More Patients Turning to 'Direct Primary Care'

Christine Lehmann, MA

February 11, 2020

Having quick access to a primary care doctor 24/7 is very appealing to Mick Lowderman, 56, who is married with two children, ages 10 and 8. He pays a monthly membership fee to AtlasMD, a direct primary care practice in Wichita, KS.

Primary care is built on the long-term relationship between clinicians and patients. A 10- to 15-minute patient visit doesn't support that relationship, Sullivan says.

When Kevin Boyd, 64, fell on his stairs in Wichita and broke three ribs, he didn't go the emergency room. Instead, he called Umbehr, who told him to come to his office. He referred Boyd nearby for an X-ray and dispensed pain medications at his office. The total cost was $70.

In contrast, the first time Boyd fell and broke his ribs, he had Blue Cross Blue Shield and drove himself to the ER, where he saw the ER doctor, a radiologist for an MRI, and got shots for his pain. The total bill was $14,000, and he paid $2,600.

"I don't put off care the way I used to because of the money I save," says Boyd, who joined AtlasMD in 2015.

For his monthly membership fee of $75, Boyd gets several benefits, including unlimited 24/7 access to Umbehr by text, email, or phone, extended same- or next-day office visits, and free diagnostic tests and office procedures, such as EKGs, DEXA scans, and body fat analysis. If Boyd gets really sick and needs a house call, or if he needs a phone consult when traveling, those are also included in the fee.

"It's awesome that I can call or text Dr. Josh Umbehr when my children are sick and that I have a solution before they leave for school," he says.

For example, when one child woke up coughing recently, Mick and his wife, Jennifer, contacted ‘Dr. Josh,' who asked them to put her on the phone to hear her cough and then take a picture of her throat and text it to him.

"He prescribed an antibiotic, which we picked up at his office the same day."

Umbehr is part of a growing movement of primary care doctors, including those in family, internal, and geriatric medicine, who want to practice more personalized comprehensive medicine without the burden of dealing with insurance in a traditional fee-for-service system. Most choose to not accept health insurance and charge patients a membership fee instead.

"When you look at direct primary care and other models that are cropping up, it points to our broken system that doctors don't want to practice in and are looking for alternate solutions ― and so are patients," says Erin Sullivan, PhD, research and curriculum director at the Center for Primary Care at Harvard Medical School.

Umbehr is in Kansas, one of 44 states that allow doctors to directly dispense medications with the exception of controlled substances. Boyd pays $2 and $3 for typically a 3-month supply of common generic medications that he can pick up at AtlasMD or have mailed to him.

Another way Umbehr saves patients money is through contracting with specialists who agree to give his patients discounted rates. For example, when Umbehr sent Boyd for an ultrasound of a possible blood clot in his leg, he was billed $120.

The popularity of these alternative models is growing. DPC Frontier, which tracks the number of direct primary care practices nationally, estimates there are 1,219 practices in 48 states and Washington, D.C. They range in size from solo practitioners to corporate, multisite direct primary care organizations with thousands of doctors, Sullivan says.

The American Academy of Family Physicians supports the direct primary care model "as a potentially powerful disruptor in the health care payment environment that has traditionally undervalued family medicine and comprehensive care," the group says on its website.

But there are drawbacks and concerns to be aware of. For one, the monthly fee is in addition to any insurance for major medical problems. While many doctors and patients claim the direct care model results in better health outcomes, there are no studies proving that, according to an editorial in The Journal of the American Medical Association. Because it is a retainer operation, too, the model encourages doctors to target healthier patients, while others charge more for patients who have more needs.

As a premed student, I spent time in a brilliant surgeon's practice who never figured out the business side of fee-for-service insurance with all the billing and coding. That was a peek into a bad business model. Josh Umbehr, MD, CEO of AtlasMD in Wichita, KS

The American College of Physicians, too, warned in its policy paper on the practice that the direct care model can "potentially exacerbate racial, ethnic and socioeconomic disparities in health care and impose too high a cost burden on some lower-income patients."

Umbehr chose to establish a direct primary care practice right out of residency. "As a premed student, I spent time in a brilliant surgeon's practice who never figured out the business side of fee-for-service insurance with all the billing and coding. That was a peek into a bad business model."

While the membership payment model in concierge medicine appealed to him, "we wanted an affordable version for the masses." Concierge primary care practices offer similar outpatient services and amenities to members but typically charge higher membership fees, and many also bill insurers.

Direct primary care practices charge an average monthly fee of $78, while concierge practices charge an average monthly fee of $183.00. Umbehr also saves money on overhead with no front office or administrative staff and one registered nurse for each of AtlasMD's five doctors. "There's a good chance one of us will answer the phone," he says

Umbehr limits his patient volume to 700, compared to a typical "in-network" primary care doctor who sees 2,500-3,000 patients total. This allows him to see five to six patients a day instead of 20 or more seen in a typical primary care office.

Lowderman and Boyd say that Umbehr can take care of most of their health care needs, including minor office procedures that don't require anesthesia or sedation. If needed, they will pay cash for a specialist or use their major-medical insurance plan if something more serious happens. Major-medical plans, sometimes also called catastrophic insurance, will cover things like trauma care, emergency surgeries, and more. They feature low monthly premiums and high deductibles.

Lowderman, who has 12 employees in his pest control business, pays AtlasMD $50 per employee monthly to provide primary care services to them. Because he also gets customized major medical insurance through AtlasMD, he pays a total of $375.00 monthly per employee. Traditional employer insurance would have been double or triple the cost, he says.

Managing Care

When Umbehr started his practice a decade ago, Mike Scheidt and his wife, Jolene, (now deceased) were among his first patients. "I don't know if I would have joined if my wife had not been so sick with cancer and he could streamline perfunctory things," Scheidt says.

For example, Jolene had frequent urinary tract infections. "Before Dr. Umbehr, we would call her internist and he would tell us to come down to the clinic to do the lab work. My wife had one leg and a half amputated due to infection. I was an executive with Raytheon at the time and would have to take time off from work, hire a home health nurse to collect the urine specimen and drop it off, wait 3 days to get the lab results, and then go to Walgreens to pick up Bactrim, which always worked."

When Umbehr became their primary care doctor, Jolene would call him up and mention a UTI, and he would start her on Bactrim, which he often dropped off at their house on his way home. Then, a lab technician or home health nurse the Scheidts hired would collect the urine specimen for analysis to confirm the diagnosis.

"She didn't need to leave the house! I finally felt like she was being treated like a head of state. My wife told me many times that dealing with such serious matters wasn't as scary with Dr. Umbehr shepherding her through difficult medical situations," Scheidt says. "That alone was worth a pot of gold to her, and certainly to me as well."

Leaving Traditional Insurance

Jeffrey S. Gold, MD, opened Gold Direct Care in 2015 in Marblehead, MA, after being employed as a family medicine doctor by North Shore Medical Center in Boston for 7 years. "It was a typical insurance-based practice where I was seeing 20 to 22 patients a day. I wanted to practice medicine and not insurance paperwork, billing, and coding."

Gold was feeling burned out at age 36. "I was thinking of either quitting medicine completely or teaching at a local medical school. I saw no sustainability in seeing people in 10-minute increments daily for the rest of my career."

Two years later, he left North Shore.

He read about Umbehr's practice online and then visited him in Wichita to see it firsthand and decided to adopt a similar model. However, "there are differences between Wichita and Boston ― this area is heavy with big hospital systems that are insurance-based. Employers equate insurance with care, and trying to educate them about the value of this different primary care model is challenging."

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In addition, Gold couldn't negotiate discounted cash prices with radiologists in Massachusetts, because the MRI equipment was owned by hospitals. Instead, he negotiated the discounted rates with radiologists in nearby New Hampshire. Gold's patients pay $700 cash up front for MRIs in New Hampshire, compared to the $3,900 they would have paid in Massachusetts.

Another difference is Massachusetts prohibits doctors from dispensing medications directly to patients. But Gold finds ways to save patients money by prescribing generics and using coupons on GoodRx.

While he would prefer to limit the total number of patients he sees to 750, he needs to take on another 60 patients to meet his expenses, including the rent and the loan he took out to start the business.

His patient Laurianne Bourque, 42, who works in Boston, credits him with probably saving her life. "I was feeling winded a lot and have a family history of heart disease. Because I am overweight, none of my previous doctors thought to investigate a heart problem, although I kept saying something didn't feel right. They would tell me I was fine and send me on my way."

She found Gold last summer. He asked questions about her heart and wanted to order an EKG, but before that happened, she was hospitalized and diagnosed with congestive heart failure.

"Gold came to the hospital and talked to the doctors, got all the information, and helped me understand what was going on, which was a hardening of the heart muscle itself."

Gold also helped her figure out the reason she was so tired during the day. He suspected sleep apnea and recommended a home sleep test kit. He knew that she was uninsured and that the test kit was significantly cheaper than sending her to a sleep center.

If Bourque feels anxious about a medical problem, "I can call or text him, and he gets back to me right away. He spends a lot of time talking with me about things and making me feel comfortable, which other doctors didn't do."

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Concierge Medicine Gets More Popular

Concierge medicine has also grown since the movement started in the 1990s. For example, MD-Value in Prevention (MDVIP) says it has a network of more than 1,000 primary care doctors nationally who care for more than 325,000 patients. Concierge Medicine Today, a national trade publication, estimates that 12,000 doctors are now practicing concierge medicine. This figure is based on interviews, as there is no federal registry or official database collecting this information.

Thomas W. LaGrelius, MD, 76, considers himself an early adopter of the concierge model, having founded Skypark Preferred Family Care in 2005 in Torrance, CA.

They became almost as abusive to patients and doctors as the HMOs, which stands for horrible medical organization. Thomas W. LaGrelius, MD, founder of Skypark Preferred Concierge Care in Torrance, CA, discussing preferred provider organizations, or PPOs

The practice now has three full-time primary care doctors who also specialize in geriatric medicine, and eight administrative/medical assistants to manage appointments and help with other tasks.

LaGrelius has come full circle. He started doing family medicine in 1974 in a private group practice with no insurance contracts. He has been a solo practitioner since 1983 and accepted some PPO insurance contracts until the mid-1990s. "They became almost as abusive to patients and doctors as the HMOs, which stands for horrible medical organization," he says.

He accepts only standard Medicare, which "pays far less than what is needed to deliver quality care. Beginning in about 1996, my practice was contract-free, and the membership concierge model was launched in 2005, the first in the area."

Although LaGrelius had a cash-based practice for several years before converting to a concierge practice, his patient load was much higher. "I had a patient population between 2,500 and 7,000, and was working at 110 hours a week. My wife said I would have a heart attack if I kept that up. So, I mentioned I could start a concierge practice, and she said do it!" He has more free time for his family and hobbies, including piloting his own plane.

He now has about 400 active patients. He and the two other doctors in his practice charge annual fees based on age ranging from $800 for adults under age 35 to $2,400 for seniors over age 65. "When I converted my solo practice to concierge, the most amazing thing happened ― the sickest most complex patients wanted to join who didn't have a lot of money, including teachers and plumbers," LaGrelius says.

He offered those patients who couldn't afford his fees a financial aid program.

More Time With a Doctor

Karen Keegan, 63 has been a patient of Jeffrey S. Puglisi, MD, an internist and founding partner of Glenville Medical Concierge Care in Greenwich, CT, for the past 18 years. When the practice converted from a traditional insurance model in 2015, Keegan's family of six stayed with Puglisi and another doctor in the practice.

"While we were getting good care before, I think we get better advice now. There are many situations in which we have symptoms and don't know whether they are critical or not. I feel the accessibility and quickness of reaching a primary care doctor is important rather than going to a clinic and waiting a long time to be seen," Keegan says. "The immediacy provides more peace of mind."

Keegan appreciates the help and support her family receives wherever they are, and she continues to pay the annual membership fees for her four grown children. "If we didn't have that type of service, my children wouldn't have the safety net they need to be young adults in the world. I feel that it's very important to give a doctor/practice the extra financial support so they have the time to think ahead and be available, whether to explain surgical procedures or reach out to other doctors."

Puglisi, who has limited his practice to about 600 patients, values the extra time he has for them and for pursuing his clinical interests. "I decided my partners and I could provide better quality of care and improve our quality of life, too, with the concierge model. Rather than trying to just get through the day when I saw more patients, in the past 5 years, I have lectured for a cardiovascular company, done hospice care, lectured nationally about concierge medicine, and dabbled in functional medicine. I feel more fulfilled and healthier as a person."

His mantra is, "I want to provide better care, be healthier as a person, and smarter every year in this practice."

Cost, Insurance, and Other Considerations

These alternative practices, whether direct primary care or concierge, may not be for everyone. People who join still need to pay for insurance. The doctors in both models emphasize that their services are not an insurance plan or a replacement for one.

Direct primary care practices typically don't accept insurance, including Medicare, but encourage members to have at least catastrophic coverage. If patients need regular specialist care that is outside the scope of the primary care doctor, they may get discounted rates but will have to pay in cash. The alternative is buying a more expensive comprehensive insurance plan.

In contrast, many concierge practices may bill insurance or Medicare for services they cover, such as medical visits. Although they typically are not "in-network" providers, they may try to refer to specialists in members' insurance networks.

The membership fees are an extra cost that's not covered by insurance, although Umbehr and Gold say some members use their health savings accounts and flexible spending accounts to pay for them. Sullivan advises people to "understand your current insurance and coverage since neither membership model deals with catastrophic events. If you are in an employer insurance plan that goes with a direct primary care practice, find out what will you be paying on top of the current insurance."

She also says that prospective members should vet the practices and interview the doctors before joining. If they do decide to join, they will want a clear written agreement that covers the enrollment terms, whether insurance is accepted or not, the cancellation policy, and what happens if there are grievances.

Sources

Josh Umbehr, MD, CEO, AtlasMD, Wichita, KS.

Jeffrey S. Gold, MD, founder, Gold Direct Care, Marblehead, MA.

Jeffrey S. Puglisi, MD, founding partner, Glenville Medical Concierge Care, Greenwich, CT.

Thomas W. LaGrelius, MD, founder Skypark Preferred Concierge Care, Torrance, CA.

Kevin Boyd, Wichita, KS.

Mick Lowderman.

Mike Scheidt, Wichita, KS.

Laurianne Bourque, 42, who works in Boston.

Karen Keegan, Greenwich, CT.

Richard and Vicky Wood, Roswell, GA.

Erin Sullivan, PhD, research and curriculum director, Center for Primary Care, Harvard Medical School.

Journal of the American Board of Family Medicine: "Direct Primary Care: Practice Distribution and Cost Across the Nation."

Harvard Medical School, Center for Primary Care: "Background Note on Direct Primary Care."

Annals of Family Medicine: "Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation."

VineMedical.com.

GlenvilleMedicalConciergeCare.com.

SkyParkPFC.com.

GoldDirectCare.com.

Atlas.MD.

MDVIP.com.

American Academy of Family Physicians.

DPC Frontier.

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