Dr. Adam Balin (left) and Dr. Nicole Hemkes at the Fair Oaks Avenue office of Advocate MD.
These days the idea of having a doctor hanging out a shingle for a solo practice, without being a member of an HMO or other health care service network, may seem like something out of Mayberry. But this model, known as direct primary care, is growing in the Madison area.
In 2019 when Dr. Nicole Hemkes opened Advocate MD in Middleton, she was the only direct primary care doctor in the area. (Several doctors had tried similar models in the Madison area in the past and failed.)
Hemkes has now opened a second office on Madison’s east side and is looking to add a third location. This month, another direct primary care option emerged when Dr. Amanda Preimesberger opened her practice, RootsMD, in Verona. And Dr. Wendy Molaska is planning to open the area’s third direct primary care office, Dedicated Family Care, in Fitchburg this spring.
Direct primary care differs from the medical system in the U.S. as we have come to know it. Doctors charge patients a monthly fee, after an initial enrollment fee, kind of like a health club membership. The doctor does not bill insurance, and direct primary care is not insurance. For the monthly fee, patients can see the doctor as many times as they want and can call the doctor at any time. Generally these practices cover health and wellness, chronic disease management, urgent care (colds and flu, sprains and other sports injuries, lacerations, strep throat and the like) and some procedures, though these will vary from practice to practice. The doctor also refers patients to specialists or helps set up other procedures with private labs or smaller hospitals, at more reasonable costs than a large insurers’ bill. Hemkes sees direct primary care as being a “one-stop shop” where she can even be the pharmacy, providing most drugs at lower cost without co-pays.
The idea is that the direct care doctor can see patients more often, know them better, and keep them healthier. Most people who opt for direct primary care also take out a high deductible or “catastrophic” health insurance plan.
Since Hemkes started Advocate MD in 2019, much has happened to make patients feel increasingly at sea in the health care system. Legal threats to the Affordable Care Act continue, and health insurance costs remain a burden for many Americans. COVID-19 limited the ability of primary care providers to see patients; the virtual doctor visit reigns.
But keeping patients out of a clinic waiting room during COVID wasn’t a problem at Hemkes’ office, where she continued to see one patient at a time.
Hemkes opened the Fair Oaks Avenue practice in August, adding a second physician, Dr. Adam Balin. She hopes to add a third office location with a third physician. Currently Hemkes and Balin split their time between the east and west locations.
Advocate MD has also added more in-office services including X-rays, ultrasounds, cardiac monitoring, prolotherapy and vasectomies.
Hemkes has started working with small employers who have added direct primary care (with subsidized or covered membership fees) as an option for their employees, which can then be paired with a high deductible insurance plan. “These are often businesses with 5-70 employees, which I did not have in the beginning,” says Hemkes, who appreciates the greater stability this brings to her practice. She’s also talking with larger businesses who might also want to offer their employees a direct primary care option.
Dr. Amanda Preimesberger opened her office, RootsMD, in Verona on March 1. She left SSM Health after 12 years to start the practice. “I’m not worried about demand,” Preimesberger says.“Especially in the last five to seven years, patients are paying more than ever and getting less time with their physicians.” And she as a doctor felt “frustrated within the system. The to-do list was escalating. You feel like you can’t do a good job or practice to your full extent.”
Dr. Amanda Preimesberger
Big medical systems are under pressure to make money, Preimesberger says, and their physicians are seeing so many patients a day they’re burning out. At the same time, it’s harder for patients to get a doctor, as nurse practitioners and physician assistants take over more of the primary care duties.
Preimesberger says she had 2,300 patients under her care previously; at RootsMD, she hopes ultimately to have about 450 patients. “I think there are enough folks out there who are looking for something different,” she says.
Preimesberger knows that it will take time to get 450 patients, but she is confident: “It’s not going to happen overnight, but it is a long game that requires a little patience. There is financial risk to me doing that, but I believe in it so much.”
In addition to wellness, chronic condition care and urgent care, she also offers prenatal care through 28 weeks for an additional fee; then she helps transfer the patient into the system to get ready for delivery. OB-GYNs like to get the referrals, she says, as these are generally healthy, low-risk pregnancies; at the same time, Preimesberger can be “way more accessible to [pregnant women] than a 10-minute prenatal visit in the system.”
The larger medical systems do have their place, Preimesberger says. “We need hospital access and access to advancing technology, but if you can carve primary care out of that — we can do a better job more efficiently and [it’s] less costly. We take some of the burden off the system, yet can still be the source for the referrals to specialists when needed.”
Preimesbeger planned for her move to direct primary care for over two years. She’s temporarily renting a small office while building her own clinic from the ground up in downtown Verona. She hopes that new space, which will have three exam rooms and one procedure room, will be ready by mid-September. There’s room there for her to take on a partner; in the meantime some of the space can be sublet to a medical professional like a psychologist/counselor or physical therapist.
So far the patients that have come to her have had “a variety of stories as to why they think DPC will work for them,” says Preimesberger. One is an independent contractor without insurance but who wanted access to preventative services and basic primary care. People, she says, are “trying to navigate health care outside the system.”
Another direct primary care option is headed to Fitchburg: Dedicated Family Care. Dr. Wendy Molaska has worked in a variety of health care settings, from hospice to a federally qualified community health care center to UW Health. She sees direct primary care as a better way to help patients with everything from diabetes to weight loss to mental health — with a focus on a person’s personal goals for health.
Dr. Wendy Molaska
Molaska is finalizing an office space while accepting patients and fielding questions via her website.
She is especially concerned about equity and inclusion in access to health care and sees direct primary care as a path to that. She also plans to provide discounts to care when that is needed: “After all, I’m running this business, I can charge people what I want.”
Patients, she says, are “fed up” with the length of time it can take in the big systems to get to see their own doctors, and the short visits when they do. Direct primary care offers her the opportunity to “do medicine the way I like to do medicine.”
