Dr. Leslie Surbeck felt like she was always telling her patients she was sorry. As a primary care physician in a busy clinic operated by a major health care system, she said she often had to apologize to her patients for running late, for being hard to reach or having a fully booked schedule.
This wasn’t the way she wanted to practice medicine. “Year after year of continually having to say you’re sorry to people for running behind does take an emotional toll,” she said.
When the health care organization decided to restructure her clinic and move physicians to other locations, Surbeck took it as a sign that she should do something different. She began looking into new ways to practice medicine.
One option she discovered was direct primary care (DPC), a model of medicine where patients pay physicians directly, based on a fixed monthly fee, without sending claims to insurance providers. In a DPC model, physicians are able to see fewer patients, allowing them to be more responsive and to spend more time with each appointment.
After a lot of research and outreach, Surbeck felt confident that DPC was the right model for her. She reached out to Dr. Anita MacDonald, a former colleague who had also been told she needed to relocate, and asked if she’d be interested in opening a DPC practice. MacDonald, who’d shared Surbeck’s frustrations with the pressures of insurer-driven health care, was excited. She’d actually been researching DPC on her own.
“A lot of it was finding each other,” MacDonald recalled. “I had been thinking about doing it myself, but it seemed like such a big thing to do alone. Leslie told me, ‘I’m going to do it. If you want to join, I’d love it.’” (Disclosure: MacDonald was formerly my primary care physician.)
The pair then met Dr. Shary Vang, a physician who’d worked in an international medicine clinic operated by the same health plan. Vang too was enthusiastic about DPC.
“We were all trying to look for our next career move,” Vang said. “We were all thinking, ‘Where is that going to be? At another health organization? Outside of medicine?’ For me personally I was contemplating whether to leave medicine altogether because it has changed so much for me from what I wanted.”
Once they understood that they all had the same objective, Surbeck, MacDonald and Vang decided to go into business together. In October 2021, they opened Evergreen Primary Care, a small DPC clinic located in a medical building a few blocks North of University Avenue in St. Paul.
Evergreen patients pay a set monthly fee ($30/month for patients age 12-17, $60/month for patients age 18-39, and $80/month for patients age 40 and older) in exchange for unlimited visits and direct physician communication. In-office procedures and annual routine labs are included for no extra cost. The clinic does not bill insurance companies, and emergency care, visits to specialists and complicated medical procedures must be handled by other providers.
The partners all said that the freedom that comes from running their own practice in the way they feel best serves their patients is empowering. Without the pressure to stick to patient quotas or work within specified time limits for visits, they’re beginning to realize that they have the power to operate a medical practice in the way they’d always wanted to.
“We haven’t had to say, ‘I’m sorry’ for so long that when we had a vaccine drive in our office a while ago and people had to wait 10 minutes for their vaccine I started saying, ‘I’m so sorry,’” Vang recalled. “Then I realized I haven’t had to say ‘I’m sorry’ in my job for months. It was a great feeling.”
Pros and cons of DPC
Direct Primary Care isn’t for everyone, especially patients who need to regularly see specialists for specific health concerns, or for people who can’t afford a membership. MacDonald, Surbeck and Vang say they have tried to keep their prices affordable for most people.
“For the average 50-year-old it would cost them $960 a year,” Vang said. “Then if you add to that the occasional blood test that you might do it might get closer to $1,000 a year for out-of-pocket to be a member of the practice.”
People with high-deductible insurance plans who rarely meet their deductible can benefit from a DPC membership, Vang added: “The average deductible in America for a high deductible plan is $4,000 or $5,000.” In those cases, a yearly DPC membership could make seeking medical care feel more affordable.
“A huge number of people don’t go into their clinic very often for routine care because they’re afraid of how much it is going to cost,” MacDonald said. Waiting to see a doctor until you are ill can actually make chronic conditions worse, she said. “In this model, people are more likely to get regular care.”
Many of the clinic’s patients do have insurance and choose a DPC membership as a supplement, sometimes because they have a high-deductible plan or because they have a strong traditional insurance plan but want easier access to their physician.
“Some of what we have right now is people with good insurance but they’re just not happy with the access that they’re getting or the communication and they want a way to have a direct line to their physician,” Surbeck said.
The clinic is also speaking with small-business owners about offering clinic memberships as an added benefit to their employees. “We have one employer who ran the numbers and found that they save on health care costs by paying for the memberships of their employees,” MacDonald said. “They combine it with a higher-deductible insurance. Their employees are healthier.”
While DPC, along with concierge care (an often-more costly approach that charges patients an annual fee in exchange for exclusive access to their physician) is taking off in other parts of the country, Minnesota still has relatively few clinics operating under this structure.
MacDonald thinks this is because for decades, most Minnesotans were pleased with their health insurance options. “People were pretty well covered with insurance here compared to other parts of the country,” she said.
But recent plan and health system consolidations have changed the landscape: “We’re at a point in time now in Minnesota where there is a lot of strain on the system. Everything has gotten so big and complicated. I think there is an amount of dissatisfaction now that wasn’t there in the past.”
More time, less money
Before she, Surbeck and Vang opened Evergreen Primary Care, MacDonald said that she and her partners all felt that their former employers’ requirements that doctors maintain a large panel of patients made it hard to be the kind of physicians they wanted to be.
“We all had independently been looking at the DPC model for a while because of our frustrations with corporate-based health care, where increasingly more and more of our time was spent doing things for insurance companies,” she said. “There’s a pressure to see more patients and a feeling like we had lost our autonomy. We were not able to provide the kind of care we like to provide because we’re just going from patient to patient.”
The DPC model gives the physicians the ability to pick the number of patients they see each day — and the amount of time they devote to each office visit. “You can have an appointment that lasts an hour with your patient,” MacDonald said. “You don’t need to rush.”
Full-time physicians working in most corporate-run clinics often have as many as 2,400 patients. As a part-time doctor, MacDonald was responsible for 1,500 patients, an amount that still felt overwhelming.
Physicians in DPC clinics carry smaller patient loads, usually between 400-600 for a full-time doctor.
In a DPC practice, patients can also easily reach their physician, and when the situation warrants, they can usually get in for an appointment the same day. One of MacDonald’s patients was recently worried about her high blood pressure. “We were emailing back and forth and she called today and asked, ‘Can I come in early?’” MacDonald recalled. “I said, ‘Come on over.’ And I spent an hour with her.”
Because DPC practices are less focused on quick turnaround and building large patient panels, physicians may make less money. But many who have tried the model say that the lower pay feels worth it.
“I’m willing to have less salary to have more balance and time with my patients,” MacDonald said. “That’s important to me.” Surbeck agreed: “I’m willing to make a little bit less in order to feel better about what I’m doing.”
The partners say that one of the biggest differences between their former medical practices and their new clinic is the direct connection they now have with their patients. In the past, if a patient wanted to ask their doctor a question, he or she had to leave a message with a nurse, who would reply in a day or two. With their new DPC practice, MacDonald, Surbeck and Vang give patients their direct phone numbers.
“Our patients call us and they still are oftentimes shocked to get right through,” Vang said. “They often think they are leaving a message with the front desk — but it’s always just us.”
While my Medicare monthly premium rose from $148.50 in 2021 to $170.10 in 2022, my BCBS COST plan (supplemental) DECREASED from $134.50 to $130.00… while INCREASING benefits:
• I have NO copay to visit my physician, and $15 for a specialist or chiropractor (though in actuality, the latter only costs $5.64)
• No referrals needed for me to approach any provider of my choosing (who accepts BCBS)
• Annual physical at no cost
• I pay NOTHING for all lab work, and ALL radiology (MRI, CATz scans, x-rays, and the like)
• $200 for a hospital stay, regardless of length
• TWO annual dental exams/cleanings/xrays (one annual panoramic xrays)
• TWO annual eye exams at no cost – plus $125 toward glasses or contact lenses
• Access to medical care across the entire country (anywhere Medicare and BCBS are accepted, which pretty much includes all 50 states)
The list goes on and on…
If this country (the ONLY industrialized nation without national health care for all) were to expand Medicare to everyone – costs would diminish, and with a similar supplemental COST plan, virtually everyone would have unlimited access to medical care for less than $300 per month (with no deductibles, and minuscule – if any – copays)!
Contrast that to many who pay over $1,000 per month in premiums with astronomical deductibles that prohibit actually benefitting from such unaffordable insurance policies!
The idea that you could expand Medicare and give everyone coverage for $300 per month in completely false. The reason is that the premiums you are paying now are not funding your care. You (and everyone else) has been paying into Medicare your entire working life. Those funds, and the funds being paid by workers not yet Medicare-eligible is funding it.
Putting everyone on Medicare or something similar would likely save money as opposed to private health insurance, but the premiums would rise significantly. Or of not the premiums, the increase in taxes necessary to fund it.
I’m good with paying a little bit more in taxes if it means I never ever got a bill afterwards. Even before I started going through major medical issues this year, having a system with no cost at point of use just makes sense.
It encourages people with minor issues to go in and get checked out before they become major (and expensive) problems, saving everyone heartache and money.
And that’s before we even dip into the problem of scarcity under the for-profit model, which is closing and consolidating sparsely populated rural areas, leaving those people with lengthy drives if they have a medical episode.
We should just get the job done and switch to government run tax funded healthcare rather than dance around our broken insurance system like a kid who has to go to the bathroom but is reluctant to use it after Uncle Bob is done with his business in there.
Sure, I would love to pay a little bit more in taxes to not get bills. The problem is that I wouldn’t pay a little more – I would pay a lot more, especially if we are going to subsidize care in sparsely populated rural areas. Again, the ideas that it would cost $300 person per month for full coverage is absurd.
And the reason we don’t just switch to government funded healthcare is that people overwhelmingly oppose doing that. Its because many Americans have health insurance paid for by their employers. And the people pushing Medicare for all and similar ideas seem to have no idea how healthcare works.
I would love to have government funded, single payer healthcare. But to get there people actually have to understand how it works.
Very interesting.
So if you do this, you still need get health insurance for major medical coverage and specialized care. But instead of paying out-of-pocket for primary care visits under a high-deductible plan, you pay the monthly fee. I don’t think I have every spent more than $1,000 in a single year on primary care visits. I suppose there is non-specialty care where you would, though, right?
Yes!
Hopefully, more physicians do this. You can also bet Insurance and Health Care Inc will try to make it illegal.
Be interesting to see how health care (and health insurance) companies handle the problem if there is a significant departure of PCPs to be in this type of care.
I think they would be happy about it. It would relieve them of healthy patients who take up a lot of unnecessary doctor visits.
I’m a bit confused here. What exactly is it that one is paying for with this membership? From what I can tell, acute care isn’t offered ie, go in for suspicion of say strep throat or some other minor issue, testing for such is also not included. Chronic care that requires a specialist is ALSO not included so for common stuff like cardiac care, allergy stuff etc… one is still on the hook. I mean, I get that the ability to sit and chat with a doctor is nice, is it worth 1000 bucks a year? Seems like a very niche service for a very particular sort of patient, one that requires a great deal of hand-holding and/or direct supervision of a rather limited set of conditions. For the vast majority of either relatively healthy, or particularly unhealthy people this is an added cost without any real benefit.
That is what I was trying to figure out, and I think you are exactly right. This is for people who are healthy but still like to go to the doctor a lot.
The point of this type of practice is to essentially have a “first contact” who can look and see if there is a problem requiring specialist care or if it is a standard problem that can be readily resolved without significant cost. For parents with kids, this is great. Kids do all kinds of stuff that needs a quick check to see if it is a minor problem or more. So, the “get help now” part of the business meets that specific need. IMO, this is not for the people who think they are bulletproof (i.e. they don’t think they need much healthcare). They would not pay the $1k/yr cost because (in their opinion) it is an unnecessary expense they do not need. Until, of course, something happens and they *do* need it. There are other groups of people who would also consider this type of care–for the reasons cited. They do not have significant health or medical issues, so what they are really doing is buying access to the health care system in case they do need it. Cheaper to catch a problem early and have it checked in order to try to stop it before it becomes a major medical expenditure.
But you aren’t buying access to the health care system. You are buying access to a thin slice of it. You still need to get medical insurance – their website explicitly states this. Even with a high deductible policy, you still get the insurer’s negotiated discount and it would take 3-4 visits a year to hit $1,000 in out-of-pocket expenses.
They also don’t treat kids under 12 – its not a pediatric clinic. This is hypochondriac care. This is for healthy people who like to go to the doctor a lot.
But what are they actually DOING once they provide that point of access. Lab work is extra, specialized care is extra, seemingly anything that requires any sort of medical TREATMENT, (you know, what doctors are generally paid to perform?) seems to not be included. What it seems to be is a very expensive, in-person version of WebMD, which hey, if you wanna spend your money, go ahead, but not exactly a health care solution for anyone but a minute fraction of the population.
Pat Terry is correct in his most recent post that Direct Primary Care is not a replacement for medical insurance. If one needs a specialist or hospitalization DCP will not cover you. It is an extra expense on top of an already overpriced mess.
Earlier comments in this thread seem to suggest the US cannot afford Improved Medicare for All. Why would that be true? Multiple detailed studies by top level economists show we can insure the population for less than we now pay. How can this be true? By allowing Improved Medicare for All to negotiate drug prices we would save a huge chunk. Our current mess is so complicated that administrative costs involving insurance companies, hospitals and clinics currently absorbs 30% of our health care dollars. This is twice the administrative cost of single payer systems. Bottom line: 1. The US resident vastly overpays for healthcare (almost double that of other modern countries who insure everyone.). 2. US healthcare results are not as good as other modern countries. 3. Insuring everyone with a single payer financing mechanism would cost us less than we now pay.
There are many myths propagated by the current health care companies to discourage improving US healthcare. Why? US healthcare is hugely profitable for healthcare businesses. They are dedicated to protecting their profit margins…..at the expense of the average person.
Physicians for a National Health Program (PNHP) and Health Care for All Minnesota (HCA-MN.org) are happy to provide you with accurate information. Once you understand the current US mess you will also understand the fix.
To be clear, I wasn’t saying that we couldn’t afford an expanded Medicare system that covers everyone. My point was that it would cost more than the $300 per month suggested because that amount doesn’t reflect the actual costs.