June 3, 2024
Is Direct Primary Care Right for You?
By Rita Colorito
Like many owners of direct primary care practices, Jlyn Pritchard, DO, a family medicine doctor in Spokane, had struggled for years with the constraints and burdens of working in a fee-for-service model.
"It was an 8-to-5, no negotiation, no wiggle room," says Dr. Pritchard. As a mother of three young children, that meant she often missed being there when they were sick or had a special event. "The corporate system of medicine is a tough business. And it doesn't really allow moms, in particular, to really show up," she says.
To achieve the autonomy she values, Dr. Pritchard opened her direct primary care practice, Thread Health Clinic, in October 2022. And she's never looked back.
Direct primary care is a membership- based practice model where the physician contracts directly with the patient instead of with an insurance company. For a small but growing number of physicians in Washington, direct primary care presents an attractive option to sidestep the headwinds facing traditional primary care practices today. And they are substantial: shrinking reimbursements from government payers, high overhead costs, high rates of physician burnout, ever- increasing administrative burdens from insurance carriers, and, as Dr. Pritchard faced, schedules not conducive to a work- life balance. It's no wonder interest in primary care specialties among medical students continues to decline.
Those headwinds convinced Kim Ha Wadsworth, DO, to start Essential Direct Primary Care in Olympia in January 2022. During her locum tenens assignment immediately after residency in Yakima only six months earlier, she saw some 30 patients a day.
"We are supposed to do no harm, and yet I looked around at the lack of continuity, gaps in care, not having readily available appointments for patients to follow up ... I just looked at that and said I don't want to practice medicine this way. It seems like I would do more harm than not," says Dr. Wadsworth.
The state of innovation
Washington state is the birthplace of the direct primary care model, with the Legislature codifying it into law in 2007. Since the beginning, the WSMA has supported physicians' ability to choose the model of care delivery that fits their career needs. "The WSMA does not express a preference for any one practice model but supports the availability of a variety of practice options for physicians to meet the diverse care needs of the state and to create a strong health care system," says WSMA President Nariman Heshmati, MD, MBA, FACOG.
In recent years the care model has gained traction. There are 81 direct practices registered in Washington state, a net increase of 25 over the previous year, according to the December 2023 Direct Practice Report by the Office of the Insurance Commissioner. "That's a significant increase," says Dr. Heshmati, "particularly in our current health care landscape, when you consider that the number of independent fee-for-service practices is dwindling."
So far, direct primary care practices in Washington have yet to gain a significant market share. Out of an estimated 7.9 million Washington state residents, only 0.4% are enrolled in a direct primary care practice, up from 0.31% in 2022, according to the OIC report. "A big part of the lack of utilization likely has to do with how many residents are familiar enough with direct primary care to seek its services," says Dr. Wadsworth, a point echoed by other direct primary care practitioners.
There's also a question of whether regulatory hurdles contribute to this slow growth, unlike the notable expansion seen in states like Colorado. The WSMA has heard from members of the direct primary care community who have pointed to onerous annual reporting requirements from the OIC, for example. To that end, the WSMA House of Delegates in 2023 passed a resolution, spearheaded by Dr. Wadsworth, to approach the OIC about these regulatory hurdles for direct primary care practices, with the goal of supporting the ability of physicians to utilize the practice model.
Benefits and challenges
When the 2007 legislation was passed, many theorized that the direct primary care model would help relieve problems caused by a shortage of primary care physicians. Today, proponents are more likely to see the model as helping to further the Quadruple Aim: enhanced patient experience, improved population health, reduced cost, and a more fulfilling and balanced life for doctors.
"Direct primary care is an incredible model, but it doesn't address the physician shortage," says Dr. Pritchard. "What it does address is the patient backlog that often happens when people can't access care ... Urgent cares are great. But they were created because people couldn't get in to see their PCP. So, we sort of transition that relationship back to what it should have been all along."
Among Dr. Wadsworth's first direct primary care patients were two she had seen in residency. They made the switch to Essential Direct Primary Care, she says, because they could not get timely appointments with their physician.
"They were always seeing the PA or nurse practitioner. They were tired of getting handed off to whoever happened to be there that week," says Dr. Wadsworth. They now travel from Yakima to Olympia twice a year for checkups and via telehealth or call otherwise.
Running a direct primary care practice comes with its own set of challenges. The promised one-on-one patient-physician relationship means physicians are on call as needed.
Dr. Pritchard now works more hours than she did in a fee-for-service practice. "I view it as a time exchange," she says. "I have the ability to show up to the things that are really important in my life ... instead of being obligated to someone else's schedule."
Most of her patients have been very respectful of her time, says Dr. Wadsworth. In the last two years, she's only needed to go into the office twice on a weekend for an urgent patient issue.
"I have to almost pull teeth to say, hey, you know, you could have called me about that," she says. "It brings back the joy of medicine, that we can really take care of patients when they need us."
Direct primary care practices charge a set monthly fee for all primary care services, regardless of the number of visits or care provided. Setting pricing that's affordable but factors in resources, time, and care needs of your patient population is a major challenge, says Dr. Pritchard.
Direct primary care tends to attract patients with complex conditions who often aren't getting what they need in the traditional care system, says Dr. Pritchard. "Time management, resource management, as well as just expectation management from people has been a challenge," she says.
Solutions to care
Physicians practicing direct primary care pride themselves on offering patients same-day or next-day appointments for urgent medical issues. Under a direct primary care model, Dr. Pritchard says she's able to offer creative solutions that fit her patients' needs.
On one recent morning, she had a young father scheduled for osteopathic manual therapy. His wife texted to say their two kids were sick. Dr. Pritchard suggested he bring them in during his appointment so she could see what was going on.
"It really didn't take a whole lot of extra effort on my part to see them," she says. Under a fee-for-service model, says Dr. Pritchard, everyone would need separate appointments, if they could get them that day, or use urgent care-the default when patients can't get in to see their primary care physician.
The direct primary care model allows physicians much more time with their patients so they can practice to their full scope, says Dr. Wadsworth. This, in turn, she says, also helps alleviate pressure on specialists.
"They have waiting lists three to six months out. So, they really appreciate it when we, as family physicians, take care of a lot of that initial workup," says Dr. Wadsworth. "I'm not sending patients right away to a specialist because there are many things that I can do in house first."
Physician autonomy
Getting rid of insurance burdens for the care they provide appeals to many primary care physicians.
"I get to make decisions about how to take care of my patients, as opposed to being beholden to whatever rules the insurance company imposes on me," says Dr. Wadsworth. "I often joke that the insurance companies are practicing without a medical license."
Under a direct practice model, physicians opt out of insurance billing, significantly reducing the administrative overhead involved in reimbursement from insurance payers. But that doesn't mean direct primary care physicians avoid all insurance paperwork. Drs. Wadsworth and Pritchard often need to write prior authorizations for medications, labs, or imaging.
Dr. Wadsworth, for example, has a patient on Cosentyx who needs prior authorization for refills. "There's no way she can afford that without her insurance," she says. Because the patient can't get in to see a rheumatologist for another nine months, Dr. Wadsworth manages her arthritis care in the meantime.
"To have that autonomy ... It's worth something that I'm not burnt out five years from now," says Dr. Wadsworth.
Affordability
Cost and affordability are common criticisms of the direct primary care model. One fundamental misunderstanding: That direct primary care is concierge care-very low patient panels and very high cost.
More than half of direct primary care practices reported average monthly fees between $61 and $120. The most expensive monthly fee, at $1,253, belonged to the Bellevue location of a multistate, self-described "luxury concierge" group.
"I have yet to meet a direct primary care doc who wasn't first and foremost focused on affordability and accessibility," says Dr. Wadsworth. "I like to say that direct primary care is concierge without the Cadillac prices."
Essential Direct Primary Care charges tiered monthly membership fees by age group, each tier priced at less than $100 per person per month. Thread Health offers individual, family, and employer- paid memberships at different price levels, depending on patients' needs.
The direct primary care model gives physicians latitude to provide additional discounts to patients who are struggling financially, says Dr. Wadsworth, who has several patients on Medicare and Medicaid. "If I were to see that same Medicaid patient and bill Medicaid, I can't make exceptions to their rules, because I have to treat all the patients the same."
For care outside their practice, direct primary care physicians spend considerable time negotiating reduced prices on ancillary services, such as medication, lab work, and imaging. "We pride ourselves on finding the best deals," says Dr. Wadsworth. "I can get patients $41 X-rays now. I worked two years on that deal."
For lab work, Thread Health works with a group-purchasing organization. "They negotiate prices on our behalf to offer the cheapest rates to our patients," says Dr. Pritchard. Most of the time, typical labs are a fraction of what patients might pay with insurance: a lipid panel costs less than $4.
Some critics worry direct primary care practices will worsen the physician shortage in rural areas. Dr. Pritchard argues the direct primary care model may incentivize physicians to move to underserved communities.
"There are hundreds of direct care practices across the country that are located in these rural locations that are serving patients in a completely different capacity," she says. In Washington state, direct primary care practices operate in 20 counties, many in rural areas.
A tough sell
Attracting and retaining patients is a constant concern when running a direct primary care practice. It's the reason why Rebecca Hoffman, MD, shuttered her Vancouver direct primary care practice, New West Family Care, in 2012 after two years.
The misconception that direct primary care only caters to the wealthy may be one of the reasons the care model hasn't taken off, says Dr. Hoffman. "It's a tough sell. People in this country aren't used to paying retainer fees," she says. "You have to know your market and who you're drawing from. It requires constant promotion."
Another reason for the lack of marketplace traction: Some patients use direct primary care as a waystation, says Dr. Hoffman. It's why one colleague recently closed his direct primary care practice. "After doing this for several years, he wasn't getting many long-term patients. They were in it for a bit but would leave when they got a new job," she says.
Making ends meet
Many direct primary care practices have adjusted their business from a direct- practice-only-or-bust approach. In 2023, only 49% of direct primary care practices reported that 100% of their business is direct practice. Twenty-one direct primary care practices reported also participating as in-network providers in a health carrier's network in 2022, a significant change from 2007 when all reporting practices performed direct primary care exclusively.
Neither Dr. Wadsworth nor Dr. Pritchard practice direct primary care exclusively. Dr. Wadsworth also offers fee- based osteopathic manipulative therapy (OMT). Dr. Pritchard also works for a Washington-based clinic doing telehealth part-time, and offers fee-based OMT, a guided weight loss program, and lifestyle counseling (included in Thread Health's advanced and deluxe memberships).
Having a hybrid practice, suggests Dr. Hoffman, who had both a direct primary care and a fee-for-service practice, may help transition patients who would otherwise leave once they got a job or health insurance. "Then you can still see them and that will be great for continuity of care," she says.
"This model is not for everyone," says Dr. Pritchard. "But what it has gifted me is the ability to show up for my family, to be seen as a human being, and to interact with patients the way I have always hoped ... and to give patients back the ability to feel heard."
Rita Colorito is a freelance writer specializing in health care.
This article was featured in the May/June 2024 issue of WSMA Reports, WSMA's print magazine.