Frustrated with ‘corporate’ health care, three physicians open a direct primary care clinic in St. Paul

22December 2021

Dr. Leslie Surbeck felt like she was always telling her patients she was sorry. As a primary care physician in a busy clinic operated by a major health care system, she said she often had to apologize to her patients for running late, for being hard to reach or having a fully booked schedule.

This wasn’t the way she wanted to practice medicine. “Year after year of continually having to say you’re sorry to people for running behind does take an emotional toll,” she said.

When the health care organization decided to restructure her clinic and move physicians to other locations, Surbeck took it as a sign that she should do something different. She began looking into new ways to practice medicine.

One option she discovered was direct primary care (DPC), a model of medicine where patients pay physicians directly, based on a fixed monthly fee, without sending claims to insurance providers. In a DPC model, physicians are able to see fewer patients, allowing them to be more responsive and to spend more time with each appointment.

After a lot of research and outreach, Surbeck felt confident that DPC was the right model for her. She reached out to Dr. Anita MacDonald, a former colleague who had also been told she needed to relocate, and asked if she’d be interested in opening a DPC practice. MacDonald, who’d shared Surbeck’s frustrations with the pressures of insurer-driven health care, was excited. She’d actually been researching DPC on her own.

“A lot of it was finding each other,” MacDonald recalled. “I had been thinking about doing it myself, but it seemed like such a big thing to do alone. Leslie told me, ‘I’m going to do it. If you want to join, I’d love it.’” (Disclosure: MacDonald was formerly my primary care physician.)

The pair then met Dr. Shary Vang, a physician who’d worked in an international medicine clinic operated by the same health plan. Vang too was enthusiastic about DPC.

“We were all trying to look for our next career move,” Vang said. “We were all thinking, ‘Where is that going to be? At another health organization? Outside of medicine?’ For me personally I was contemplating whether to leave medicine altogether because it has changed so much for me from what I wanted.”

Once they understood that they all had the same objective, Surbeck, MacDonald and Vang decided to go into business together. In October 2021, they opened Evergreen Primary Care, a small DPC clinic located in a medical building a few blocks North of University Avenue in St. Paul.

Evergreen patients pay a set monthly fee ($30/month for patients age 12-17, $60/month for patients age 18-39, and $80/month for patients age 40 and older) in exchange for unlimited visits and direct physician communication. In-office procedures and annual routine labs are included for no extra cost. The clinic does not bill insurance companies, and emergency care, visits to specialists and complicated medical procedures must be handled by other providers.

The partners all said that the freedom that comes from running their own practice in the way they feel best serves their patients is empowering. Without the pressure to stick to patient quotas or work within specified time limits for visits, they’re beginning to realize that they have the power to operate a medical practice in the way they’d always wanted to.

“We haven’t had to say, ‘I’m sorry’ for so long that when we had a vaccine drive in our office a while ago and people had to wait 10 minutes for their vaccine I started saying, ‘I’m so sorry,’” Vang recalled. “Then I realized I haven’t had to say ‘I’m sorry’ in my job for months. It was a great feeling.”

Pros and cons of DPC

Direct Primary Care isn’t for everyone, especially patients who need to regularly see specialists for specific health concerns, or for people who can’t afford a membership. MacDonald, Surbeck and Vang say they have tried to keep their prices affordable for most people.

“For the average 50-year-old it would cost them $960 a year,” Vang said. “Then if you add to that the occasional blood test that you might do it might get closer to $1,000 a year for out-of-pocket to be a member of the practice.”

People with high-deductible insurance plans who rarely meet their deductible can benefit from a DPC membership, Vang added: “The average deductible in America for a high deductible plan is $4,000 or $5,000.” In those cases, a yearly DPC membership could make seeking medical care feel more affordable.

“A huge number of people don’t go into their clinic very often for routine care because they’re afraid of how much it is going to cost,” MacDonald said. Waiting to see a doctor until you are ill can actually make chronic conditions worse, she said. “In this model, people are more likely to get regular care.”

Many of the clinic’s patients do have insurance and choose a DPC membership as a supplement, sometimes because they have a high-deductible plan or because they have a strong traditional insurance plan but want easier access to their physician.

“Some of what we have right now is people with good insurance but they’re just not happy with the access that they’re getting or the communication and they want a way to have a direct line to their physician,” Surbeck said.

The clinic is also speaking with small-business owners about offering clinic memberships as an added benefit to their employees. “We have one employer who ran the numbers and found that they save on health care costs by paying for the memberships of their employees,” MacDonald said. “They combine it with a higher-deductible insurance. Their employees are healthier.”

While DPC, along with concierge care (an often-more costly approach that charges patients an annual fee in exchange for exclusive access to their physician) is taking off in other parts of the country, Minnesota still has relatively few clinics operating under this structure.

MacDonald thinks this is because for decades, most Minnesotans were pleased with their health insurance options. “People were pretty well covered with insurance here compared to other parts of the country,” she said.

But recent plan and health system consolidations have changed the landscape: “We’re at a point in time now in Minnesota where there is a lot of strain on the system. Everything has gotten so big and complicated. I think there is an amount of dissatisfaction now that wasn’t there in the past.”

More time, less money

Before she, Surbeck and Vang opened Evergreen Primary Care, MacDonald said that she and her partners all felt that their former employers’ requirements that doctors maintain a large panel of patients made it hard to be the kind of physicians they wanted to be.

“We all had independently been looking at the DPC model for a while because of our frustrations with corporate-based health care, where increasingly more and more of our time was spent doing things for insurance companies,” she said.  “There’s a pressure to see more patients and a feeling like we had lost our autonomy. We were not able to provide the kind of care we like to provide because we’re just going from patient to patient.”

The DPC model gives the physicians the ability to pick the number of patients they see each day  — and the amount of time they devote to each office visit. “You can have an appointment that lasts an hour with your patient,” MacDonald said. “You don’t need to rush.”

Full-time physicians working in most corporate-run clinics often have as many as 2,400 patients. As a part-time doctor, MacDonald was responsible for 1,500 patients, an amount that still felt overwhelming.

Physicians in DPC clinics carry smaller patient loads, usually between 400-600 for a full-time doctor.

In a DPC practice, patients can also easily reach their physician, and when the situation warrants, they can usually get in for an appointment the same day. One of MacDonald’s patients was recently worried about her high blood pressure. “We were emailing back and forth and she called today and asked, ‘Can I come in early?’” MacDonald recalled. “I said, ‘Come on over.’ And I spent an hour with her.”

Because DPC practices are less focused on quick turnaround and building large patient panels, physicians may make less money. But many who have tried the model say that the lower pay feels worth it.

“I’m willing to have less salary to have more balance and time with my patients,” MacDonald said. “That’s important to me.” Surbeck agreed: “I’m willing to make a little bit less in order to feel better about what I’m doing.”

The partners say that one of the biggest differences between their former medical practices and their new clinic is the direct connection they now have with their patients. In the past, if a patient wanted to ask their doctor a question, he or she had to leave a message with a nurse, who would reply in a day or two. With their new DPC practice, MacDonald, Surbeck and Vang give patients their direct phone numbers.

“Our patients call us and they still are oftentimes shocked to get right through,” Vang said. “They often think they are leaving a message with the front desk — but it’s always just us.”

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