My Direct-Pay Primary-Care Practice: 2 Years Out

I'm still standing.

When I left my "normal" practice over two years ago and opened up my new "direct-pay primary-care" practice a few months later, I had no idea what a significant statement, "I'm still standing," would be. It's not that the practice of medicine has gotten significantly harder (much to the contrary), but running a business from start-up to steady success is something I had absolutely no training for. Despite this fact, my practice has grown close to 600 patients, and what was once a radical change in care has become a happy "normal" for me, my staff, and my patients.

Here are three things the past two years have taught me:

1. This model really does work.

Here is the model I adopted (and have yet to change):

• Patients pay a monthly fee of $30 to $60 per month (depending on age). There are family discounts and a $50 registration fee. I don't require a commitment for a certain number of months.

• There are no copays for office visits. (I found copays added complexity without increasing income significantly.)

• Labs and procedures (such as immunizations) are done at cost.

• Patients get access to me via secure messaging or phone messages.

My patients are extremely happy (with very few of them leaving my care). While the increased patient panel has made caring for immediate problems a bit of a challenge at times, we continue to focus on giving an extraordinary customer experience and high value for all patients. We also continue to work to improve care for our patients who are not in the office. (Something I never did in my old practice). Finally, we still have significant room for growth, and I am finally seeing a steady-enough income to not be nervous about paying my bills at home.

2. New ideas take time to be accepted.

Given the unusually good experience I give my patients (and the usually bad customer service given in most other practices), it would seem that people would flock to my practice. But even for people who were my patients previously, most still don't understand how paying a monthly fee could bring significant value to their healthcare. People don't understand that consulting myself or my nurses about a perceived urgent problem can often prevent a visit to the ER (or hospital). Nor do they understand the principal of turning away from high-volume care, so that we can give our patients high-quality, high-value care. Yet an increasing number of people who tried my practice but were initially scared off by the cost, have now rejoined and are gladly paying our monthly fee.

3. Healthcare can still be a "mission."

An axiom of business states that: Those working in a business must have a significant financial stake in the business's success for it to succeed. Yet there is another force that isn't often addressed: the mission of the business. My nurses share my passion for our patients, and have expressed gratitude and excitement at, once again, being able to do whatever our patients need. Interestingly, the patients themselves share in this emotion, constantly thanking and encouraging us for our work, (and being far more patient when we miss our mark). For those who think the "calling" of healthcare is lost, I emphatically offer my practice as proof to the contrary.

I think the direct primary-care model is still young, and so is still only for those brave enough (or crazy enough) to make the change. But from where I now stand, two years after making my first patient encounter (as a house call), I am confident that I've found the right way to give care to my patients. It's right for doctor, nurse, and patient - and it is right because it has a mission that works to reduce the cost of excessive and unnecessary care. My practice is not close to being perfect, and it certainly isn't easy, but it continues getting better each month - which is something I could never say in my old practice.

Robert Lamberts, MD,who is board-certified in internal medicine and pediatrics, practices in Augusta, Ga. In October, 2012, he left his "traditional" primary-care practice and opened a cash-only "direct care" practice.  His writings on this and other topics can be read on his popular blog, "Musings of a Distractible Mind." Dr. Lamberts can be reached at rob.lamberts@gmail.com.