Direct primary care may be the free market approach long sought by many

There are now an estimated 15 DPC providers in Wisconsin, and 1,300 across the country.
Nicole Hemkes

We don’t often talk about doctors and entrepreneurs in the same conversation. Here in HMO-dominated Madison, independent clinics such as Wildwood and Associated Physicians are the minority. Rarer still is an emerging model known as direct primary care, or DPC. The concept: An enterprising medical doctor hangs a shingle, bills a monthly membership rate instead of pay-per-service and doesn’t accept insurance.

“Two years ago I had never even heard of direct primary care,” says Dr. Nicole Hemkes, who opened her Middleton DPC clinic, Advocate MD, in November 2018. After 10 years practicing in larger health care systems, she’d grown disillusioned with jampacked days that seemed more focused on billing and coding than patient relationships. When a colleague in another state told her about starting a DPC practice, she researched the model and found a growing national movement. “I felt like I could, for the first time probably, put my patients first in a way I couldn’t as an employed doctor,” she says. Within three months, Hemkes opened for business. Now her Middleton practice has grown to nearly 400 patients, and in August she opened an east Madison location with a second doctor to preserve a manageable patient-to-doctor ratio.

While that patient load may seem high, Hemkes notes that a traditional fee-for-service, insurance-based doctor has about 2,500 patients in their panel. She used to see as many as 25 patients a day before going home to spend hours filling out the patients’ charts. Now Hemkes sees between five and 10 patients a day.

For a monthly flat fee of $22 per child and $66 to $111 for an adult, members get a range of chronic disease management, preventative and acute services; labs and procedures; and deep discounts on hundreds of generic medications. Hemkes estimates cutting out insurance has lowered overhead costs by 30% to 50%. Her flexible schedule allows for fitting in last-minute visits, or making phone calls to price shop procedures outside her scope, which vary widely — hence the name, Advocate MD.

“There’s a whole profession of people out there called patient advocates. Some are nurses, some pharmacists, but basically they get paid to advocate on your behalf,” she says. “But the fact that we need a whole profession to do that says something about how broken the system is.”

When the coronavirus pandemic hit, it was business as usual for Hemkes. With a low volume practice, she never had groups sitting in a waiting room. She already used telemedicine, and home visits were already part of her practice. She never suffered a personal protective equipment shortage or struggled to obtain COVID-19 antibody testing kits.

DPC is the free market answer some have been waiting for. Hemkes says a third of her patients have no insurance and another third have a high-deductible insurance policy. The remaining third have full health care coverage but “they’re just sick of the system,” she says. “They’re willing to pay the extra $60 or $80 a month to get a doctor they can actually spend more time with.”

DPC isn’t for every doctor, though. Like many entrepreneurs, Hemkes was faced with the tough choice of leaving a busy but lucrative job with good benefits for the flexible but uncertain world of self-employment. For physicians who might have hefty student loan payments equivalent to a mortgage, that swap can be a particularly — sorry — hard pill to swallow. “You have to be somewhat of a risk taker,” she says. “It’s a leap of faith like starting any business.”

Hemkes hopes other physicians will take that leap. There are now an estimated 15 DPC providers in Wisconsin, and 1,300 across the country.

“I hope in the coming years we see more free market-driven health care alternatives like DPC, like more outpatient imaging facilities and more private specialists outside the system, because that will drive down costs,” she says. “And I think once people see that health care doesn’t actually cost as much as we thought it did, then they might be more open to looking at these sort of alternatives.”

Maggie Ginsberg is a monthly columnist and senior contributing writer for Madison Magazine.