Entrance to Senate Chambers in the Wisconsin State Capitol. (Photo by Baylor Spears/Wisconsin Examiner)

The state Senate Health Committee cleared three bills Thursday, two of them on bipartisan votes, advancing them to the full Senate for consideration.

SB 4 allows direct primary care doctors, who charge patients on a monthly subscription, to practice without being regulated as part of the insurance industry. 

The bill passed 3-2, with the Senate committee’s two Democrats, Sens. Jeff Smith and Dora Drake, voting against recommending it for passage.

Drake said she voted against the measure because it lacked non-discrimination language that had been included in a previous version of the bill.

The bill from the 2023-24 legislative session included a non-discrimination section listing a series of civil-rights protections for patients. One of those items, forbidding discrimination on the basis of “gender identity,” led two organizations, Wisconsin Family Action and the Wisconsin Catholic Conference, to oppose the legislation.

Although the legislation passed the Assembly on a voice vote in 2024 and was unanimously endorsed by both the Assembly and Senate health committees, it died after the state Senate failed to take it up.

The current bill states that direct primary care providers “may not decline to enter into or terminate a direct primary care agreement with a patient solely because of the patient’s health status.”

It has replaced language enumerating specific civil rights protections with a more general stipulation that it “shall not be construed to limit the application” of Wisconsin’s civil rights statute to a health care provider’s practice. The civil rights law bars discrimination based on race, sex and sexual orientation, but is silent on gender identity.

“As Chair of the Legislative Black Caucus, I refuse to support a new version of a bill that doesn’t provide protections for Wisconsinites that prevents discrimination from healthcare providers,” Drake told the Wisconsin Examiner via email.

The committee voted unanimously Thursday to recommend the other two bills.

SB 23 would make it possible for women who are covered by Medicaid in childbirth to maintain that coverage for a full year after the child is born. The postpartum Medicaid legislation has broad bipartisan support, but Assembly Speaker Robin Vos (R-Rochester) has opposed extending the coverage, claiming it would expand “welfare.”

SB 14 requires health care providers to obtain a patient’s consent when they teach medical students how to do pelvic exams by having them practice on women under anesthesia. Authors of the bill and advocates have reported that some providers have a history of training students on the procedure with unconscious patients who have not been informed or given consent.

The committee also added a requirement that hospitals institute written policies for informed consent relating to pelvic exams under anesthesia. The amendment replaces language requiring an administrative rule implementing the requirement.

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Dr. Wendy Molaska of Fitchburg testifies on Feb. 12 in support of legislation to clarify that doctors charging patients under a monthly subscription program are not in the insurance business. (Screenshot/WisEye)

Dr. Wendy Molaska is a Wisconsin family practice doctor, but her patients don’t use their health insurance — if they have it — when under her care.

Instead, Molaska’s patients have a subscription for her services, paying $70 a month. They go to Molaska’s office when they feel sick, need a checkup, or have some other routine medical concern. She’ll see them as often as they need, she says — no extra charge.

Molaska is a direct primary care practitioner. Direct primary care, DPC for short, is prepaid outpatient health care. While both the doctors who practice it and their patients are just a drop in the health care ocean, their numbers are growing.

In back-to-back meetings last week, the health committees in both the Assembly and the Senate considered legislation to make it legally explicit that the subscription programs used by DPC doctors are not insurance plans and don’t have to be regulated like insurance.

The identical bills, AB-8 and SB-4, spell out some definitions, along with rights and standards, for direct primary care agreements and state that they are exempt from insurance law. More than half of states in the U.S. have similar laws. 

The concept won bipartisan support in the 2023-24 session of the Legislature but failed to make it to the governor’s desk.

“In insurance, you risk-share,” said Dr. Nicole Hemkes, owner of a group of direct primary care clinics, Advocate MD, testifying at the Assembly hearing Wednesday. “You’re paying a bunch of money into a [pool] and then the insurance is paying out on claims.”

Direct primary care is “basically a transactional relationship where you’re paying a monthly membership,” Hemkes said.

‘Old school medicine’

“This is the old school medicine of being able to actually take care of your patients the way they need to be taken care of,” Molaska told the Assembly Committee on Health, Aging and Long-Term Care.

She testified that neither she nor patients have to deal with the question of what insurance covers and what it doesn’t. The $70 monthly fee covers a broad range of in-office procedures and visits as frequent as a patient requires, she said.

Prescriptions, which she can dispense, and lab tests are extra, but Molaska said in an interview that they are often much less expensive when paid for out of pocket rather than as part of an insurance plan.

Molaska said there are about 100 direct primary care providers in Wisconsin, a number that has grown markedly starting in the first years of the COVID-19 pandemic. If each provider has 500 patients, a typical DPC caseload, that would mean 50,000 Wisconsin people have joined the trend from the patient side.

In an interview, Molaska said that removing the uncertainty over whether regulators would try to apply the state’s insurance law to their operation could help motivate more doctors to provide direct primary care.

DPC practitioners say their approach is both cost-effective and patient-friendly.

Hemkes said patients with high-deductible health insurance plans might forgo a routine visit to the doctor to avoid an out-of-pocket expense they can’t afford.

“We are not trying to replace insurance,” Hemkes told Assembly members. Direct primary care “[is] meant to make health care more accessible to more people.”

Access to care without insurance

Some people opt for DPC as an alternative to a more expensive, comprehensive health plan, however. Molaska testified that in the Madison suburb of Fitchburg, where she practices, “the number of people without health insurance is 7.4%. At my clinic, 41.3% don’t have other health insurance.”

Many low-wage service workers have employers who don’t cover health care, and their own incomes are too high for Medicaid but not high enough for them to buy their own insurance, Molaska told the Wisconsin Examiner. With a direct primary care subscription, “at least they’re able to access primary care,” she said.

For specialty care and hospitalization, patients are still likely to need health insurance or alternative forms of coverage of some kind. Nevertheless, Molaska said, her fixed fee covers as many non-specialist visits to her office as a patient might need to make, as well as being able to call or text for consultation.

Molaska said the system has allowed her to limit the number of patients to about 500 people, in contrast to conventional medical groups where a single doctor’s caseload can be two, three or even four times that many.

Molaska said she calculated her monthly fee based on what existing DPC doctors were charging, the size that she chose for her caseload and her overhead costs and staff: two nurses, a certified medical interpreter and an office assistant. With direct care she doesn’t have to hire someone for coding insurance claims or billing for visits, she observed.

Longer visits, shorter waits

Some patients have health insurance that covers primary care, but choose a DPC provider instead, paying the monthly fee themselves — valuing the short wait time to get in and the longer and less-hurried visits, Molaska said.

Evan Danells, a Madison chef and restaurant owner who also testified at the Assembly hearing, told lawmakers that many restaurant operators have profit margins too small to allow them to buy insurance for employees. Direct primary care made it possible for him to cover his employees for basic health care, he said.

Danells is one of Molaska’s patients. He said her much smaller caseload allowed for more personal care rather than rushed appointments with a doctor who would “look at me like they’re seeing me for the first time over and over again . . .  because they just had 2,500 patients last year.”

Hemkes said direct primary care doctors aim to make their services broadly affordable — not like medical practitioners who provide “concierge medicine,” charging wealthy patients five-figure sums for special access.

Another misconception, Hemkes said, is that direct primary care “selects out healthy patients.”

The legislation guards against that possibility with a provision stating the direct primary care providers “may not decline to enter into or terminate a direct primary care agreement with a patient solely because of the patient’s health status.”

At Advocate MD, which has three clinics in the greater Madison area and one in Janesville, “our patients in our practice run the spectrum from young, healthy people to older people with multiple chronic medical issues,” Hemkes testified. “Having an hour-long visit with that patient is very useful to be able to provide comprehensive care to them, to help them navigate all their specialists.”

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