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Several health care professionals and one patient urged lawmakers Wednesday morning to support a measure authorizing direct patient care agreements in Montana, reviving a debate that has surfaced in the Legislature at least twice in the past.

Sen. Cary Smith, R-Billings, introduced Senate Bill 101 to members of the Senate Business, Labor and Economic Affairs Committee, stating that the legislation would help strengthen relationships between health care providers and their patients and give Montanans access to another option for affordable health care.

“One of the really, really high costs of health care is insurance, and one of the things that adds a lot of bureaucracy and complexity to having a relationship between a physician and a patient is government regulation, state regulation,” Smith said. “This bill makes it clear that in this type of arrangement, you don’t have that problem.”

Under a direct primary care agreement, patients pay directly to their provider a regular fee that covers an established list of services, including routine office visits and basic health interventions and procedures. Such agreements are already legal in Montana, and eight separate clinics now offer direct primary care (DPC) services. SB 101 would establish specific requirements for those agreements and officially put into law an advisory memo issued by former State Auditor Matt Rosendale in 2017 that DPC agreements are not considered insurance and are therefore not regulated by the state.

Smith noted that under the provisions of SB 101, DPC agreements could be adopted by a wide range of health care providers, including dentists and chiropractors. Patients would not be allowed to use insurance to cover DPC payments.

Similar bills passed through the Legislature in 2015 and 2017. However, both were vetoed by then-Gov. Steve Bullock, who stated that direct primary care agreements “offer little or no added value to most consumers” as they cover services that are already paid for by insurance policies. Gov. Greg Gianforte has not said if he supports SB 101.

Several physicians who are already operating DPC clinics spoke in favor of the bill. Todd Bergland from Fountainhead Family Med in Whitefish told lawmakers that he moved to the DPC model after a decade in private practice to escape the limitations of the modern insurance-dominated system. The administrative demands are “discouraging or even infuriating,” Bergland said, distracting professionals from focusing on one-on-one patient relationships. The stories he heard about patients struggling to pay for health care only added to his frustration.

“I heard the following statement several times from patients,” Bergland recalled. “‘You know, doc, I’m paying more for my health insurance premiums than I am for my mortgage and I still have a $5,000 dedcutible. I’m going to be paying out of pocket for this test, so do I really need it?’”

At Fountainhead Family Med, Bergland continued, he’s able to take as much time with patients as he feels necessary, and those patients know exactly how much they’ll be paying for the visit. His patients pay a monthly membership fee of $70. According to a 2018 study by the American Academy of Family Physicians, 65% of adults receiving care at DPC clinics paid between $50 and $75 per month for that care.

Paula Sweeney, a DPC patient from the Flathead Valley, said the DPC model has made her physician far more accessible and approachable. If it ever became necessary, Sweeney said, she’s confident that she would even receive a housecall.

“There are no bean-counters or insurance companies telling her what she can and can’t do or what we can and can’t talk about or what care I can and can’t receive,” Sweeney said. “It’s consensual, it’s contractual. There’s just no interference by any outside entity.”

Two conservative policy organizations also testified in support of SB 101. Henry Kriegel with Americans for Prosperity testified that encouraging direct primary care in Montana would give physicians the power to be more “entrepreneurial.” Frontier Institute President and CEO Kendall Cotton said DPC agreements would reduce government regulation and limit the presence of third parties in certain health care situations. 

Representatives of three separate insurance groups spoke in opposition to Smith’s bill. Speaking on behalf of the Mountain Health COOP, Bruce Spencer countered proponents’ claims that insurance-based health care detracts from doctor-patient relationships. His personal experience has been the opposite, he said, and he regularly communicates with his primary care physician with no issues. 

John Doran with Blue Cross Blue Shield clarified that his organization would support the bill if an amendment is added to bar physicians from charging insurers for services a patient has already paid for directly. Even with that change, Doran cautioned that DPC raises a number of concerns. Patients relying on DPC agreements could still require high-cost services not covered by those agreements, such as emergency transportation by an air ambulance.

“If this is not considered insurance, which it is not, and it should not be, anyone who has the direct payment agreements but does not have a health insurance policy to back it up is going to shoulder those enormous air ambulance costs all on their own,” Doran said. “We’re talking $50,000 and above. That’s medical bankruptcy.”

Lawmakers continued to debate this point, questioning what types of insurance policies might cover unpredictable high-cost services such as air ambulances or cancer treatments without duplicating the services covered by DPC agreements. Doran informed them that polices do exist to specifically cover catastrophic health care events.

The committee is expected to vote on SB 101 tomorrow or next Tuesday.

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Staff reporter Alex Sakariassen covers the education beat and the state Legislature for Montana Free Press. Alex spent the past decade writing long-form narrative stories that spotlight the people, the politics, and the wilds of Montana. A North Dakota native, he splits his free time between Missoula’s ski slopes and the quiet trout water of the Rocky Mountain Front. Contact Alex by email at asakariassen@montanafreepress.org.