More Colorado primary care doctors are opting out of insurance as direct-pay model grows

After seven years in medicine, Dr. Rebecca Bub knew she needed a change.

She was burned out from working long hours in primary care. An attempt to fix the problem by switching to a part-time schedule hadn't helped, because she had to see the same number of patients in half the time. So she decided to strike out on her own, opening a direct primary care practice in Jefferson County where she sees only five to 10 patients in a day, compared to the 25 to 30 she previously juggled.

With the extra time, Bub says, she can work through each patient's needs — and even help them find the lowest-cost option if they need care her office doesn't offer.

"You're not getting the doctor's best" when providers are pushed to see too many patients, she said.

Direct primary care, a health care model under which patients pay a monthly fee and their doctors don't bill an insurance provider, has been growing in Colorado and nationwide. How far it can scale up remains to be seen, however, since providers see fewer patients, and buying a membership isn't feasible for everyone.

Some patients choose not to have insurance at all, but doctors don't advise that, since they would be vulnerable to large hospital bills.

Colorado has 90 direct primary care practices seeing about 63,000 patients, which is 256% more patients than in 2018, according to data from Hint Health, a company that connects direct primary care practices with business customers. The state has one of the highest direct-care patient rates compared to population in the country, it says.

Colorado's well-established direct primary care community has encouraged doctors who are considering a switch, said Dr. Brad Brown, a physician in Erie and medical director for Hint Health. Patients in the area also are particularly interested in a different model, he said.

"It wouldn't be a favorable environment if the demand wasn't there," Brown said.

"We're not just on the conveyor belt"

Katie Clark, a Littleton resident, said she started seeing a direct primary care provider about six years ago, when her second son was struggling to gain weight as an infant. Before that, she said, the doctor she'd been seeing could only offer relatively quick appointments, which didn't feel personal and increased her anxiety.

Now, all three of her children are doing well, but she's stayed with direct primary care. She likes the hour-long appointments and the feeling that her doctor knows them personally.

For her family, it's also cheaper. They don't have insurance and rely on the combination of the primary care membership and a health-sharing arrangement. (While health sharing is generally cheaper than insurance for people who don't qualify for subsidies, some patients have been left with large bills because those arrangements don't have to cover pre-existing conditions.)

"I like the feeling that we're not just on the conveyor belt," Clark said. "They listen, which I think is a hard thing to find."

Demand for primary care services in general is growing fast in metro Denver. Its residents had about 5% more visits to primary care providers between January 2021 and March 2022 than they did between January 2019 and March 2020, according to Trilliant Health. Visits are expected to increase another 3.7% by 2026, more than double the average projected increase nationally — at least in part because so many people in late-middle age have moved to the area in recent years, Trilliant's market trends report said.

Dr. Vance Lassey, president of the Direct Primary Care Alliance, estimated that a new direct primary care practice opens somewhere in the country at least once a week. He said he switched from working at a hospital-owned clinic to running a direct-care practice in 2016 because he felt that the pressure to bill as much as possible was doing financial, if not physical, harm to patients.

"I was burned out because I couldn't do my job," he said.

In a typical primary care practice, each provider could be responsible for anywhere from 1,000 to 4,000 patients, according to Fierce Healthcare. Direct primary care providers see far fewer.

Dr. Kyle Hampton, owner of Arktos Direct Care in Fort Collins, said he limits his patient load to 350 at any given time. Some can't afford insurance but can manage a $100 monthly fee. Others just like having hour-long appointments where they can talk in-depth about nutrition and wellness, he said.

"We can tailor things a lot to prevent chronic disease," he said.

Primary care field faces increasing shortages

While doctors and patients may like the more personal relationships they build in a smaller practice, it's not clear how the health system as a whole would fare if many providers decided to cut back.

The Health Resources and Services Administration estimates the country was short about 8,000 family medicine physicians in 2020. It projects the gap may expand to 14,000 by 2035. The American Association of Medical Colleges estimated the broader primary care field, which includes some pediatricians and geriatricians, could be short between 17,000 and 48,000 doctors by then.

That shortage is at least partially offset by increases in the supply of nurse practitioners and physician assistants, who can provide some primary care but are typically required to work under a doctor.

Still, if a majority of primary care doctors reduced their patient loads along the lines of the direct-care model, it could exacerbate the shortage.

Supporters of direct primary care argue that the shortage is at least partially due to working conditions, which foster burnout and encourage people to leave.

"If everyone practiced like this (with fewer patients), we'd have plenty of primary care physicians," Bub said.

The other major question is money. Whether patients spend or save more with direct primary care depends on how their insurance is structured, whether the additional attention spares them from expensive care like hospitalizations, and other factors.

Lassey said that in his practice in Kansas, the fee is based on age, with 40-year-olds paying about $50 a month for their routine care, for example. If primary care is affordable, he said, patients could purchase insurance only for catastrophic incidents — in the same way that they have car insurance in case they get in a crash, but not for routine maintenance.

"Why are we insuring something that can be affordable?" he said. "Primary care does not need to be insured."

That model doesn't exist at this point, though, because federal law requires insurance plans to cover most primary care services. It's not clear if carving those out would generate enough savings on insurance to cover patients' memberships, since most of the cost of health insurance is for drugs and hospitalizations.

As is, the financial trade-off varies from person to person.

Someone with a high-deductible plan who frequently needs primary care might find that it's cheaper to buy a monthly membership, rather than pay for each service. Someone who only needs care once or twice a year is less likely to come out ahead financially, particularly if the insurance plan doesn't require them to shoulder high out-of-pocket costs.

Dr. Brieanna Seefeldt, founder of Direct Osteopathic Primary Care in Lakeside, said that under the traditional model, each office needs people in charge of billing and coding so they can get paid by insurance. Doctors then have to see more patients to cover the overhead costs — and then they risk having to hire still more people to manage insurance claims, she said.

"When you bill insurance, it's like running on a treadmill," she said.

Unlike a traditional model, in which the doctor is paid by the visit or service, the monthly payments from direct primary care provide a stable income, Seefeldt said. The challenge is to maintain a balance of high- and low-need patients, since her practice and most others don't limit the number of visits members can make, she said.

Direct primary care isn't right for everyone, since patients drawn to it expect deeper relationships as part of their membership, Seefeldt said. But it does give providers the time to be "advocates" for their patients in ways they often can't, she said.

"It brings the joy back into that relationship on both sides," she said.