, nurses and other professionals who provide the care.

The clinic, which is on East Euclid Avenue, is part of a controversial shift in Iowa’s Medicaid program. The state last year hired three national companies to run the $4 billion program, which insures more than 500,000 poor or disabled Iowans. The clinic is owned by the corporate parent of one of those three companies, Amerigroup.

Skeptics worry the arrangement could lead the medical staff to skimp on treatment to save Amerigroup money.

Clinic leaders say the fear is unfounded. They say the operation focuses on patients who otherwise would not regularly visit a clinic, and who are likely to have chronic health problems that could lead to expensive hospitalizations. “Our patients are difficult to get engaged with, to get in the door, but once they come in here, they love us,” said Ethel Condon, an internal medicine physician who leads the staff. “It’s about preventing those problems that could cause catastrophes five or seven years from now.”

The clinic opened April 1 in a commercial area northeast of Grand View University, near some of central Iowa’s poorest neighborhoods. Its neighbors include a Goodyear tire shop and a B-Bop’s hamburger stand. The building used to house a clinic run by UnityPoint, one of the Des Moines area’s two dominant hospital and clinic systems.

The new clinic has served about 400 patients, all of whom are Medicaid recipients who receive coverage through Amerigroup. One of them is Robert Bruns of Colfax, whom clinic leaders hold up as a success story.

Bruns said in an interview that he has no problem with the fact that his new clinic is owned by a health insurance company. All he knows is the clinic’s staff saved his life.

Bruns, 62, rarely went to see a doctor. But he’d been feeling weak and achy for months, so when he learned in April that he had been assigned to a new clinic on Des Moines’ east side, he went right in. The staff spent about three hours with him, asking extensive questions and taking all kinds of tests.

“I never had a checkup like that in my life,” he recalled

The next day, which was a Saturday, his nurse practitioner went into her computer to call up test results from the day before. She noticed right away that Bruns had extremely low levels of blood platelets, cells that help stop bleeding. The tests suggested he was suffering from leukemia, a cancer that destroys bone marrow. He needed to get to a hospital immediately.

The nurse practitioner called the patient’s home. Bruns’ grandson, who answered the phone, said his grandfather was fishing at the local quarry and didn’t have a cell phone. The worried nurse practitioner called police, who sent an officer to the quarry to try to find Bruns. The officer eventually got word to him to call the clinic. Bruns' wife got him in the car, and took off for Mercy Medical Center in Des Moines.

Mercy doctors confirmed he had leukemia. They started him on three weeks of chemotherapy but couldn’t guarantee he’d survive. The cancer is now in remission.

“I feel better than I have in two years. I’m doing great,” Bruns said.

Bruns also has diabetes and has suffered two heart attacks. CareMore clinic leaders say they’re focusing on patients like him. Staff members call Amerigroup members whose records indicate they rarely have seen health care providers in the past. If need be, the staff will go knock on potential patients' doors and arrange rides to the clinic.

Condon worked more than 20 years in traditional health care settings, including several in Des Moines, before taking the CareMore job. She said she appreciates the company’s commitment to helping patients manage chronic health problems, such as diabetes, heart failure, high blood pressure and chronic obstructive pulmonary disease.

“If you don’t do that, you cycle into reacting to every health care crisis a person has,” she said.

Some patients come several times per week for guidance on how to manage their conditions, Condon said. The clinic’s features include an on-site lab, so patients can often be told of their test results before their appointments are over. The facility is open evenings and Saturdays, and it is located near a city bus line. The operation also has on-site mental health professionals, including therapists every day and a psychiatrist once a week.

The CareMore clinic isn’t the only Des Moines area agency focused on Medicaid patients. Leaders of two others, Broadlawns Medical Center and Primary Health Care, expressed reservations about the newcomer.

Kelly Huntsman, Primary Health Care’s executive director, said she initially was concerned about the idea of an insurance company owning a clinic. However, she said, the CareMore staff has been good about communicating with existing health care agencies.

“Do we feel a new clinic was necessary? Probably not,” she said. “But we’re working together to serve this population.”

Broadlawns, which is a public hospital, is building a new east-side clinic on East University Avenue, about 3 miles from the CareMore site. Spokeswoman Katie Wengert expressed wariness about CareMore.

“We've never experienced a situation where a payer also owns and provides care in a clinic or health care setting, so obviously we have some measure of hesitation, as this is a  group of patients that we've always provided high-quality care for in a very cost-effective manner,” she wrote in an email to the Register. “That being said, CareMore has stated to us that their main priority is to simply help us handle the influx of new patients eligible to receive services due to Medicaid expansion. As we expand our physician provider network, we'd expect they would begin to direct those patients toward the Broadlawns physician network.”

Psychiatrist David Drake worked part time at the CareMore clinic until late July. Drake said he initially was skeptical of the idea of an insurance company owning a clinic. “I wondered, ‘Does that mean they’re going to try to limit care?’” he said.

Drake said the clinic leaders convinced him they had good motives. “They want people to come in. They want to engage people,” he said.

Drake said he left the clinic position because his version of psychiatric practice didn’t fit well with their set-up. But he supports the overall operation. He also noted that all patients are free to use other care providers that accept Amerigroup’s brand of Medicaid. “People have a choice,” he said.

Unlike developers of new hospitals and nursing homes, organizers of new clinics are not required to prove to state regulators that the facilities are needed.

An Amerigroup spokeswoman said the company hasn’t decided whether to set up other such clinics in Iowa. However, she noted that in most other states where the company is active, it has opened just one clinic.

The two other Medicaid managed-care companies operating in Iowa plan less extensive versions of the idea.

Amerihealth Caritas plans to open “community wellness centers” in Des Moines, Cedar Rapids and Sioux City. “The centers will provide new member orientations, care management and provider relations services, assistance with doctor appointment scheduling, and education programs that will help Iowans learn how to manage their health and access local resources,” spokesman Joshua Brett wrote in an email. He said the centers’ staff would not offer direct health care.

UnitedHealthcare is using an in-home health care service called TeamMD. The company says the service combines primary care services with case management. It is being used by more than 900 Iowans "that cannot access traditional clinic-based care due to complications related to aging, disability, or chronic disease."