We at CovenantMD are over five years into the project we started when we opened our doors on January 4, 2016. During the few months leading up to our opening, I “hit the pavement” talking with anyone who would listen about the concept of direct primary care (DPC), which at that time was totally unknown in our local healthcare market. I was featured on the front page of LNP on a Sunday morning. I held numerous town halls. I launched our website, launched a Facebook page, and I started a blog. These efforts helped us open our doors with 77 patients. Over the ensuing months and years, we were privileged to be one of the fastest-growing DPC’s in the nation.
As part of our launching efforts in the fall of 2015, I wrote a three-part series on our blog entitled, What is Direct Primary Care? in which I highlighted what I see as the three main tenets of DPC: access, value, and time. At that time, I could only write from the perspective of a doctor with a dream and the readiness to take a risk on starting his own medical practice. The rest is history. We now have two doctors at our Lancaster location, and a second location in York that we opened in January, 2019. I am thankful for our journey so far and excited for the future of CovenantMD.
The blog has gotten a little dusty from misuse the past couple of years. This is due to a combination of factors, the biggest of which was having more prospective patient interest than we could handle (so no need to market our services!). This caused us to begin waiting lists at both locations. It is only now that we’re getting to the end of those lists, and will soon (as of this writing) be able to once again open our website to “live” signups. So there is no better time to dust off the blog and revisit the subject of direct primary care. I’ll again divide the subject into three posts, discussing DPC’s benefits of access, value, and time. I think this go round will be different (and better), as now I’ll be able to speak from my experience of doing DPC for over 5 years.
So let’s begin. What is direct primary care in a nutshell? It is a model of primary care payment in which the doctor contracts directly (hence the name) with his or her patients, and not with a third party, such as an insurance company or the government (as with Medicare or Medicaid). In DPC, patients pay a monthly fee in order to be “members” of the practice. In CovenantMD, this fee is tiered by age (from $20/month for kids up to $85/month for seniors). Because we are paid by our patients, CovenantMD does not bill health insurance for any of our services (with the single exception of vaccines). This opens up a whole host of benefits that the typical primary care practice cannot match, from same and next-day appointments, to substantial discounts on labs and medications, to increased time with the physician.
So why DPC? Why would a doctor leave the security of the fee-for-service world, with its hospital-owned practices and cadillac benefits? Or why would a patient choose to enroll in a DPC practice if they have health insurance that “already pays for” primary care. I think both questions have a common answer: the doctor/patient relationship. It’s just hard, really impossible, to prioritize that relationship while both doctor and patient are on the treadmill of insurance-based primary care. I’ll elaborate with this and my two subsequent posts.
Now let’s get into the nuts and bolts of DPC. First I’ll talk about the concept of TIME. This is the most important ingredient in the doctor/patient relationship. And it is the one least valued in our modern healthcare system today. Why is that? It’s because the modern primary care doctor’s job is to merely a conduit feeding a larger system. He or she is there to prescribe the latest designer drug, to refer to specialists, and to refer for procedures. With such little time in appointments, it is hard to establish relationships, or to delve into the complexity of chronic disease, or to emphasize lifestyle over drugs or procedures. Rather, too often a primary care doctor has no recourse but to be as time-efficient as possible. This means seeing patients as a list of symptoms and lab data, all pointing to a particular “medication deficiency.” Or we might refer to an endocrinologist to treat our patient’s diabetes, or a nephrologist to treat our patient’s high blood pressure, or a dermatologist to do that skin biopsy.
But direct primary care allows us to have ample time with our patients. I’m talking about 30 to 60 minutes, or more, per appointment. How can we do that? If our patients are paying us directly, we’re able to carry far fewer of them on our panels. At CovenantMD we’re averaging about 600 patients per provider, compared to the 2000 to 3000 patients that most of our family practice colleagues are handling in the fee-for-service world. This no longer means 20 to 30 patients a day, but 5 to 8. And fewer appointments means more time with our patients.
Now that I’ve been at this for five years, I’ll tell you the one biggest benefit I see in having that kind of time with my patients: it’s being able to ask open-ended questions, and then sit back and let the patient take the conversation where he or she wants it to go. Questions like, “Where should we start?” or “Can you tell me more about that symptom?” or “What health goals do you have for yourself?” An oft-cited study came out years ago that observed doctor/patient interactions in exam rooms. The researchers found that, on average, the doctor interrupted the patient a mere 11 seconds into their first answer. It’s not uncommon for me to sit quietly for five to ten minutes or more while a patient answers a question. But to be honest, before I switched to DPC, I too was that impatient doctor. With 15 minute appointments (about eight minutes of which was actually doctor/patient time), and 25 appointments to get through, asking open-ended questions was about the worst thing I could do. It was just not time-efficient. DPC makes that a thing of the past.
Just last week, I spent 85 minutes of face-to-face time with a new patient with multiple medical problems. We didn’t have to rush. And we got through her entire list. Adequate time with the doctor means patients leave our office feeling like they’ve been heard and that we’ve listened to and are focusing on their priorities. In short, they feel that they are valued.
That’s what direct primary care is all about.
Patrick Rohal, MD, FAAFP is a family physician and founder of CovenantMD, a direct primary care practice, with offices in Lancaster and York. He lives in Landisville with his wife Lynn and three kids, ages 10 to 14.