If you’ve been on our physician communities for a while, you know that burnout runs deep. One subset of physicians particularly susceptible to burnout are physicians in primary care specialties, who have seen patient volume and the amount of charting and administrative burden skyrocket, as well as compensation continually threatened. This has led to an inability to spend as much time with patients as most physicians and patients would like, which detracts from the heart of what many of us love the most about medicine, the doctor-patient relationship. When voicing these frustrations, there is a louder and louder growing contingent of the group who expresses how switching to direct primary care (DPC) was a career saver for them.
For those that don’t know about DPC, it can seem like a vague concept, so our goal here is to elucidate what DPC is and how different specialties can explore it.
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What is Direct Primary Care (DPC)?
At the heart of it, DPC offers patients a different model of healthcare built on a membership system, where the patients pay a (typically monthly) fee to have access to their physician. It’s called direct for this reason - it eliminates the middleman and allows both parties to focus on the doctor-patient relationship. Although each physician may choose to structure their practice differently, the fee typically covers primary care services, and depending on the practice can also cover things like labs, basic imaging, basic clinical serves, and care coordination. Since it can’t cover all health needs, patients typically also carry insurance coverage for catastrophic care and subspecialty procedural care. Some practices will even offer house calls or other access to the physician not typically available to patients, such as the ability to text or email them.
What are some key differences between DPC and Concierge Medicine?
Both of these models charge membership fees to patients and offer a higher touch, personalized form of care. However, unlike concierge practices, which tend to bill insurance, in its traditional form, DPC will not bill insurance for visits and access to the physician. DPC practices don’t participate in insurance, either from Medicare or Medicaid, or commercial payers. This is one of the largest differences.
While every concierge practice and DPC practice has its own model, there are other key differences. Since the concierge practices are also billing insurance, their fee is primarily not to pay for the physician’s time, but rather to pay for the level of access that patients get to their physicians. They may have appointments outside of typical working hours, typically can personally call the physician directly, and may be offered a broader range of services. Concierge physicians may even travel with their patients or go to visits with specialist to facilitate care coordination and patient navigation.
DPC membership fees tend to be lower than concierge membership fees. Concierge medicine typically requires an annual membership that can’t be canceled, whereas many DPC practices offer the ability to pay a monthly or quarterly membership. DPC is actually specified as a form of acceptable non-insurance healthcare coverage in the Affordable Care Act, whereas concierge care is not.
Although DPC practices don't take insurance, they can be a great solution for uninsured patients and elderly patients as well. As the average membership fees are often more affordable than insurance premiums, and there are opportunities for patients of these practices to take advantage of the significant discounts that DPC practices may have on labs and medications. DPC practices can also be a great fit for complex and older patients who desire a deeper doctor patient relationship and more transparent and affordable pricing. These patients will then use their insurance for diagnostic evaluations and referrals, as well as more significant needs such as hospitalizations. There can be some nuances to whether DPC physicians are able to work with Medicare and Medicaid eligible patients, which can be discussed directly with the practices. Otherwise, concierge medicine remains an option for these patients desiring a more personalized primary care experience.
What are some benefits of DPC?
In addition to the stronger focus on the doctor patient relationship, because there are less insurance hassles, running a DPC practice can have less administrative burden than other practices. Things like getting credentialed and contracted with insurance companies, billing and coding, etc. are not as necessary depending on how strictly you stick to a pure DPC model. As such, you can also reduce overhead as you don’t need as much staff.
An additional perk to not dealing with insurance companies is that you are generally better reimbursed for your work as the costs are staying between the physician and the patient. As such, you don’t have to see as many patients to make the practice profitable. While in a traditional primary care practice, you may be seeing 30+ patients in a day, you can likely see 10-15 in a DPC practice. This of course means more time for each patient visit, a stronger bond between physicians and their patients, and less charting at night.
You can also choose to tailor your practice the way that you want. Some practices will do a hybrid of inpatient and telemedicine visits, which means that you could create the flexibility to work from home some days. In general, you likely have much more flexibility in figuring out what the optimal interactions are with your patients. Since you don’t have to worry about insurance, you can elect to take care of something over the phone or messages instead of having them come in if that feels more ideal to both parties as well.
The other upside to DPC is that you can choose to make as much or as little as you want depending on how you decide to structure your practice and your fees, provided that the market will allow it. We’ve seen some physicians on the communities making in the 100,000 dollar range but working part time and very happy with the income, to physicians that continue to work full time and add lots of ancillary income streams to the practice who earn over $500,000 a year.
What are some of the downsides of DPC?
Because patients are paying a membership model, they will generally expect to get an elevated level of service for that payment (which hopefully, you are also wanting to provide!). They may expect you to be more available, to squeeze them in when they need to be seen, to have more follow up conversations about things that you discussed, and to have to do more research on things that you may not be well versed in instead of simply referring them out to a specialist.
Direct primary care is still a relatively new model, so it may also take some time to figure out what the right business model for you that also works for your patients and referring physicians is. There is a business aspect to this practice just like any private practice, so you also have to be willing to deal with the hassles that come with being a business owner as opposed to an employee of a hospital system. This means marketing, finding a referral base, dealing with staffing issues, and even figuring out what to do if your refrigerator stops working.
The other potential downside, of course, is that not all markets or subsets of patient populations are conducive to DPC practices. If your passion is in serving underserved communities in areas of low socioeconomic status, you will likely have a hard time building a practice that you find fulfilling as your target patient population may not be able to afford a monthly service fee.
No matter where your market is, it will likely take some time to build out a patient panel that gets you the compensation you’re used to as an employed physician or successful private practice owner with a traditional insurance based practice, so you have to plan accordingly financially for the ramp up period.
What are some ancillary income streams you can add on to Direct Primary Care?
Your creativity is likely the limit here, as again, you can run this practice however you want. We have physicians in our Facebook communities that have added ear piercing to their practice, lifestyle medicine components with personal trainers, nutritionists, and mental health counselors, and more. If you choose niches you are interested in, you can really bring patients into the practice who that niche resonates with, and then form collaborations or business lines related to that. You could see a situation where you also have a massage therapist, a physical therapist, meditation and yoga, etc.
What about vacation time when you’re running a DPC?
As part of the membership model, your patients will be signing agreements that govern how you interact with them. Most physicians have found it’s very important to outline expectations and boundaries here, including how often you may be on vacation, what they can call after hours about, expectations about timelines to be seen, or whatever else you’d like to specify. Many DPC practices will form collaborations with other DPC practices so that their patients can have coverage during their vacations, and actually may have practices in distant locations that their patients can access when their patients are vacationing as well!
What other specialties have started DPC practices?
Although the model name says direct primary care, many specialties are exploring this model, and it’s not just family medicine, internists, and pediatricians. On our communities, we’ve seen sub specialists also exploring these practices. Of note, these tend to be non-procedure oriented specialties given that the costs to patients of paying for more involved procedures out of pocket could really be prohibitive.
Conclusion
For those physicians in primary care or non-procedural specialties that are feeling the churn of the insurance based practice lifestyle and looking for a change or to scratch that entrepreneurial niche, DPC can be a great avenue to explore. You’ll likely have a steep learning curve at the beginning (but don’t worry, there’s lots of support within the community for those looking to learn this business model), but it can be a great step to building out life in medicine on your own terms.