Pros and Cons of Switching to A Subscription Practice

Doctors are burning out.  They are tired of working for insurance companies instead of patients.  They are tired of spending more time looking at computer screens than listening to patients.  They are frustrated at the ever-increasing rules that dictate how they must practice and afraid of the consequences should they step outside those rules, even in error.  While one option is to quit practicing medicine altogether (and many doctors are doing so), there is another option that an increasing number of doctors are choosing: Subscription medicine.

Four years ago, I was faced with this dilemma when I had a "divorce" from the other partners in the practice I had worked in for 18 years.  Do I join another practice or a hospital system and jump back into the insanity of healthcare? Do I go to a "safe" practice, like the VA, where the conditions might not be great, but the payment system isn't as chaotic?  Or, do I start a solo practice, and make my own kind of practice in the form I want it to be?  Obviously, the last option is wide open, as it encompasses many different models of care, ranging from "traditional" fee-for-service to high-end boutique practice, micro-practice, and the no-frills low-overhead alternative some solo docs are embracing.  As I looked at the options, a last choice emerged as the most compelling to me: direct primary care (DPC).  DPC is basically a low-cost subscription practice (under $100 per month) where insurance is not accepted.  All payment comes from the patient, giving the DPC physician ample motivation to give as much value to the patients as possible.

I've written multiple articles on the subject, so if you want more details you can go back and read those, but my reality is that I am now four years out and have nearly 700 patients in my practice (with only two medical assistants on my staff).  I have succeeded in building a self-sustaining subscription practice, where my patients pay between $35 and $65 per month for care.  Given my relative success in building this unique practice, I am often asked if I would recommend following the path I have taken in DPC.  It certainly is not for everyone, as it was not easy.   So here is my advice, my pro's and con's, about starting a DPC/subscription practice.

Cons

Let's start with the negatives, as it is good to paint a realistic picture about things.  The first and largest negative about subscription medicine is that you may not earn as much money as you did in the fee-for-service world.  While my income has continued to steadily rise over the last four years, I have yet to reach the income I had in my old practice.  I think it's unrealistic to think otherwise.  Plus, I had several years of significant austerity where I was building the practice and relying on money I had saved.  Even the best planned practices will take time to become profitable enough to pay you a good salary, so you should expect and plan for a significant pay cut.

The second negative of being in a subscription practice is the relative isolation you have from the rest of the medical world.  I left a practice with five physicians and two advance practice providers, I also had lots of interactions with other physicians in the community, through committees and physician organizations.  But these organizations and committees are largely formed around the fee-for-service payment model, and leaving that behind, I left my medical social life behind.  I do still interact some with specialists and other primary care doctors, but I must be much more intentional about it than in the past.

Pros

The biggest positive of a subscription practice is the freedom to focus on the patient.  Once you are no longer obligated to document for insurance compliance or submit data for government programs, you feel an amazing freedom to focus on the person who actually should be at the center.  I spend much more time with people now, teaching, explaining, listening, and consoling.  I do those things I wanted to do, and am rewarded because my patients are also my happy customer.  It truly is far better for me, my staff and my patients in terms of relationship.  "I'm sorry" is not said much. "You're welcome" is often said.

The other big positive is that I get to really focus on the practice of medicine.  I feel much more like I am doing the job I was trained to do: listen, diagnose, come up with a plan, solve problems, and educate.  In the last days of my old practice I remember feeling a sense of despair at the lowering of the quality of care I was giving to my patients because of all the other demands on my time.  Now I don't have to worry about that.  I really get to practice real medicine, and that's an incredible thing.

Obviously, I am biased toward the subscription practice.  I am looking from the perspective of one who has a successful, growing practice.  Certainly, anyone who is considering moving toward DPC or other subscription models should do their due diligence.  Visit practices who are doing what you want.  Talk to other doctors.  Go to conferences.  The more you know, the less pain you will have and the easier the transition will be.  Subscription medicine is not for everyone, but it certainly is the best decision I've made as a doctor.