Considering a direct care practice

In my last article, I asked readers to perform a thought experiment about office flow. Instead of moving patients through an elaborate maze of handlers, imagine that you, the physician, collect the patient from the waiting room and walk them to the exam room, where you take your own history and measure vital signs. Since more direct, hands-on care has been shown to improve both patient and physician satisfaction, I argued that this relatively simple change to patient flow could revitalize your practice.

A quick refresher on why: while practice management experts insist that the solution to physician burnout is increasing reliance on ‘the healthcare team,’ the truth is that much of the work done by ‘the team’ is redundant and creates a bottleneck in patient flow. Since every chain is only as strong as its weakest link, large and poorly functioning teams increase the risk of medical error for which the physician ultimately holds responsibility. Having more staff members increases overhead costs, and with challenges in staffing everywhere in the time of ‘the great resignation,’ finding qualified team members has become increasingly difficult.

Despite the logic of returning to a physician-patient-centric model of care, convincing a corporate entity to reject the assembly line model may prove impossible. If this is the case in your organization, perhaps it is time to consider an alternate practice model that will allow you to reprioritize the physician-patient relationship: direct care.

What is direct care?

Direct care, called direct primary care (DPC) when offered by primary care physicians, is a model of health care that eliminates third-party payers—insurance companies or government payers like Medicare. Instead of submitting insurance claims, patients pay their doctor directly for services, usually by a monthly membership or on a fee-for-service basis. There are more than 1600 DPC practices across the country, and the model is endorsed by the American Association of Family Physicians, which offers annual conferences related to the practice. Increasingly, physician specialists are also electing to provide direct care to patients.

Direct care is not the same as concierge care. Most direct practices charge a flat monthly fee for all services and do not bill patients separately for office visits. In contrast, concierge practices generally require a periodic fee for access to the practice and non-covered services, but also bill the patient or insurer for office visits. DPC practices tend to be much less expensive than concierge care, with an average monthly fee of $77 compared to $183 for concierge memberships. Compared to a traditional family medicine patient panel of 2,300 patients, DPC practices average about 600 patients, while concierge practices often have smaller patient panels.

How do patients benefit from direct care?

Sixty percent of patients wait two weeks for an appointment with their primary care physician, and only 10 percent can see their doctor on the same day. This wait time often leads patients to feel anxious, worried, and frustrated.Once at the office, the average patient waits twenty minutes for a 10–15-minute office visit, another source of frustration. Many patients report difficulty contacting their physician’s office, including complicated telephone triage systems and confusing portals.
Because of smaller patient panels, most direct care practices offer same or next-day appointments with minimal waiting. Patients see the same physician for all visits which are usually scheduled for 30-60 minutes. Many direct care practices offer multiple ways to access the office, including email, text, telemedicine, and video consults. Some also provide home and facility visits.

Patients without health insurance or with high deductible plans benefit from low, transparent pricing. Many direct care doctors also provide low-cost wholesale medications through in-house dispensing at prices even lower than Mark Cuban’s Cost Plus Drug startup, as well as client-billed labs at rates up to 95% less than traditional rates.

How do doctors benefit from direct care?

According to studies, it would take 21.7 hours per day for a primary care physician to provide all recommended acute, chronic, and preventive care for a traditional patient panel of 2,500 patients. With physicians being set up for failure, is there any wonder that doctors are reporting high job dissatisfaction? One way to solve this dilemma is by reducing patient panel sizes to a level that allows physicians time to provide high-quality care.Opting out of third-party payments also allows doctors to spend less time clicking boxes and more time engaging their patients in practices like motivational interviewing and wellness counseling. And without worrying about submitting records to an insurer, physicians can streamline office notes to what is truly medically necessary, eliminating the need for ‘pajama time’ with the electronic health record.

Rather than depending on the whims of an insurance company or congressional payment cut, direct care physicians may experience more financial security. For example, many direct care doctors reported increased resilience during the COVID-19 pandemic compared to traditional practices.

Downsides to direct care

Drawbacks of the direct care model include cost for very low-income patients (although some DPC practices specialize in underserved care) and concerns about lack of access due to smaller patient panels (although primary care may become more attractive to medical students who learn about the model). Direct care physicians must plan for delayed income during practice growth. It takes the average DPC practice about three years to reach full capacity and therefore maximal physician income, with practice growth dependent on variables like location. For example, practices in states with Medicaid expansion or areas with high HMO saturation tend to grow more slowly than areas with more health insurance barriers.

But probably the biggest barrier for physicians, who tend to be risk-averse by nature, is fear. Fear of the unknown. Fear of failure.Fear of criticism.Fear of success. Fear of letting people down. Fear of going against the grain, and fear of what others will think of you, especially if you are a by-the-book person with a play-by-the-rules personality. Fortunately, there are antidotes to fear. The first is knowledge, and that’s something that doctors excel in attaining.

In this series, I’ll help provide you with some of that knowledge, taking you through the A-B-Cs of starting your own direct care practice. You may be surprised at just how simple it can be. After all, you had the fortitude to graduate medical school and residency—you can do this, too.

Rebekah Bernard MD is a family physician in Fort Myers, FL and the author of How to Be a Rock Star Doctor and Physician Wellness: The Rock Star Doctor’s Guide.