What is Direct Specialty Care?
This is best answered by first understanding it’s origins, firmly seated in the Direct Primary Care movement. As the healthcare industry has continued to move away from providing an environment conducive to practicing responsible, accessible, affordable medical care, leaving both doctors and patients. dissatisfied, several innovative primary care physicians began to look for another business model.
The typical private practice model had, and continues to, become more and more difficult with excessive administrative burden creating higher overhead, a landscape of lower reimbursement and ever greater patient volumes, just in order to exist.
Most of this has been related to the endless metric based regulations tied to governmental payment programs and excessive administrative costs with diminishing returns related to contracting with commercial insurance. They found that a monthly subscription based billing program, opting out of Medicare, not participating in Medicaid and not contracting with commercial insurance, provided a reasonable and predictable revenue stream and allowed significantly lower overhead; satisfying physician leadership an autonomy and, most importantly, the ability to care for patients without so many irrelevant barriers to providing care.
The idea of “Direct Care” is a growing movement, but one that has primarily been made up of family practice physicians.
Those of us that have subspecialized or practice procedural specialties, have found ourselves similarly dissatisfied with many of our employment situations, excessive paper pushing and administrative requirements, a lack of respect, lack of autonomy, nonsensical regulations, difficulties with patients not having adequate access to our expertise and inflated and questionable costs. Some, left employment for locum work, have switched to concierge models, fee for service (FFS) models, or quit clinical medicine.
However, a few are attempting to practice in a Direct Care model, or went back to their primary care training to start DPC clinics. Several of us, who are now well versed in the DPC culture, began to discuss how we could use the model to provide specialty based care; the goal being autonomy for physicians and affordable, accessible care for patients. DSC does not yet have a legal or financial definition in governmental regulations or policy, but the primary values are: physician owned and led, affordable pricing, accessible care, pricing directly between patient and physician rather than 3rd party insurers and the offer of a membership option to keep pricing accessible. There are some practices that may be better suited to a FFS or other models of private practice. We believe that these, although not DPC/DSC, contribute valuable care options to the free market of medicine and we hope to work with them towards better medical care options for our communities.
What is Direct Primary Care (DPC)?
DPC Primary Care clinics charge patients an affordable membership fee, directly, and do not deal with insurance companies, making it available and affordable for everyone. This type of clinic business model is focused on the doctor-patient relationship and putting the patient first. This style of practice has gained momentum as a more affordable option for primary care and specialty care while also providing a higher level of care. Most patients pay a monthly membership fee (similar to a gym membership) which allows them to seek affordable care, providing unprecedented access and a predictable income stream for the physician. DPC clinics have been compared to boutique or concierge practices because they both charge a membership fee. However, there are important differences. Boutique and concierge practices appeal to wealthy and VIP clients and choose to charge significant convenience fees and they still bill insurance for care provided in most cases. DPC is about making care affordable and accessible for more people, while allowing the physician the time and freedom to provide more effective and comprehensive care. DPC clinics charge modestly priced monthly fees and still offer a unique and personalized doctor patient relationship. Most DPC doctors have a relatively small number of patients, roughly 400-800 as compared to the 2,500-3,500 a traditional primary care physician maintains. This allows for more flexible and personalized care. When paired with a health savings account (HSA) or a high-deductible catastrophic insurance plan to pay for hospitalizations and emergencies, membership at Leeton Medical will be similar in cost or cheaper than most medical coverage, with the added advantage of excellent, personalized, and easily accessible primary care. A Leeton Medical membership can also be added to supplement your existing health care coverage; this allows for personalized care, convenience, and flexibility for patients who want full control of their medical care. At Leeton Medical, we offer the additional benefits of greatly reduced laboratory tests and on-site dispensation of some of the most common medications. This will further increase the value of your membership. If you decide to become a member, you will quickly see that we can actually save you a lot of money.
If I take insurance (including Medicare) in one setting, can I just take cash in my own DSC/DPC office?
Medicare follows the practitioner so if you’re opted in your subject to the same rules everywhere and if you’re opted out you can’t be in Medicare anywhere. Some make the argument that offering something like integrative or lifestyle medicine is not part of normal Medicare benefits and so would be subject to an ABN agreement and would fall under this sort of concierge medicine. Most of us have chosen not to wait into that murky area because the last thing you want to do is get on the bad side of Medicare. It affects every future job and application that you fill out. As far as commercial insurance, my understanding is that if you have contracts that you are personally named in and signed on with private insurers, you can’t work outside of those or around them. I don’t take commercial insurance so I can’t speak with authority.
Do any practices participate in Medicare?
Most DPC physicians opt out of Medicare. There are a handful of DPC that have Medicare hybrids. DPC means NO commercial insurance contracts with practices. Pricing and contracting is DIRECT, between patient and the practice. Direct Specialty Care is not yet legally defined or a clearly laid path, so much of this is being actively discussed. Medicare is more likely to be a part of many DSC practices, snd may even be necessary for many specialties, but not all.
The DPC movement in general is about eliminating insurance contracting for the improved happiness for DOCTORS and PATIENTS.
Many of the exisisting Medicare hybrid practices limit the amount of Medicare patients in the practice. The key is that a balance is maintained in avoiding unnecessary administrative work, like trying to comply with Medicare incentive programs such as MIPS etc. Most practices would be able to eliminate additional overhead and administrative work by opting out of Medicare, but have chosen not to for specific, practical reasons. For instance, perhaps during their startup phase, they need to continue to have part time employment or locum work. It is quite difficult to find work outside of your practice, if you have opted out of Medicare, since almost all health care systems are dependent on Medicare funds. Some specialties may commonly involve cost intensive treatments such as biologics or chemotherapy and have panels of mostly Medicare aged patients. This may influence the decision to opt out of Medicare. If you opt out, you can still issue orders, such as admission or order medications and testing that can be billed to Medicare, but you cannot bill Medicare for medical services provided and billed directly to you.
One of the common sayings amongst the DPC culture is “building your parachute on the way down” and that is very much true of the birth of DPC and now DSC, as we are literally defining what DSC is and will be. To our knowledge, there are many specialists working on innovative cash based care models, but very few are doing it similarly to DPC and no one is doing it in quite the same way. However, we all see the need for change and we are all pursuing the path to success. It is our hope to organize, brainstorm, and build a community of peers that support one another and build upon each others’ successes and failures in order to blaze a path for those wanting to leave or otherwise avoid the predominant employed practice model. In doing so, we hope to expand the medical care free market and improve the quality and cost of medical care in this country.
Is there a good place to start for understanding how this all works?
The most defined space is Direct Primary Care. Diving into the world of DPC, soaking in the culture, reading through the social media threads, reading the seminal books about starting DPC, is a great step. DPC already has an established following. It’s a frame of mind and a culture.
Look through the information on DPCAlliance.org and read through their DPC University curriculum. Most of the „most experienced and established” practices are only five to ten years old. The “Direct Care” approach is still novel and very much still evolving. DSC is a mere neonate.
What are the foundational books about DPC?
What websites do you recommend?
Are there any social media resources?
Are there any easy ways to locate DPC practices?
A DPC Mapper can help you locate nearby physicians with practices that run on similar models and fellow doctors with similar goals. Note, there are nonphysician practices in the DPC Frontier mapper. DPC Frontier Mapper
DPC Alliance has a membership directory, Physician only, a great place to find a nearby practice in order to find a mentor, collaborator, peer.DPC Alliance Directory
What about taking traditional insurance but also charging an annual membership fee?
Taking traditional private insurance AND charging patients on top of that, is generally a Concierge Medicine model. That is a different model, that may be worth exploring for yourself. That is not what DSC is aiming for. DSC is attempting to pattern after the basic model of DPC.
How would referrals for new consults work etc.?
Without insurance billing restrictions, patients can directly refer themselves to you at any time. Primary care doctors can still refer to you, as per usual consultation orders. However, for referrals, you have to have clear policies about what payment models you accept, your pricing and structure, and it is best to educate the local physician communities about your structure, so that patients are referred with clear expectations. Remember, reasonable and transparent pricing is a key feature of the DPC/DSC culture, so educating your community on your pricing and process is very beneficial and an overall positive option for care.
Can I just join an existing practice? What if I can’t take on opening my own practice?
If you are hesitant to open your own practice for whatever reason: you are risk adverse, uncomfortable with the administrative demands of owning a practice, don’t want the work load of running a business, then you could certainly consider joining someone’s practice. When innovating and opening a business, there is no reasonable way around taking on some risk. Ideally, you do your due diligence and it is a calculated risk. Individuals that enjoy that type of challenge are best suited or you may find yourself unhappy or in a poor financial situation. To our knowledge, none of the current established DPC practices have an employed specialist at this time, but many are needing and looking to hire another doctor for primary care patients and there very well may be an opportunity to work together or at least in some form of partnership or collaboration. For example, perhaps you share space, or make other mutual arrangements. There are other ways to minimize risk: having low personal debt/overhead/expenses, maintaining Medicare Opt-in status and working part time or taking regular locums work, partnering with a similarly minded physician and opening the office together to share the risk, success and the overhead.
How would specialty medications, such as biologics work in a DSC model?
You are a licensed physician, able to send orders to pharmacies, as per usual. If you prescribe treatments that are generally given in infusion centers or require particular licensing, such as chemotherapy, obtaining or maintaining credentialing with nearby hospital systems is very convenient and beneficial. For routine prescription needs, many states allow office dispensing of medications. As a practice/clinic, you are able to order these at direct pricing (much of the pricing is 50% less than program pricing such as GoodRX) and then dispense to patients at very reasonable prices. You will also likely use Pharma assistance and sample programs. Insured patients can utilize their insurance to pay or access through options you make available, if it is less than their copay or deductible responsibility. Most practices try to offer the price options and allow patients to choose what works best in respect to their budget and resources.
For example, therapeutic phlebotomy at the hospital system infusion center, with all the upcharges,, nursing care, facility fees and so on, can add up to $500-$1000. The phlebotomy kit costs about $5 from medical supply and can be utilized at the office. This is similar for things such as IVF’s. You can utilize specialty pharmacies to handle prior authorizations for oral chemotherapy and such.
Which is less risky - being the first specialist to join an established PCP group, or starting a DSC on my own? I am risk averse, but I’m deeply dissatisfied with my current situation and I am quickly getting burned out.
At the end of the day you are going to have to be okay with some risk. You will need to be able to think outside of the box a fair amount. You will be happiest if you like to do that and enjoy the challenge. In reality, everything about going out on your own has risk. The desire for higher salaries with less risk and less responsibility is how many doctors ended up owned by hospitals and now frustrated and burned out. One way in which the Direct Care model helps, is that a membership component does provide a predictable income rather than feast or famine from month to month. Not only does this allow for more personal stability but it also facilitates building the practice with a predictable revenue stream to base your plans and budget on. Everyone’s situation and personality is different. Learn as much as you can and then decide what your plan is. The very purpose of this organization is to provide a platform for us to support one another and learn from each other.
If DPC charges a membership, how is the concierge model different?
Concierge usually collects from insurance.and charges a „retainer” fee, basically a VIP type set up for patients who can afford to pay that extra retainer to have their own doc at their fingertips. DPC does not bill insurance or contract with insurers, in any way. They charge a reasonable, affordable monthly fee that includes all the doctor’s services and then generally provides cash options for labs, meds etc, so that patients can afford great care without the financial barriers. An example, from an existing practice: patients pay a one time new patient registration fee of $150/month and then ongoing $50/month. If they want to use client lab or rx prices, they can, whichever saves them the most $$. In this practice, client pricing for a CBC is $2.00 and 90 days of Metformin is $1.80. With this model, many patients, for the first time ever, can afford to have regular monitoring and medications. This allows them to properly manage their chronic illnesses or even reverse them. That’s the mission of DPC, the heart of why doctors want to do this. With low overhead and a responsible household budget, many offices will make enough revenue to business overhead and household overhead with 200-300 patients.
In the DPC model, is your income solely from the membership fees, or is there any additional profit from the labs and meds?
Since providing the low cost options for the labs and meds is generally an essential part of making the medical care accessible and successful for the patient, it’s not really a focus to make significant profit off of them. Most practices upcharge by a small amount in order to cover the time and effort put in by their staff and the supplies purchased. Some states prohibit this. Some states prohibit office dispense. DPC frontier has a good state by state rundown. This model is best for you if it starts with your „why”. You’ll have to figure that one out. The general sentiment is that, if your “why” is your enjoyment of doctoring patients, your profits will come from that doctoring. It’s not charitable care. It is the concept that “I am not doctoring in order to be profitable. I am profiting from doctoring, which is what I love to do.”
Do you charge a per visit fee too, or is it simply $50 per month covers all aspects of unlimited care and visits?
In general, there are not usually per visit fees in DPC, if the patient is already paying a membership fee. There may be a one time enrollment fee for new members or a one visit fee schedule for nonmembers. This will vary some from practice to practice.
Can Internists practice primary care and their specialty?
There is at least one practice doing this, possibly more. A typical structure may be maintaining a base membership, such as 200 DPC members, and then taking specialty consults on a FFS basis or adding them as DSC members. Remember, if you have seen one practice, you have ONLY seen one practice. You can do many things, depending on your setting (rural vs metro), your practice style, your innovation and your financial goals. Let’s all work together to find different viable models!