Ramstad: The Minnesota doctor’s offices where you don’t need insurance

I’ve got a physical checkup next month and a dilemma: How much can I tell my doctor about some elbow pain without converting a preventive visit covered by insurance to a nonpreventive one that will cost me hundreds of dollars out of pocket?

If Dr. Laura Slings was my doctor, there’d be no dilemma.

Earlier this year, she started True North Direct Primary Care in White Bear Lake. Her patients become “members” of the practice, with adults paying $90 a month. No insurance is involved.

For their membership fee, patients can see her as often as they like, usually with same-day availability, and talk about whatever they want to without ever worrying about insurance, health networks or unknown fees. She offers all the services of a regular family practice, including stitches and casting. Lab work costs extra, though much of it is surprisingly inexpensive.

“I had a mom whose 2-year-old woke up with a rash and a fever. A lot of times those things are viral, and you don’t necessarily have to come in,” Slings said. “I said, ‘Can you just text me a picture of the rash?’ And so she did, and I thought it may be scarlet fever. And I replied, ‘I think you should bring her in.’ We tested for strep. It was positive. She got a prescription. She’s out in 15 minutes.”

Slings, who spent 20 years working as a family physician in one of the major health systems in the Twin Cities, said her patients used to wait two to three months to see her. And she began to notice over the last few years that they seemed more reluctant to open up about their health.

“Money would be in between us as a patient and doctor,” Slings said. “They had issues they wanted to talk about with me at their physical, but yet they didn’t know how much their bill was going to be afterwards.”

There are just a dozen or so doctors in the metro area who have set up direct primary care practices, or DPCs. Slings and her husband Steve, office administrator at her practice, recently hosted a meet-up for doctors who had started or were interested in direct care. Twenty-seven came.

Nationwide, approximately 3,000 doctors have opened DPCs. In a country of 1.1 million physicians, that’s a small step back to the days when people went to neighborhood doctors and paid directly for care. Even so, it’s a fascinating swing of the pendulum, and it may accelerate as Congress considers whether to allow Medicaid patients to turn to DPC physicians.

It’s happening because both doctors and patients are tired, upset and confused by sprawling care provider networks and the gigantic insurance firms that police and pay them. Doctors are burned out seeing patients in an assembly-line fashion and being pressured to “code” their interactions in ways that draw more revenue from patient and insurer.

Patients want more interaction with their doctors and a better idea of what they will have to pay.

“People have found our practice to be a place of healing and a place of trust where they can come and ask us the silliest questions and the hardest questions,” said Dr. Shary Vang, who started Evergreen Primary Care in St. Paul with two partners in 2021. The DPC clinic has since added two more and is now the largest direct-care practice in the Twin Cities.

“The strength of primary care is when you have a physician who is in a space [where] they can listen to you,” Vang added.

For doctors, the economics are promising. Some charge a flat fee for all ages while others, including True North and Evergreen, assess lower fees for children and higher ones for people 65 and over. Both clinics offer discount pricing for families.

With a client base of 500 to 600, a fraction of the 2,000 to 3,000 they might see in a major health system, a DPC doctor charging an average monthly per person fee of $80 would generate around $500,000 in annual revenue. That would well cover the average salary for a family doctor, which is about $225,000 nationwide, and leave room to pay for other expenses, perhaps an office administrator and part-time nurse.

For patients, the calculation can be more complex. Slings and Vang told me most of their patients maintain insurance to cover emergencies or the prospect of hospitalization. Some turn to health shares, many of which are organized by faith organizations and serve as pools of funds designed to cover catastrophic care for their members.

If the deductible on your medical coverage is high, like mine, then taking on the additional fees of going to a DPC doctor represents a gamble.

It will pay off if you wind up visiting the doctor two or three times in a year on top of a physical. That’s because for most single adults with a high deductible policy, a physical is usually covered but each additional visit can be several hundred dollars, costs paid out of pocket until reaching the deductible of $2,000 or $3,000 or more. Cumulatively, those out of pocket costs could exceed the annual cost of a DPC doctor.

For a couple or family, it seems to me there’s a greater likelihood of needing a doctor multiple times before reaching the deductible, even if that threshold is higher than for a single person.

Of course, even if it costs extra, some people may feel it’s worthwhile to have more time and quicker access with a doctor. If direct primary care proliferates, new types of insurance may form around it.

For the Slings, starting a DPC clinic yielded immediate nonfinancial rewards. Laura said she enjoys being able to spend more time with patients and no longer feeling pressured to generate revenue for a larger system. Steve, who has become adept at finding discount prescriptions and other cost-saving services for patients, said his wife’s stress level has gone way down.

“It’s still a business. It takes a lot of hard work,” he said. “But I can see the joy and satisfaction she has when she gets to make a difference for these patients. And that happens a lot where, at the end of the day, she’ll just say, ‘I feel like I helped so much today.’”