A growing club: Membership-based direct primary care reimagines health coverage [The Keene Sentinel, N.H.]

Nov. 12—Before Siobhan Benham started her own medical practice, she was consistently overwhelmed by her job.

The nurse practitioner saw upward of 22 patients in a 12-hour shift — about average for a primary care provider. Able to spend just a few minutes per appointment in order to keep up, Benham said there was never enough time to really listen to people.

"I forgot how much I used to apologize. 'I'm sorry the front desk was rude. I'm sorry the [medical assistant] didn't listen to which arm to take your blood pressure,' " the Peterborough resident said. "I mean, you'd be exhausted before you could even get to the meat of the visit."

Now, her patient intakes look much different.

She sees between four and six patients per day, taking 30 minutes to an hour to talk with each about their medical concerns. Her patients also have her personal phone number so they can call, text or video chat with her.

Benham's focus has shifted, too. She's no longer mainly reacting to serious health issues, but rather working with patients on how to prevent them.

This is all made possible through direct primary care — a model in which patients pay a monthly fee directly to their provider for services instead of the physician billing insurance.

Benham's clinic, Hearthside Family Health in Peterborough, opened in 2017, joining several others across New Hampshire and the country.

"We wanted to just take medicine back to what it used to be," said Dr. Carrie Klonel, a partner and physician at Hearthside.

The DPC model

Though the concept of direct primary care predates insurance and the health landscape we know today, it gained traction as an official model of care in the 1990s.

There are now more than 1,850 of these practices in 48 states and Washington, D.C., according to DPC Frontier, which tracks direct primary care providers nationwide and helps facilitate the movement's growth.

The website lists eight in New Hampshire: Hearthside, as well as practices in Keene, Concord, Lebanon, North Hampton, Manchester and Portsmouth.

Experts say the combination of provider burnout, patient dissatisfaction and ballooning employer costs in traditional primary care settings has led to an uptick in these alternative practices in recent years, as well as more patients using them.

From 2017 to 2021, the number of active direct primary care clinicians per 100,000 people increased nearly 160 percent nationally, according to 2022 data from Hint Health, a direct primary care management platform. The data show that the number of more traditional primary care providers went up only 6 percent in that same time frame.

Patient membership has also grown. In 2017, there were 48 direct primary care members per 100,000 people, the data show. By 2021, membership had bumped up to 163, translating to a 240 percent increase over those four years.

In addition to more time with their doctor in person or via telehealth, patients of these practices receive primary care with no copays or surprise medical bills. And, without insurance companies acting as a middle man, providers say patients often get wholesale pricing on medications and tests. House visits are typically offered too, if needed.

Direct primary care patients are also less likely to require a trip to the emergency room or be admitted to the hospital due to the preventative care available to them, various studies show.

One case study by the global Society of Actuaries — cited in an academic article published by the American Journal of Lifestyle Medicine in April 2021 — found a nearly 13 percent decrease in overall demand for health care services and more than a 40 percent reduction in emergency department visits compared to those with traditional health plans.

And without having to bill insurance, physicians under this model have more time and a low overhead, with no need for receptionists and similar staff. Typically, the practices employ only one or two providers

"It's kind of eye-opening — the freedom and the happiness that I feel that I want every doctor to know is possible, without being a professional cashier," said Dr. Aurora Leon, co-owner of Monarca Health, a direct primary care practice in Keene.

Pros and cons

The monthly fee for direct primary care services varies drastically nationwide, but in the Granite State, the memberships range from about $30 to $125, depending on the patient's age.

Generally, memberships include in-person and virtual visits, wellness checks, nutritional counseling, sutures, biopsies, chronic-disease management and other primary care needs. It's also common for direct primary care practices to offer basic laboratory and pharmaceutical services at an additional, wholesale cost.

Some direct primary care patients still carry a high-deductible insurance plan for non-primary medical care and emergencies, but others just pay out-of-pocket costs, which can be discounted for people without coverage.

Critics of the model have argued that the monthly fee is too expensive, especially for those on a fixed or limited income who may not already be paying for medical insurance.

All five of the direct primary care providers interviewed by The Sentinel — from in and out of state — said they try to work with patients who may not be able to afford their membership by offering a sliding payment scale.

Skeptics of the model also worry that adding more direct primary care practices could actually worsen the ongoing primary care physician shortage.

Dr. Bob Berenson — an institute fellow at The Urban Institute, a nonprofit research organization in Washington, D.C. — said because direct primary care providers take on fewer patients by design, it could make it harder for people to find care.

"My opinion is that [direct primary care] is pretty good for docs, but not necessarily good for the health care system," he said.

Kirk Sanger, assistant professor of nursing at Keene State College, echoed Berenson, saying he, too, worries that the model could exacerbate the need for physicians.

But, generally, he said he feels direct primary care is "super multifactorial" and that it's "neither good nor bad."

"I think it has potential both to fail and to really help people; it just depends on how it's implemented," Sanger said.

Local physician, patient experiences

At Monarca Health — which opened on Keene's West Street in 2020 — the monthly membership fee starts at $69 and goes up to $109. The practice does not see children.

Co-owned with her life partner, Dr. Joaquin Carral, Leon said Monarca has about 200 patients, with a goal of reaching between 400 and 600.

Among them is Sara Henry of Alstead.

The 33-year-old is Leon's neighbor, which is how she first heard about the practice and the direct primary care approach.

Henry described her previous primary care experience as "unsatisfactory."

"It's been so hard to get access to my primary care provider. I'll make appointments online or I'll call the secretary at the office, and it's either months out or they just send me right to the ER," she explained.

Under Leon's care, Henry said her relationship with medicine has changed. Not only does she get 24/7 access to Leon if needed, she also is receiving the preventative care she didn't think "was ever possible."

"I love how the things that need resolving ASAP, she's there, either telehealth or in person," Henry said. "But then, yeah, the longer-picture things, she'll just teach me. She'll educate me, she'll empower me to find the resources that I need."

Hearthside in Peterborough offers monthly memberships for children and adults up to age 26 for $30, $55 for those between 27 and 59 and $80 for anyone older.

Benham said she and Klonel have about 650 patients combined, which is their capacity. They stopped accepting new patients for now, but have a waiting list in case someone cancels their membership.

Jessica Hipp, 40, of Temple, and her family of four have been patients at Hearthside for nearly five years.

She said she felt "really rushed" with other doctors and that her copay was "incredibly expensive."

"It was always, 'Am I really gonna shell out $50 or $75 to talk about this thing or do I wait until it gets worse?' And of course, with kids, it adds up," Hipp said.

One of her children, Eli, 8, has asthma, and her daughter, Miriam, 4, has a rare medical condition. So for Hipp, having consistent access to a provider has been helpful to manage their symptoms.

"I think when I first switched, it was definitely a leap of faith, but I don't think I would ever go back to the traditional system at this point," she said. "It feels a lot like what I experienced as a kid: that family doctor that knew not just our health, but what was going on in general in our lives."

Providers also said the ability to design their own schedules allows them to do more outside of work, and while in the office, their time is freed up to focus on the patient.

"If I'm less stressed, and happy, then I have space for empathy and to be there for whatever the patient comes in for," Leon said.

The same goes for Dr. Eric Kropp, physician and owner at Active Choice Healthcare in Concord. The direct primary care practice was the second to open in the state, launching in 2016.

"All the things that were a problem, that prevented me from being able to take good care of my patients, were not an issue with direct primary care ... ," he said. "I could have the kind of practice — a small practice — that I wanted and make ends meet and take really good care of [my] patients."

Initiatives out of state

In some parts of the country, providers have doubled down on the direct primary care model to give residents more independent health options.

Table Health in Traverse City, Mich., has been offering direct primary care since 2020. Operations Manager Christine Straley said the local hospital system has a monopoly on health care in that community, which is why the practice decided to try a different model.

That's similar to the Granite State, with Dartmouth Health and other hospital systems owning a majority of practices, including in the Monadnock Region.

"We worked really hard to make sure our prices were affordable and we really value transparency in everything we do," Straley said. "So, the big hospital conglomerate doesn't love what we're doing — they may see us as a threat — but we don't care because we're helping people ... and that's all that matters."

Table Health is the only direct primary care provider in its area, with about 350 patients, according to Straley. And as the practice continues to grow, she said Table Health plans to expand its offices across northern Michigan and further into the Midwest. This December, it plans to open its second office in Petoskey, Mich.

She said the company has been able to draw more patients through community conversations and by working with local businesses to offer direct primary care memberships as their employee insurance.

For example, Table Health is working with a local manufacturer, which operates four other companies under its umbrella. The hope, Straley said, is to have between 150 and 200 people sign on to Table Health through those employers.

"If we can start a practice at half capacity, that's a big win-win for everyone," she said.

Monarca and Hearthside have also worked with a handful of area businesses to help expand their clientele, both owners said.

And in Maine, the first health insurance with direct primary care at its center, known as Taro Health, hit the market this month, allowing these patients to use this model while expanding their coverage beyond primary care.

Co-founder and CEO Frank Wu said the company was founded in 2021 and began offering its insurance plan to Cumberland County residents on Nov. 1 through the state marketplace.

"My co-founder and I discovered direct primary care, and we were enamored by the model and the amount of access it gave to patients," he said. "... We took that concept and thought, 'Why are people not buying into DPC today?' "

The answer, Wu explained, was people were already paying for insurance, medications, co-pays and other non-medical bills. So, rather than asking residents to get rid of their insurance or tack on another monthly fee, Taro Health took direct primary care and turned it into a revamped insurance plan.

The benefit to that goes beyond cost savings. As a major insurance plan, Wu said Taro Health must include health benefits beyond primary care.

"We built a network that includes DPCs, and then a network on top of them with specialists that DPCs trust ... MaineHealth is one of our primary partners, so that means Taro Health [patients] can not only see a DPC, but they can go to any of the MaineHealth specialists," he said of the hospital system.

Taro Health is sticking to the one county for now, but Wu said the company eventually hopes to expand to the rest of Maine and states across the country.

Looking forward in New Hampshire, local direct primary care providers said they hope to see more growth within their own practices and outside of them to diversify and increase options for residents.

"I'm a big advocate for independent physician-led practices, whether its DPC or anything else," said Kropp of Active Choice. "I feel like that's really critical to maintaining choice for patients."

Funding for the Monadnock Region Health Reporting Lab comes from several sources, including The Sentinel and several local businesses and private donors. We continue to seek additional support. The newsroom maintains full editorial control over all content produced by the lab.

Olivia Belanger can be reached at 352-1234, extension 1439, or [email protected]. Follow her on Twitter @OBelangerKS.

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