Physicians Taking Back Medicine: Can DPC save the rural health crisis?

Rebekah Bernard, M.D.

Host, Physicians Taking Back Medicine

Fifteen years ago, family physician Lee Gross, M.D., was running a small private practice in southwest Florida and struggling to stay afloat. Reimbursements were declining, administrative costs were rising and Medicare requirements grew more burdensome each year. The turning point came when a small business owner approached him with an unusual proposal: since all the employees already saw Gross as their doctor, why not pay him directly to take care of them?

That conversation sparked an epiphany. Gross realized that much of the cost and frustration in primary care came not from the care itself but from the insurance bureaucracy that surrounded it. Filing a claim for every visit, navigating hundreds of thousands of billing codes, chasing copays and deductibles — all for routine, predictable services — was both costly and unnecessary.

In 2010, Gross launched Epiphany Health, a flat-fee subscription model that eliminated third-party billing entirely. Patients paid a monthly fee — $89 for adults, $30 for the first child, $15 for each additional child — for unlimited office services, with no copays, deductibles, or surprise bills. The model not only saved his practice but inspired him to help thousands of other physicians launch similar practices through the Docs 4 Patient Care Foundation.

A rural lifeline

Lee Gross runs two offices, including one in rural southwest Florida, one of the state’s lowest-income regions. He notes that in traditional fee-for-service medicine, a rural practice must panel 2,000–3,000 patients and maintain a packed schedule just to survive. In sparsely populated areas, where patients might be scattered across 100 square miles, that’s a near-impossible task.

Direct primary care changes the math. By keeping overhead low, a DPC practice can be sustainable with as few as 300–400 patients. For rural physicians, that smaller panel means they can stay financially viable without requiring state or federal subsidies.

Gross has even made the case to lawmakers. Testifying before the U.S. Senate, he contrasted DPC’s affordability (just $1,000 per year for his patients) with the $5,000 per-patient annual cost of federally qualified health centers (FQHCs). The difference, he explained, wasn’t in care but in bureaucracy. FQHC costs include layers of federal administration, oversight and reporting systems. In DPC, those layers simply don’t exist — freeing resources for patient care.

Critics worry that reducing reporting requirements could undermine oversight. Gross counters that primary care isn’t the main driver of health care costs; the real expense comes from the downstream consequences of poor primary care — avoidable ER visits, preventable hospitalizations and unnecessary specialist referrals. Medicare already collects utilization data, he points out, making it possible to measure a clinic’s efficiency without burdening it with redundant paperwork.

Case studies in rural DPC

After completing her training, Leah Gilliam, M.D., returned to her hometown in rural Tennessee. “I married my high school sweetheart, a cattle farmer and it just made sense that we would come back live on the family farm, and that I would practice here,” said Gillium.

While she initially took a hospital-employed position in a neighboring town, Gilliam discovered that seeing 25–30 patients a day in 15-minute slots was incompatible with providing the kind of care she believed in. Within two years, she walked away and opened The Doctor’s Office @ 83 S. Main. Seven years later, she says the move transformed both her life and her community, which has high rates of chronic disease and many working uninsured residents. Unlike urban areas, her region lacks charity clinics or other safety nets. Her practice fills that gap.

Opening a traditional fee-for-service practice in her community is not a viable option, said Gilliam. “Between uninsured patients and the number of Medicaid and Medicare, which does not reimburse well, small practices have a tough time surviving here,” she said. “If they’re not surviving, they can’t stay, and we’ve seen several go out of business in recent years.”

In rural Indiana, Noemi Adame, M.D., owns and operates Culver Pediatric Center. “We are a health care desert,” said Adame, noting that the area’s local hospital has closed down service lines, service lines starting with pediatric rehab and infusion services, then obstetrics and the ICU. Specialty care moved farther away, leaving local primary care physicians to manage increasingly complex cases.

For Adame, DPC offered a solution. By keeping her patient panel small, she could spend more time with each family, managing conditions that might otherwise have been referred out. She emphasizes that the “magic” she can offer is time, a resource corporate medicine can’t provide. That time also allows her to focus on prevention, including a plant-based nutritional wellness program for her patients.

In rural Oklahoma, Katie Burden-Greer, M.D., a Muskogee Creek Native American, practices just a mile and a half from her family’s allotment land after the Trail of Tears. After leaving an employed position where patients were booked in five-minute increments, she spent eight years commuting two and a half hours daily to work as a hospitalist for another tribe. Eventually, she opened Outlaw Medical, a 140-patient DPC clinic. While that number might seem small, in a town of just 800 people, it’s enough to keep her practice viable and her neighbors close to home for their medical care. To supplement her income, Burden-Greer works a day per week at a nearby Indian Health Center.

The Medicare Opt-Out Dilemma

For DPC advocate Lee Gross, opting out of Medicare was an absolute necessity to sustain his practice. “Every time we tried to find a way to stabilize our finances, Medicare would take our knees out from under us by adding new requirements while continually paying us less. It was an unsustainable model.”

Initially, he worked to lobby legislators for improvements to Medicare, including better pay and less red tape. “I'd go with a group of family doctors to Congress and say, ‘Don't cut our pay.’ And I'd walk out, and the anesthesiologists would be waiting in the lobby and they'd come in next and they'd say, ‘Don't cut our pay.’And then they'd walk out and the surgeons would be behind them,” said Gross. “We quickly realized that we were all fighting for larger pieces of a very small pie, and there was always going to be somebody that loses in that battle.”

Tired of fighting a losing battle, Gross stopped taking Medicare and offered patients the option of paying directly for care. This is not an easy decision for every physician. “Medicare rules are very strict, and if you are taking cash for a patient for a service that Medicare covers, then you must opt out of the Medicare system across the board,” said Gross. This becomes a barrier for new practices, restricting a physician’s ability to moonlight in settings like urgent cares, hospitals, or hospices while their practice is growing. “It’s a high-risk proposition, because it’s difficult to find alternate ways of generating income,” said Gross.

Leah Gilliam, M.D., decided not to opt out of Medicare. “It's been a tough call for me to make,” she said, “Dealing with Medicare is a challenge, and I wish was something that I didn't feel compelled to do, but I have patients that I've cared for years that I love and I’m just not willing to give them up.”

Instead, Gilliam has a hybrid DPC practice that bills traditional Medicare for her established patients, noting that she receives a payment penalty for not participating in Meaningful Use attestations. “I would have to pay a staff member significant overtime to help me compile and submit the data, and its just not worth the undertaking at this point.” Gilliam also sacrifices the 20% co-payment from her dual eligible patients because she is not enrolled in the Medicaid system. “I just do it because in my heart it feels like the right thing,” she said.

Being permitted to bill Medicare in other practice settings would have made it easier for doctors like Leah Gilliam to start their direct care practices. “I needed those moonlighting opportunities, and I still need them,” she said, noting that she also works as a hospice medical director and serves as her county’s medical examiner.

Lee Gross and other direct care advocates are talking with the current administration regarding changes to the Medicare opt-out provision. “We have been working with the policy director of CMS, and I can tell you that it's something that they're receptive to,” he said, noting that the subject will need to be closely examined to avoid potential pitfalls.

A Growing Movement

When Lee Gross first embraced direct primary care, there were perhaps a dozen similar practices nationwide. Today, there are thousands, in every state, spanning primary and specialty care. For some, DPC extends careers that might otherwise have been cut short by burnout. For others, it makes primary care an attractive career choice again, both financially and emotionally.

Gross is the first to admit that DPC isn’t a cure-all. Building a practice takes hard work, patience and, often, financial sacrifice. But he’s encouraged by the growing number of young physicians and residents attending his conferences. Many arrive disillusioned by the system after only a year or two in practice. They leave believing there is a sustainable path forward — one where they can make a living, serve their communities and practice medicine the way they always intended, including in areas of greatest need across the country like rural America.

Rebekah Bernard, M.D. is a family physician in Fort Myers, FL and the author of four books on health care, including How to Be a Rock Star Doctor.

Music Credits
Medical Education by Art Media - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

Introduction to DPC and Rural Health care Crisis (00:00:14) Overview of DPC, recent policy changes, and the episode’s focus on rural health care and DPC.

Dr. Lee Gross’s Background and Early Practice Challenges (00:00:52) Dr. Gross describes his medical background, move to Florida, and frustrations with traditional practice.

Electronic Medical Records and Medicare Barriers (00:01:53) Early adoption of EMR, government regulations, and financial penalties from Medicare.

Medicare Payment Cuts and Practice Sustainability (00:02:47) Struggles with declining reimbursements, attempts to find alternative revenue, and the unsustainable fee-for-service model.

Epiphany: Transition to Direct Primary Care (00:03:47) Realization that insuring primary care is inefficient; inspiration to start a subscription-based DPC model.

DPC Business Model Details (00:04:50) Explanation of DPC pricing, services, and the elimination of third-party billing.

DPC in Rural Florida: Practice Viability (00:05:22) Challenges of rural practice, patient volume, and how DPC enables sustainability with fewer patients.

DPC as a Rural Health care Solution (00:06:28) Discussion on why DPC fits rural areas and legislative efforts to promote it.

Telemedicine vs. DPC in Rural Settings (00:07:09) Limitations of telemedicine alone and the value of continuity with a known primary care doctor.

Cost Comparison: DPC vs. Federally Qualified Health Centers (00:08:57) Senate testimony on DPC’s cost-effectiveness and the administrative overhead of traditional models.

Introduction of Rural DPC Physicians (00:10:18) Transition to interviews with three rural DPC physicians.

Dr. Lee Gillum’s Background and DPC Journey (00:10:24) Dr. Gillum’s return to rural Tennessee, dissatisfaction with traditional practice, and switch to DPC.

Impact of DPC on Rural Community (00:11:45) How DPC has improved access for uninsured and underserved patients in rural areas.

DPC and Rural Practice Sustainability (00:12:33) Challenges for small practices, Medicaid/Medicare reimbursement, and how DPC enables survival.

Dr. Nehemiah Weimar: DPC in Rural Indiana (00:13:35) Dr. Weimar’s pediatric DPC practice, local hospital closures, and the importance of time in patient care.

Dr. Katie Worden Greer: DPC in Rural Oklahoma (00:15:19) Dr. Greer’s background, transition from tribal health to DPC, and building a practice in a small town.

Medicare Opt-Out Dilemma for DPC Doctors (00:16:51) Explanation of Medicare opt-out rules and the catch-22 for rural DPC physicians needing supplemental income.

Dr. Lee Gross on Medicare Opt-Out Policy (00:17:56) Gross discusses the risks and advocacy efforts to change Medicare opt-out requirements for DPC.

Dr. Lee Gillum on Medicare Challenges (00:19:25) Gillum shares his hybrid practice, difficulties with Medicare, and the impact on patient care and finances.

Administrative Burdens of Medicare (00:21:00) Discussion of data submission requirements, reduced payments, and the impact on small practices.

Balancing DPC and Community Roles (00:23:14) How DPC allows flexibility for rural doctors to serve multiple community roles.

DPC’s Role in Rebuilding Trust in Rural Health care (00:24:24) Importance of time and trust in rural communities, and how DPC addresses these needs.

Advice for Starting DPC in Rural Areas (00:25:25) Dr. Greer encourages physicians to consider DPC in rural settings and explains patient acceptance.

Future of Direct Care Model (00:26:31) Dr. Gross reflects on DPC’s growth, its challenges, and the hope it offers for younger physicians.

Podcast Conclusion (00:28:40) Host wraps up the episode, summarizing the stories and mission of the podcast.