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Direct primary care in Idaho


Primary-care physician Julie Gunther couldn't be happier with her new direct-pay practice. She says it allows her to be the physician she trained to be.

Physicians are typically a self-sufficient group of professionals who are trained to make decisions quickly and autonomously. The lives of their patients can depend on it. Unfortunately, the opportunities to practice medicine independently are shrinking as economic factors push more physicians into group arrangements or hospital employment.

One option that is picking up steam across the U.S. is forsaking the fee-for-service paradigm and embracing a direct primary care (DPC) model, sometimes called cash-only or direct-pay practice.

Related: Practice Innovators: Reinventing primary care

DPC practices usually don't accept private or government insurance (although some recommend patients purchase a high-deductible insurance policy for noncovered emergencies), but typically charge "a monthly, quarterly, or annual fee (i.e., a retainer) that covers all or most primary-care services including clinical, laboratory, consultative services, and care coordination and comprehensive care management," according to the American Academy of Family Physicians. Usually DPC fees are very affordable in contrast to a true concierge practice that charges patients a much-more expensive annual retainer.

Idaho has a favorable climate for small business, says family physician Julie Gunther, who just opened a direct primary care practice, sparkMD, in Boise in 2014. "Idaho has sort of a 'you do your thing, I'll do mine,'" she says. "So in terms of being a small business owner, there's a lot of opportunity for innovation." She says that her state's openness to entrepreneurship makes it easier to create the practice she always dreamed about. "Physicians are really being asked to make some choices about what they want their practices to look like. And in Idaho I think they have the autonomy to do that."

After her residency, Gunther worked for a large medical system in southern Idaho for five years. But she quickly found that she couldn't practice the type of medicine that she knew was right because of insurance constraints. "I wasn't the doctor that I wanted to be," she says, "I was saying 'I'm sorry' [to my patients] 17 times to 20 times a day." Gunther, who is a frequent public speaker on DPC, asks her audience to think of a task that takes roughly seven minutes to complete. She then points out that the average face-to-face visit with a physician takes seven and a half minutes. "The system is broken and it won't change until docs say, 'I know the service I trained to do, that I want to do, and I can't do it in seven and a half minutes," says Gunther.

Related: Diversifying your practice

Gunther is a full-spectrum, outpatient family physician (she does not round at the hospital, nor provide obstetrical care), who provides home visits and social rounds at the hospital for her patients. Her fees are $10 a month for children and $60 a month for adults.

She also has an in-house drug dispensary, which she says patients love. "If you think about it, when you are sick and your doctor says, 'You need a Z-Pak, it's $2.40, and I have it right here,' insured or uninsured [the patient says] 'OK, done and done!'"

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Jennifer N. Lee, MD, FAAFP
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