When Eli Hall was in his thirties, he had a kidney stone that needed surgery. Despite having medical insurance, his out-of-pocket costs for the procedure came to $4,000.
Mira promises that most routine visits will cost around $99 or slightly above.
Hall, an Arizona-based small business owner soon discovered that such costs were proving to be the norm. As a result, he stopped buying insurance altogether. Now he pays in to a subscription-based model of healthcare where $300 per month will get him, his wife, and two children unlimited access (either over the phone or through in-office visits) to doctors in the Redirect Health network. This subscription also meets the Affordable Care Act insurance mandate.
Hall's move away from the traditional insurance care model might have been deliberate, but not everyone is as lucky. In 2018, the Centers for Disease Control and Prevention reported that 30.1 million people under the age of 65 were uninsured in the United States. Now, a new startup called TalktoMira is helping those without insurance access doctors for routine visits — affordably.
The service, accessed through the website (or phone or text), evaluates a user's symptoms and returns recommendations for specific doctors that factor in wait times, traffic conditions, and pricing. Khang T. Vuong, the founder and CEO, expects that doctors will be willing to provide discounts through this model, as they're eliminating the administrative costs associated with the insurance middleman. Some discounts can be as high as 50 percent, according to the website.
Mira promises that most routine visits will cost around $99 or slightly above. "This provides people who can't afford paying $3,000 to $4,000 per year in insurance premiums an alternative to access basic healthcare," Vuong says.
As of press time, Mira is available in the Washington D.C., Northern Virginia, and Dallas, and will soon expand across the country via a partnership with a national network of healthcare providers.
"For those who live in places where we don't have a presence, users can still search for the nearest and least busy urgent cares. The goal is to build a national database of walk-in clinics with straightforward upfront pricing so the 30 million uninsured and 56 million underinsured have access to same or next day primary care at an upfront affordable cost," Vuong says.
Getting Around Traditional Insurance
Mira caters to the uninsured by helping them navigate the healthcare system the moment they need it. "Currently cash patients have to rely mainly on Google for searching for options," Vuong says, adding that patients do also occasionally work with the app ZocDoc for booking. "However [ZocDoc] info has no pricing information; we fill in that much-needed gap," Vuong says. In focus groups TalktoMira conducted, a majority (70 percent) reported cost of service as their main barrier to healthcare.
As Hall's subscription-based model proves, cash-driven access like TalktoMira is not the only option for the uninsured. Direct primary care like the kind that Redirect Health delivers is another way to get around high premiums. It does so by effectively eliminating the administrative costs associated with the middleman, says David Slepak, the director of business development at Redirect. Doctors who are tired of packed schedules and the administrative headaches involved with the insurance model are only too happy to be a part of subscription or cash-based models, explains Vuong.
But TalktoMira and direct primary care models don't resolve the challenges of insurance related to catastrophic events.
James Corbett, Principal at Initium Health, points out the uninsured can also access federally qualified health centers across the country or a free clinic, but these might have problems of long wait times.
"Not a Cure-All"
TalktoMira might not provide the same level of consistency that seeing a primary care doctor does, though Vuong says there are ways to see the same doctor again by choosing them through the system. He adds that TalkToMira also empowers patients by asking them about their satisfaction after the visit and to see if any further checkups might be warranted, thus enabling patients to rate their doctors just like they would any other service provider.
"I might not have one primary care doctor, but I have the entire system behind me," says Hall.
But TalktoMira and direct primary care models don't resolve the challenges of insurance related to catastrophic events. The subscription model won't kick in if the patient has a heart attack and needs to be hospitalized, for example. So patients are also encouraged to purchase a high-deductible, low-premium plan for such contingencies.
"We're spending so much on insurance for the car that we can't afford the gas to drive the car."
Vuong recognizes TalktoMira doesn't solve all the problems related to insurance, but it can at least start by helping to facilitate access to routine visits. Even the insured don't always seek out a doctor because of copays and high deductibles, Slepak says. "We're spending so much on insurance for the car that we can't afford the gas to drive the car," he says.
TalktoMira is hoping that by making routine care accessible, it might both lessen the crunch in emergency rooms where many people don't really belong, and also nip problems in the bud.
"It's not a cure-all, not a panacea," admits Vuong. "It won't get you a knee replacement. But at least I can get you in the system so you might not have to get to that point."
The Friday Five covers five stories in research that you may have missed this week. There are plenty of controversies and troubling ethical issues in science – and we get into many of them in our online magazine – but this news roundup focuses on scientific creativity and progress to give you a therapeutic dose of inspiration headed into the weekend.
Here are the promising studies covered in this week's Friday Five:
- Research on a "smart" bandage for wounds
- A breakthrough in fighting inflammation
- The pros and cons of a new drug for Alzheimer's
- Benefits of the Mediterranean diet - with a twist
- How to recycle a plastic that was un-recyclable
Sexually transmitted infections (STIs) are surging across the U.S. to 2.5 million cases in 2021 according to preliminary data from the CDC. A new prevention and treatment strategy now in clinical trials may provide a way to get a handle on them.
It's easy to overlook the soaring rates of gonorrhea, chlamydia, and syphilis because most of those infections have few or no symptoms and can be identified only through testing. But left untreated, they can lead to serious damage to nerves and tissue, resulting in infertility, blindness, and dementia. Infants developing in utero are particularly vulnerable.
Covid-19 played havoc with regular medical treatment and preventive care for many health problems, including STIs. After formal lockdowns ended, many people gradually became more socially engaged, with increases in sexual activity, and may have prioritized these activities over getting back in touch with their doctors.
A second blow to controlling STIs is that family planning clinics are closing left and right because of the Dobbs decision and legislation in many states that curtailed access to an abortion. Discussion has focused on abortion, but those same clinics also play a vital role in the diagnosis and treatment of STIs.
Routine public health is the neglected stepchild of medicine. It is called upon in times of crisis but as that crisis resolves, funding dries up. Labs have atrophied and personnel have been redirected to Covid, “so access to routine screening for STIs has been decimated,” says Jennifer Mahn, director of sexual and clinical health with the National Coalition of STD Directors.
A preview of what we likely are facing comes from Iowa. In 2017, the state legislature restricted funding to family health clinics in four counties, which closed their doors. A year later the statewide rate of gonorrhea skyrocketed from 83 to 153.7 cases per 100,000 people. “Iowa counties with clinic closures had a significantly larger increase,” according to a study published in JAMA. That scenario likely is playing out in countless other regions where access to sexual health care is shrinking; it will be many months before we have the data to know for sure.
A decades-old antibiotic finds a new purpose
Using drugs to protect against HIV, either as post exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP), has proven to be quite successful. Researchers wondered if the same approach might be applied to other STIs. They focused on doxycycline, or doxy for short. One of the most commonly prescribed antibiotics in the U.S., it’s a member of the tetracycline family that has been on the market since 1967. It is so safe that it’s used to treat acne.
Two small studies using doxy suggested that it could work to prevent STIs. A handful of clinical trials by different researchers and funding sources set out to generate the additional evidence needed to prove their hypothesis and change the standard of care.
Senior researcher Victor Omollo, with the Kenya Medical Research Institute, noted, “These are prevention interventions that women can control on their own without having to seek or get consent from another person,” as is the case with condom use.
The first with results is the DoxyPEP study, conducted at two sexual health clinics in San Francisco and Seattle. It drew from a mix of transgender women and men who have sex with men, who had at least one diagnosed STI over the last year. The researchers divided the participants into two groups: one with people who were already HIV-positive and engaged in care, while the other group consisted of people who were on PrEP to prevent infection with HIV. For the active part of the study, a subset of the participants received doxy, and the rest of the participants did not.
The researchers intentionally chose to do the study in a population at the highest risk of having STIs, who were very health oriented, and “who were getting screened every three months or so as part of their PrEP program or their HIV care program,” says Connie Celum, a senior researcher at the University of Washington on the study.
Each member of the active group was given a supply of doxy and asked to take two pills within 72 hours of having sex where a condom was not used. The study was supposed to run for two years but, in May, it stopped halfway through, when a safety monitoring board looked at the data and recommended that it would be unethical to continue depriving the control group of the drug’s benefits.
Celum presented these preliminary results from the DoxyPEP study in July at the International AIDS Conference in Montreal. “We saw about a 56 percent reduction in gonorrhea, about 80 percent reduction in chlamydia and syphilis, so very significant reductions, and this is on a per quarter basis,” she told a later webinar.
In Kenya, another study is following a group of cisgender women who are taking the same two-pill regimen to prevent HIV, and the data from this research should become available in 2023. Senior researcher Victor Omollo, with the Kenya Medical Research Institute, noted that “these are prevention interventions that women can control on their own without having to seek or get consent from another person,” as is the case with condom use, another effective prevention tool.
Antibiotic resistance is a potentially big concern. About 25 percent of gonorrhea strains circulating in the U.S. are resistant to the tetracycline class of drugs, including doxy; rates are higher elsewhere. But resistance often is a matter of degree and can be overcome with a larger or longer dose of the drug, or perhaps with a switch to another drug or a two-drug combination.
Research has shown that an established bacterial infection is more difficult to treat because it is part of a biofilm, which can leave only a small portion or perhaps none of the cell surface exposed to a drug. But a new infection, even one where the bacteria is resistant to a drug, might still be vulnerable to that drug if it's used before the bacterial biofilm can be established. Preliminary data suggests that may be the case with doxyPEP and drug resistant gonorrhea; some but not all new drug resistant infections might be thwarted if they’re treated early enough.
“There are some tradeoffs” to these interventions, Celum says, and people may disagree on the cost of increased resistance balanced against the benefits of treating the STIs and reducing their spread within the community.
Resistance does not seem to be an issue yet for chlamydia and syphilis even though doxy has been a recommended treatment for decades, but a remaining question is whether broader use of doxy will directly worsen antibiotic resistance in gonorrhea, or promote it in other STIs. And how will it affect the gut microbiome?
In addition, Celum notes that we need to understand whether doxy will generate mutations in other bacteria that might contribute to drug resistance for gonorrhea, chlamydia or syphilis. The studies underway aim to provide data to answer these questions.
“There are some tradeoffs” to these interventions, Celum says, and people may disagree on the cost of increased resistance balanced against the benefits of treating the STIs and reducing their spread within the community. That might affect doctors' willingness to prescribe the drug.
Turning research into action
The CDC makes policy recommendations for prevention services such as taking doxy, requiring some and leaving others optional. Celum says the CDC will be reviewing information from her trial at a meeting in December, but probably will wait until that study is published before making recommendations, likely in 2023. The San Francisco Department of Public Health issued its own guidance on October 20th and anecdotally, some doctors around the country are beginning to issue prescriptions for doxy to select patients.
About half of new STIs occur in young people ages 15 to 24, a group that is least likely to regularly see a doctor. And sexual health remains a great taboo for many people who don't want such information on their health record for prying parents, employers or neighbors to find out.
“People will go out of their way and travel extensive distances just to avoid that,” says Mahn, the National Coalition director. “People identify locations where they feel safe, where they feel welcome, where they don't feel judged,” Mahn explains, such as community and family planning clinics. They understand those issues and have fees that vary depending on a person’s ability to pay.
Given that these clinics already are understaffed and underfunded, they will be hard pressed to expand services covering the labor intensive testing and monitoring of a doxyPEP regimen. Sexual health clinics don't even have a separate line item in the federal budget for health. That is something the National Association of STI Directors is pushing for in D.C.
DoxyPEP isn't a panacea, and it isn't for everyone. “We really want to try to reach that population who is most likely going to have an STI in the next year,” says Celum, “Because that's where you are going to have the biggest impact.”