Direct primary care opens new path for physicians
By Karen Garloch
After 20 years as a primary-care physician, Kathy Weeks was flat-out tired of the pressure to see more than 25 patients a day and then spend hours filling out medical charts and insurance paperwork. So, she jumped off the “hamster wheel” of traditional medicine in 2015 and started a new practice last year that allows her to spend more time with patients.
At Blue Skies Family Medicine in Mooresville, about 30 miles north of Charlotte, Weeks no longer accepts health insurance or pays a staff to file claims. Instead, she charges a membership fee of $60 a month, or $699 a year, that includes unlimited doctor visits, same-day appointments, routine tests and discount rates on more complex tests. Patients may contact Weeks any time by phone, text or email. “It’s not a paper mill,” says Terry Ellis, a patient from Lincolnton. “We have a different kind of doctor-patient relationship.”
Weeks is one of a small but growing number of U.S. doctors adopting a business model called direct primary care. By eliminating haggling with claims adjusters and filing reports, such physicians are able to lower overhead, see fewer patients and can earn as much as peers in traditional practices.
While concierge medicine typically targets affluent patients who pay $2,000 a month or more for easier access to doctors, direct care is a blue-collar version with fees averaging $75 a month. “It’s the Honda model,” Weeks says. “We’re for the masses.”
Direct primary care has grown from 146 doctors in the United States in 2005 to more than 8,000 today, says Brian Forrest of Apex, who started his practice in 2001. In North Carolina, he says, more than 30 doctors work in direct-primary-care offices, from small towns such as Cherryville to larger cities like Charlotte. They are a fraction of the state’s 12,000 primary-care physicians.
Initially, Weeks thought most of her patients would be uninsured, although direct-primary-care patients still need insurance to cover hospitalizations and other costly services (as well as meet the Affordable Care Act’s requirement). Instead, most have high-deductible plans with lower premiums. While some people might balk at paying for both a membership and insurance, Terry Ellis says it’s a good deal.
Ellis, 63, is a self-employed health coach who has diabetes, high blood pressure and high cholesterol, chronic conditions that require her to visit her doctor eight to 10 times a year. She pays $388 a month for a $5,000-deductible insurance plan. She says it’s worth paying more for the personalized care from Weeks and her practice coordinator, Dani White.
“I get 30 to 45 minutes with them, and they answer questions in a way that I can understand,” Ellis says. “They know me. You don’t get that with a regular doctor because they don’t have time.”
Critics of direct primary care warn that the new model could exacerbate doctor shortages because physicians see fewer patients. It could also prompt doctors to cherry-pick the healthier and wealthier. But that hasn’t been the case with doctors interviewed by Katherine Restrepo, director of health care policy for the Raleigh-based John Locke Foundation. In many cases, “It’s really people with low to middle incomes who are using this model, and they love it,” she says. “A lot of these patients haven’t seen a provider in years.”
Logistical hurdles remain, too — the IRS prohibits patients from using health savings accounts or Medicare savings accounts to pay for direct primary care though bills to lift that prohibition have been introduced in Congress. It’s also unclear what would happen to direct primary care under the various reforms proposed to replace the ACA.
But politicians — and many doctors — like the model. The American Academy of Family Physicians has endorsed direct care. Supporters say the model will prevent doctor burnout and allow physicians to spend more time with patients.
Office visits in Forrest’s Apex practice average 35 minutes — more than four times longer than the average visit in a typical practice — and patients spent 85% less out of pocket, according to N.C. State University researchers. Forrest previously worked in a Winston-Salem practice where he was frustrated that some uninsured patients didn’t get enough help and physicians were always rushed. “I was seeing 30 patients a day and spent 70% of my time on things that didn’t involve patient care.”
Forrest says he can break even financially by seeing only four patients a day, though he typically sees 10 or 12. “I schedule one patient per hour. That leaves me about 15 minutes in every hour to take care of a walk-in with an acute complaint.”
Not taking insurance eliminated the need for four full-time staffers, saving about $200,000 annually. “I haven’t taken a single cent from an insurance company in 16 years.” Forrest charges $49 a month for unlimited visits, with no co-pays. Routine lab tests and office procedures, such as stitches, aren’t billed. “We’ve negotiated rates with lab companies that are incredibly low,” he says. “The last time I heard what one insurer was paying for a lipid panel (cholesterol test), it was $76. … I don’t even charge for a lipid panel.” For a more expensive test, such as a blood test for hepatitis, Forrest charges his actual cost, which can be as much as six times less than in traditional offices.
Direct primary care can also save money for employers, Restrepo says. In 2015, Union County became the first N.C. employer to offer direct primary care as an option to employees for the same price as a traditional fee-for-service insurance plan. The plan requires employees to receive their primary care at a Monroe clinic operated by Denver-based Paladina Health, which administers similar practices in 50 U.S. offices. Participants in the direct-care plan don’t have to meet the $750 per person deductible required by the traditional model. “It’s like giving the employee a pay raise,” says Mark Watson, the county’s director of human resources.
If employees in the direct care plan are referred to specialists or admitted to the hospital, their benefits switch to the same 80/20 cost-sharing formula that applies to employees in the traditional plan. The county’s insurance plan pays 80% — and employees pay 20% — of the cost of a service, up to the maximum out-of-pocket cost. After that, the plan pays 100%.
Because employees see the doctor as often as they like, medical problems are addressed before they become emergencies, Watson says. In the first year direct primary care was offered, the county spent $260 less per month on medical claims for employees and dependents in the new plan. Patients at the Paladina clinic spent 42% less out of pocket for prescriptions.
Working at the Paladina clinic is a “breath of fresh air” after practicing in a traditional Monroe office for 19 years, says William Martin, one of two doctors at the site. “I constantly felt pressured for the next appointment that was waiting for me,” he says. “If I took the time to do what I thought was right, I would end up paying for it and apologizing for being late for the rest of the day.”
One of Martin’s patients is Mitch Foard, 55, a sergeant in the county sheriff’s office. Martin once arranged for Foard to see a radiologist for a scan. After the test, Foard says he hadn’t even finished getting dressed when Martin called him with the results. He’d been conditioned to wait days or weeks. “You can’t put a price tag on that.”
Photo of Kathy Weeks at Blue Skies Family Medicine in Mooresville, taken by Hannah Sharpe