Patients pay a flat monthly fee for unlimited visits to Dr. Nicole Hemkes.
It’s a truism these days to call the health care system in this country “broken.” Insured or not, patients find their health care hard to navigate. Doctor appointments have dwindled to 15-minute slots, and that’s when people can even see a doctor. More primary care is going to physician assistants or what the industry calls “mid-level providers.”
What happened to the good old days when people just — went to the doctor?
Dr. Nicole Hemkes, a direct primary doctor, would like to bring them back. She is likely to be at the front desk when a patient arrives at her unfussy but contemporary office in Middleton Hills, and the experience is personal. “Just because people have insurance doesn’t mean they’re getting the care that they need,” says Hemkes, who launched her direct primary care (DPC) practice in January.
The DPC model gets back to the days when more doctors maintained private practices. But instead of paying for each office visit, patients pay a flat monthly fee — like people do for Netflix, or a gym membership — for unlimited visits to the doctor. DPC does not accept insurance, and it is not insurance.
“The concept was, we can do this much better if we cut out the insurance. We could see fewer patients and spend more time with them, [and have] lower overhead,” says Hemkes. And if people didn’t have to deal with co-pays and deductibles, they’d go to the doctor more often, and be healthier in the long run.
DPC grew out of so-called “concierge” medicine about a decade ago. (Like DPC, concierge doctors charge a membership fee, but they will sometimes bill insurance.)
Hemkes charges an initial enrollment fee of $99/person or $222 a family. Membership costs vary with age. An adult aged 19-30 would pay $66/month, age 40-59 $88/month and age 60-89 $111/month. One child is $44/month; additional kids are $22 each. The fee includes prevention and wellness, treatment of chronic conditions, everything from broken bones to mole removal, and most common maladies. Hemkes recommends that people take out a “catastrophic” or high deductible insurance plan or buy a health-share policy (a kind of cooperative, often faith-based system). Included in the monthly fee are specialist consultations via a telemedicine specialist service Hemkes subscribes to called Rubicon MD.
Hemkes has two spacious exam rooms; one is scaled a bit more toward kids. There’s even a mini lab onsite where she does common tests like blood count, comprehensive metabolic panels, lipid panels and urinalysis. She also maintains a small pharmacy for common prescriptions. These she offers to patients at wholesale. A typical visit with her lasts 45 minutes to an hour. She’ll even do a house call for a small additional fee.
Direct care can work for people who are basically healthy, but also for people who have chronic illnesses who may tend to get shuttled around a lot in this system, says Hemkes. “Family medical doctors are trained to do a lot, but these days they don’t get to do it.” When doctors spend more time with a patient whom they know better, they can often diagnose a problem clinically “instead of ordering tons of labs and unnecessary tests,” she says, which drive up costs. “We can cover 95 percent of problems with outpatient primary care.”
It may not be a good fit for those with diseases that require very expensive medicines.
She calls her practice Advocate M.D. “because doctors should be advocates for their patients. Most people don’t understand a lot of health care, so you explain, you advocate on their behalf, you get them the appointment they need with this or that specialist.”
This advocacy includes her negotiating lower costs for her patients for procedures and tests she can’t do herself. Patients who needs a CT scan can go to the UW, but if they can drive to an outpatient clinic in suburban Milwaukee or Rockford, what might be a $3,000 test can cost $250. Hemkes, who previously worked as a doctor for a group that staffs small hospitals in Reedsburg, Stoughton and Monroe, notes that going to one of those hospitals for a test can be much less expensive than in Madison. “It’s all about giving the patient choices,” Hemkes says.
Doctors are not trained to think about costs of procedures. Yet “knowing the cost is important and is one of the tenets of thissystem,” says Hemkes. “You know all the costs up front, say the cost of an X-ray or ultrasound before you go.”
DPC has been slow to catch on in the Midwest, which is heavily insured, and HMOs are well established here.
Hemkes says one of the challenges of starting her practice in Madison has been that “there are not a lot of private doctors here anymore,” and few independent specialists with whom to negotiate for services. This isn’t true of other areas of the country, where the DPC model has really taken off — she cites Texas, Florida, Oklahoma. Elsewhere in the country, there might be a dozen primary care physicians in a city the size of Madison.
The direct care model does not solve every problem. Sarah Davis, associate director of the Center for Patient Partnerships at UW-Madison, says that “we need a variety of models in health care, and cost control. Flat-fee can be a good idea versus fee-for-service, but it will work for some people and not for others. And it’s not a long-term solution for health care. Ideally, everybody gets insurance.” But, Davis notes, “we have a huge problem of physician burnout in this country, and the principles of this model really address many of the issues that lead to job dissatisfaction.”
A 2018 Wisconsin Legislative Council Study Committee on direct primary care looked at the care model but ultimately did not propose any legislation. In 2017, a Senate bill was proposed to clarify that DPC is not insurance at the same time proposing a pilot program within Medicaid. It failed to pass the Senate.
Hemkes grew up in Florida. She went to medical school at the University of South Florida and completed her residency at Wake Forest; she’s worked in urgent care, in ERs, as a hospitalist and an outpatient doctor but was always “owned by a big system,” as she puts it. “Physicians are burned out and unhappy with assembly line medicine. I feel like there are a lot of good doctors who are trapped in a system where they have very little say.”
In the short time since she’s been open, Hemkes has signed up about 100 patients. Her goal is 500 to 600.
“I’m not a change-averse person, but it’s a little scary because I’m doing this by myself,” she says of launching her practice. “But in general I felt like I was escaping and this was the only light at the end of the tunnel. Owning something and taking care of patients the way I think is right is so much more rewarding for me.”
Advocate M.D.
3205 Glacier Ridge Road, Middleton
608-268-6211; advocatedpc.com
