Direct Care. No More Middlemen.

Direct Care. No More Middlemen.

“Pizza places often promise to get your pie over to you in ‘30min or less.’ I’m a primary care doctor serving the underserved (and proud of it!) but my appointments are 15min slots. The delivery guy has more time to bring you your pizza than I do to manage your diabetes, console you on the passage of your mother and schedule you your mammogram. System’s broken.” – A Facebook post I made during residency in October 2017

It has been seven years since my post, and regrettably, the system is still very much broken. I am excited to announce that after extensive research, reflection, and introspection, I am ready to declare the model for Sana Sana Clinic: a direct primary care practice. There are a few of you who have heard of this model before, but for many of you this will be a new idea. In reality, this is actually a very old business model and can be explained in rather simple terms. As a physician, I offer a service–in this case that service is primary care. As my patient, you pay me for this service in the form of a monthly subscription fee directly. I will not be billing insurance nor government agencies. As such my contract is between myself, and you, my patient; not your insurer, and not Medicare or Medicaid. No more middle men. It is clear to me that this is the superior model to deliver the kind of care my patients deserve, and be the physician I was trained to be. 

You will have access to me that would simply not be feasible in a more traditional practice. My total patient count will be in the hundreds, not the thousands. I will know your name and I’ll give you the time you deserve to talk, uninterrupted. I will be there when you need me, and can dedicate much more time to you and every one of my patients as individuals, the way every one of us deserves to be treated. It is impossible to know where you are going without first having a grasp on where you are, and in discussing this “new” practice style, it is helpful to take a moment to acknowledge the (many) shortcomings of the traditional insurance based model. I have been both patient and doctor in the traditional system, and am intimately familiar with the difficulties. 

When employed in the traditional system, it was not uncommon for my patients to tell me they had waited weeks for an appointment with me. Despite having well over 3,000 patients under my name, the industry continued to demand I see more. I typically saw about six new patients every day without consideration for how many patients I was already responsible for. This is the current industry standard; it is not the fault of any individual, and my prior employers were no greedier than the next. It is a rather simple numbers issue. Under the insurance-based payment model, I am paid for every encounter I have with a patient. However, the reimbursement rate for these encounters has been steadily declining since the early 2000s. While this rate is going down, the cost of running a practice has risen tremendously in terms of wages and staff needed for billing, coding, regulations, the cost of supplies, the cost of insurance coverage, and general inflationary pressure. Simply put, we are paid for visits with patients but if the payment per visit is decreasing while the costs of running business are increasing, it is an equation from which there’s only one conclusion: increase the number of visits. More volume equates to more money. That might work for a shoe factory, but it reaches a limit when we’re talking about human beings. I don’t know what that limit is but I do know we crossed it so long ago most people do not remember or know what a primary care doctor is meant to be. 

Patients aren’t benefiting from the reduced payments to their doctors either, instead paying more by the year for high deductible insurance plans and increasingly shorter appointments with longer wait times before the visit and in the office. Predictably, this trend is reflected in a massive generational shift. Given the difficulties in access to care, large swaths of the population are opting to forego primary care entirely, instead resorting to the Urgent Care or  Emergency Room, even if they don’t consider the issue urgent or emergent. I am a millennial, a member of the largest adult generation in the country. Data from 2021 revealed that close to 32% of my millennial peers do not have a primary care doctor. In my sister’s cohort, Gen X, the percentage of those without primary care is closer to 9%. Frankly, I don’t blame my fellow millennials for opting to cut out the primary care doctor. The average wait time for an established patient who is calling in for a sick appointment is about 6 days! By the time you are seen you’re likely better or in real bad shape, and that’s only if you already have a primary care doctor. If you are looking to establish care, you can join the waitlist. May the odds be ever in your favor (spoiler: they are not). There is an urgent care on every other street corner. They don’t know your name and they don’t know much about you but they’ll take care of you and if you’re really lucky they might even be able to tend to you urgently. There is no true relationship, and these doctors are swamped with issues that would be best addressed with their primary doctor (and at much lower cost). This is not how the system was ever intended to operate. 

We have to do better, and we can do better. I am not a pioneer of this model but certainly an early adopter. If I am coming across as overly excited about this practice, it is because I am. There is no greater zealot than the new convert. Gone are the days of spending two hours on documentation and administrative needs for every one hour spent with a patient. That is not hyperbole. That is the actual ratio of time allocation for the typical primary care doctor in the old model. I will be freed of the need to over document the visit to increase my bill to your insurer. I can spend more time listening to you, and looking at you, instead of my computer screen. I can also dedicate more time to your care, in a much more meaningful way. If you are sick, you can reach out, and expect a prompt response. I will be available when you need me. As long as I am still accepting new patients, your wait time to see me will be counted in days, not weeks or months. There will always be a role for urgent cares and emergency rooms, but I will be available to handle most of these needs at no additional cost. It is estimated that close to 90% of a typical patient’s needs can be tended to by their primary care doctor (if they could manage to be seen), and I am intent to prove that. I am not a replacement for insurance, and indeed, I want every one of my patients to carry catastrophic coverage at the least, but there is no need to dole out for a premium plan. For about the cost of a monthly cell phone bill, you will have unprecedented access to your “old school” doctor, and yes, I will offer house calls when they are needed. When I have finalized my pricing tiers, they will be clearly posted on the website. No more surprise bills weeks or months after the fact. There will be much more to come, I hope you will follow along as we reshape primary care. 

American Medical Association. (2021). Medicare Payment Chart 2021. Retrieved from AMA.

Busch, F., Grzeskowiak, D., & Huth, E. (2020). Direct Primary Care: Evaluating a New Model of Delivery and Financing. Milliman, Inc. Retrieved from Hint Health.

Marso, A. (2021). What Millennials Want Out of Primary Care, and How to Deliver It. Family Practice Management, 28(3), 29-33. Retrieved from American Academy of Family Physicians.