How direct primary care reduces primary care costs

In an age of family physicians literally not being able to give away their practices, Brian Forrest has built a successful model that is similar to the age of Marcus Welby where there was a direct relationship between a patient and their doctor. Practices such as Forrest’s Access Healthcare in North Carolina run unencumbered by insurance hassles.

As word of Dr. Forrest’s direct pay practice has spread, he has had a constant stream of physicians visiting his practice so others could learn how he has a successful financial model, happy patients and a sane lifestyle – something increasingly less common in the hamster-wheel model of primary care that is prevalent in current fee-for-service based primary care practices. Dr. Forrest runs a cash-only practice sees 16 patients a day at a maximum, works a 40 hour week and takes home more than the average family physician a year with a highly satisfied patient base that pays less than those in fee-for-service, insurance models.

Dr. Forrest embodies a rapidly expanding cohort of what could be called Do-it-Yourself Health Reformers. That is, they aren’t waiting around for politicians to fix what is widely understood to be the broken facets of healthcare. Rather, through their own trial and error, they are refining care and payment models that are demonstrating impressive results.

Dr. Rushika Fernandopulle commented on the Do it Yourself Health Reform movement. “I do think that what we need to fix heath care is not more regulation, but innovation. I think many companies in healthcare simply look for market imperfections and try to take advantage of them- e.g., if there is high reimbursement for doing something, they just provide lots of it. I think the interesting companies are ones that truly can provide better quality (experience and outcomes) while lowering the total cost of care. Another way to state it is that they increase value for the customer- it’s what drives the rest of the economy.“

The need for true innovation is being recognized by the investment community. For example, venture capitalist Mark Suster has been on record as saying that healthcare is one of the truly big problems that entrepreneurs and venture capitalists should pursue rather than more trivial problems like another social media tool. Historically, much of the healthcare venture capital investment has gone into biotech and medical devices. However, increasingly there’s recognition that health outcomes and cost reductions can be achieved more effectively with new care and payment models and their underlying technology.

Not only is his monthly fee very affordable compared to insurance-based primary, he is also saving his patients significant money for ancillary services. By removing the insurance bureaucracy from his practice, dramatic savings ensue. The following table illustrates the savings:

Local alternatives Dr. Forrest’s practice
Metabolic Panel $169 $29
Cryosurgery to remove plantars warts $329 $49
EKGs, cholesterol panels, diabetes tests like HgBA1C, TSH (thyroid test) etc EKG: $225 

TSH: $150

Included in annual physical or access card

Dr. Forrest answers my questions below on how his innovations are working and their background.

Dave Chase: How do you make the lives of patients palpably better?

Brian Forrest: We create an access point to quality health care that did not exist for patients before.  People who had no insurance can now afford primary care for less than the cost of a carton of cigarettes per month.  For insured patients we provide longer visits with more streamlined service since none of their visit has anything to do with what insurance they have.

DC: How are you lowering overall costs?

BF: We lower costs for primary care by around 85%.  Getting rid of the overhead associated with billing and filing claims is a big part of that.  Also, getting buy in from specialists and ancillary service providers to give patients “cash up front” discounts for paying directly can reduce many of these costs by a similar margin.

DC: How do you engage and activate the patient in their care?

BF: First of all, we spend more time with patients- on average 3-4 times longer than a traditional practice.  We utilize that time to do teaching about goals, medications, and to coordinate referrals and resources for lower costs medication.

DC: How do you provide rapid access to care?

BF: We have had an open access schedule ever since we opened the practice where half of the visits each day are scheduled and we leave the other half as empty slots.  That way they can be filled by patients who need to be seen that day due to scheduling or acute needs.

DC: How are you contributing to improved patient outcomes for maintaining the health or helping with their chronic disease your patients have?

BF: We have participated in a PDSA (Plan-do-Study-Act) cycle of Quality Improvement continuously and have an independent auditor assess our outcomes data every three months.  The data shows that for blood pressure control, diabetes control, and cholesterol goals we are in the top tier percentile in the US.  It also shows that every quarter we continue to get better.  Essentially, you look at where you are, identify where you could improve your patient care based on an independent auditor, come up with a plan to specifically implement best practices and evidence to improve outcomes, then measure your outcomes and repeat the process.  Sort of like a sharp knife- it may already be sharp enough to get the job done- but you can always give it a slightly sharper and finer edge.  Just to give you some tantalizing data- the national average for the percentage of patients controlled to their goal blood pressure is less than 50%.  In quarter 2 of this year our practice had 85% of our patients Systolic Blood Pressure at goal.

For an anecdote- Several years ago a woman came to our practice for the first time- her husband had left her and dropped her health insurance the same day (and her 16 year old son’s too).  She was diabetic and could not afford any insurance due to this preexisting condition. Her first year after he left, she told me she spend about $5000 on medical care.  This consisted of an annual exam and 4 follow-up visits for her diabetes including blood work, office visits, an EKG, and ancillaries.  She had worked about 60-80 hours per week at two retail jobs in that interim year and could still barely afford her care and medication.  Then she found us.  When she arrived her HGBA1C was 11.9- meaning very poorly controlled.  One year later- her A1C was 6.8 (well controlled) and she had only spent about $450 for an entire year of care with us- including the annual physical, all of her follow-up visits, all of her lab work and ancillaries. As she told NPR in an interview a few years ago “We were a God send for her.”

DC: How have you (or will you) demonstrate increased patient satisfaction and how do you measure this?

BF: We use patient satisfaction surveys – we keep these relatively short to get more people to fill them out but they have routinely demonstrated an average of 5 on a 5 scale.  We still listen to and respond to any suggestions or input that patients might make in the open-ended questions.  I have actually published some of these survey results in an abstract for the Journal of Clinical Hypertension for May of 2011.

DC: How do you demonstrate high tech and high touch?

BF: We are almost totally paperless, with e prescribing, electronic records, etc.  However, I personally do not normally even take the computer in the room with me- rather I sit across from the patient and listen- often for 30 minutes,  I take a few critical notes on scratch paper if needed and then put the electronic note in the computer as soon as I exit the room when I am doing their electronic prescription refills.  The patient might not even see my computer at my office, but I am leveraging the power of electronic data to ensure better care.

DC: How do you demonstrate teamwork with other clinicians?

BF: We typically have “team huddles” at the beginning of the day to plan out what the needs of each patient might be that day and how we can best coordinate their care.  We usually do this again either at the beginning or end of lunch- for follow-up on items form the morning and to plan for the afternoon.  Having a smaller staff generally means much more efficient communication.  We definitely function as a team. Everybody knows how to “play their position” and generally waits on me just to “take the snap.”

DC: How do you increase the overall value of the healthcare services delivered?

BF: We offer full scope primary care with advanced chronic disease management for about 85% less than what those service would typically cost- that’s value- especially when the clinical outcomes are superior.  We also bundle some services (like annual comprehensive physicals).  For many patients on an Access Card- the annual physical is totally free.  This means for prevention we are putting our money where are mouth is.  Imagine a patient who normally comes in only for high cholesterol finding out that they can get a comprehensive exam with lab work, EKG, Prostate cancer screening, or PAP smear for no additional fee.  It really encourages people doing their annual physical and we have discovered a lot of disease that patients had never known about these, because at other offices they had been unable to afford to get screened.

DC: How do you simplify rather than complicate the process of getting care?

BF: Our office is ONLY about providing health care.  Since we do not have to worry about coding, billing, various CPTs, ICDs, claims appeals, etc. We can focus on patient care.

DC: Have you done anything to scale this beyond a single site/clinician?

BF: I have done lots of consulting and speaking for other organizations and docs around the country, am in the process of launching franchises and affiliate practices across the country (Direct Pay Health), and have written numerous articles in Medical Economics, Physicians Practice, and Family Practice Management.

DC: What is the biggest obstacle to expanding what you have done more rapidly? If you could have any assistance, what would it be and where would it come from?

BF: The biggest obstacle is Physician Inertia.  It takes time for physicians to be willing to embrace change of any type, as many have in the past been happy with the status quo.  However, in this era of rapidly changing health care policies and budgets, the status quo is just no longer acceptable.  Once physicians fear of the new and unknown is less than their fear of what is getting ready to happen to the practice of medicine, then you will see a sweeping movement of physicians moving to new models like direct pay.  I think the assistance in moving this forward comes from getting the word out to docs that are afraid to “stick their toe in the pool” to “Come on in the waters fine.”

DC: Who else is innovating in the healthcare arena that is an inspiration to you?

BF: There are tons of people that I have taken cues from.  I remember reading about a physician in People magazine that was in Vermont that had left her traditional practice to start “Simply Medicine” about 10 years ago.  I also read a lot of articles from Dr. Gordon Moore at the time I was starting the practice. He was even braver than I opening an office with no staff at all to prove the “low overhead” point.  Others have been successful doing slightly different models like Robert Berry, MD in Tennessee at the PATMOS clinic where each fee for service is based on the presenting complaint.

Dave Chase is CEO of, a Patient Relationship Management software company, previously founded Microsoft’s Health business and was a consultant with Accenture’s Healthcare Practice.  He can be found on Twitter @chasedave.

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  • solo fp

    A few price updates. Metabolic Panel $169 $29? Medicare allows an average of $14 for a CMP. Cryosurgey by most insurance companies is between $40-$60 allowable. EKGs are only $11-$23, avearge $16 by insurance and Medicare. TSH average $23 for Medicare.
    Three years ago I set my fee schedule to be my best PPO + 10%. I have about 15% self pay patients who appreciate the more than fair fees and willing pay their bills. I have done less free/charity care, as the fees are very fair for office visit and labs. My local lab charges $119 for a lipid panel, and I can do it for $20 in the office. Most hospitals and labs have inflated fees that hurt the self paying patients. The true fees from insurance and Medicare are much lower.

  • Stephen Schimpff MD

    Dr Forrest is doing what I predict more and more physicians will do. He is recreating the direct patient-physician professional relationship rather than a patient-insurer-physician relationship. This is as it used to be and as it should be. It saves a lot of money and, since so many patients have chronic illness, it allows the physician and team to actually take the time to coordinate the care needed. This by itself will save very large sums of money. while markedly improving care and satisfaction. And for those with insurance (commercial or Medicare), they may think the office fee is “extra” but it actually means less expense in the long run. Whether a fee for visit as with Dr Forrest or an annual retainer system, this will be the future of primary care if it is to survive.

    • Dave Chase

      Dr. Schimpff, I agree wholeheartedly that it should return to this. While I understand the power of inertia, I wonder what your perspective is on why this isn’t happening faster. It seems so clear when there’s such a high dissatisfaction amongst primary care physicians (over 50% saying they’d leave practice if they could). Meanwhile MDs such as Brian Forrest, Samir Qamar (MedLion), Garrison Bliss (Qliance), Vic Wood, Jerry Reeves and countless others not only are driving better health outcomes, they have imminently more reasonable practices (and make more money) by returning to the direct patient-physician relationship.

      While written with recognition that catastrophic insurance is critical to have (and a touch of humor), there’s a Declaration of Insurance Independence that has been written that Primary Care Physicians should review —

  • http://deleted pcp

    I think the figures for EKGs, etc., are in the wrong column.

    • Dave Chase

      You are correct. I’ll notify Kevin of the transposition.

    • Dave Chase

      This has been fixed. Thanks for alerting us.

  • Smart Doc

    Outstanding post. Best thing I have read in months.

    For those (like me) who are interested in more info on Dr. Forrest:

  • Janet Vessels

    I think you are beginning to get this healthcare situation more in line with what is reasonable. I am a mental health professional in private practice and feel suffocated by the insurance companies, I would like to be able to help children and families without starving my own family. I myself do not have healthcare for myself for several reasons, but the biggest reason is cost. I would have a high deductible and still not be covered for what I need since I am in good health. It’s more cost effective to pay cash, although I’ve not found any physician willing to negotiate prices. Thanks for your ideas on the new improved healthcare system. Finally, insurance companies have some competition!

  • Margalit Gur-Arie

    Here is what I don’t understand about this type of practice:
    What happens when the patient needs more than office visits to a primary care physician?
    The lab work, as solo fp wrote, is in the ballpark for other insurers, but how about meds and specialist care and hospitalization and imaging?
    If people are expected to buy insurance on top of this prepaid service, as I think is recommended by its practitioners, then is the Direct care recognized towards the conventional deductible?
    Also, the primary care portion of medical expenses, including the items mentioned in the table, is not the bulk of expenditure for sick patients, or health care in general. So what I am left with, from patients perspective, is an extra cost of about $500 per year for personalized quality routine primary care office visits.
    It is nice, but is that all it is?

    So if an HMO would pay you $50 a month per patient, plus $10 copay for each visit, would you be able to see 16 patients a day, work 40 hours, and provide excellent care? Would would be a comfortable panel size?

    • Dave Chase

      All good questions. Let’s break down the economics using some real world examples from both the MD and consumer standpoint. These aren’t meant to address ALL possible scenarios but it does help to take it from the abstract to the real world.

      The MD examples are those that have eliminated the vast overhead associated with their insurance billing. In one case I know of, one doctor has literally no other staff (he schedules apptmts himself, etc.).

      Panel sizes vary in these lower cost retainer models. Typically they vary from 800 to 2000. The amount they charge also varies but I’m commonly seeing them in the $50-70 range per month. This means there’s a gross revenue with those panel sizes from roughly $550k to $1M. Even with overhead (e.g., nurse, office space, computers, medical equipment), that leaves quite a bit left over. Qliance has most broadly published results and they are impressive – great outcomes, high patient satisfaction, etc. for a panel that mirrors the general population. Other such as Brian’s have similar results.

      From a consumer standpoint, when you combine the direct primary care model with a high deductible wrap-around, that can still save 30-50% off of a traditional policy with all kinds of limitations. That excess money is what I use to fund a Health Savings Account while getting a much better patient experience. Health Insurance has the lowest average Net Promoter Score (industry metric for patient satisfaction). Qliance has published their score and it’s higher than Apple or Google.

      On a related note, this sort of model has shown itself in vexing chronic disease populations. A reasonable sized pilot in Ohio of Medicaid diabetics has shown savings that if scaled statewide would be over $500MM per year. What state couldn’t use those kinds of savings. They did it with a combination of primary care MDs, health coaches and pharmacists.

      It seems we’ve done everything imaginable to complicate things when the formula is quite simple worldwide. More primary care = healthier population = less spent. That formula has been so successful in Denmark (by applying the Patient-Centered Medical Home principles) that they’ve cut in half the # of hospitals they need and expect it will be reduced another 40%. They simply don’t need that many hospitals with a healthier population. An ounce of prevention is worth a ton of cure.

      Self-funded employers realize this and are taking matters into their own hands before they are bankrupted by healthcare. Hopefully governments will figure this out. Brian Kleeper wrote about that here –

  • solo fp

    Good overall article. I do labs in the office for my diabetics and can do 4 visits a year with a CMP, A1C, urine tests easily for the $450 that you mention. I keep many patients on the Walmart $4 list for meds. The difficulties include patients with high deductible plans who do not want to pay for low cost labs or office visits. I can do an A1C for $7 and CMP for $11. I’ve gotten my UA cost down to 35 cents. I often discount my self paying patients to $80, yet most self pay patients do not want to come in more than 2-3 times a year with the diabetes or HTN diagnosis. 90% of my diabetics have an A1C less than 7, self pay or insured.
    I have found the price point for insured patients is the $35 copay. $35 makes the patient think twice about coming in for a visit. The average premium for a family of four is $19,200 for 2011, with the patients pyaing around 20% to the insurance company and the employers picking up the other 80%. Most high deductible patients attempt to get longer intervals between office visits and more phone care. Until insurance companies increase copay a bit more, the self pay practice without insurance cannot take off. The best solution would be all self pay for outpatient visits. I have a very low overhead in my practice, by streamlining much of the insurance process and Medicare procss. It costs me less than $1 a person to bill the insurance companies.
    For your model of practice, what happens if a patient has insurance and needs a CT or MRI? Most insurance companies require an in network doctor to prior auth the study. Do you send them to a primary doc who is in network? How about medication prior auths? What happens to one of your patients when he/she is hospitalized and might need thousands of dollars of care?

    • Brenda

      It’s really great that you offer these options to the uninsured.
      I don’t know the area you’re in, but in northern virginia most docs don’t. Here are some prices from that area.

  • Samir Qamar, MD

    Excellent philosophy. Our California-based direct primary care company, MedLion, has two practices currently, with two more being licensed out to forward-thinking practices. Insurance is the business of risk management. There is little risk in primary care compared to hospital stays and specialist treatments, where the insurance is needed. By forcefully removing health insurance from primary care, overutilization is avoided as most medical care goes first through the PCP gatekeepers. Hoorah for Dr. Forrest and direct primary care practices. Direct primary care is “resuscitating” the sick state of primary care.

    • Richard Foullon, MD

      Hi Dr. Qamar,
      I love the concept. When you find the time, I would very much like to hear how you, and MedLion specifically, handle the various issues outside of the primary care visits. What is your policy? What do you tell the patients that sign up for your direct primary care about what they are expected to do when they need care outside of what you can offer? e.g. MRI, surgery, hospitalization, specialist consult. How much assistance does MedLion give them with regard to working these other matters out? I read what Mr. Chase has to offer. I would very much like to hear from a physician, and what the average patient’s response is to what you advise them to do about these other often much more significant costs. Also further down on this thread you will find a post by Nance Beckmann. She is wondering how MedLion handles the medical malpractice risk? I am too.

  • Kwame Asamoah

    Great blog about an innovative approach to reducing healthcare costs! As a new urgent care owner, I am continually exploring new ways to offer affordable and quality healthcare to my self pay patients. One approach we introduced is a membership card that covers 5 different visits throughout the year. Kudos, Dr. Forrest for cultivating the physician-patient relationship.

    • Richard Foullon, MD

      I have owned and run a free standing, independently owned urgent care since 1984. I would be very interested in learning a bit more about the membership card you mention in your comment. You can email me directly if you would like.

    • Jarod Carter PT, DPT, MTC

      Just a thought Kwame… if you carry out the membership card idea, I would definitely market them to the parents of the youth sports athletes and football teams in the area.
      Jarod Carter

  • Richard Foullon

    Very interesting topic.
    I am still having a bit of a problem understanding what you either offer, or recommend to patients who need healthcare services that are not able to be taken care of in the ‘Direct Pay Practice’? What do you advise or workout for the patient who needs an outpatient MRI, an outpatient surgery, a specialist consultation, a hospitalization? I have not read every topic related article, but would very much appreciate your referencing a couple that take this critical subtopic by the horns and provides me facts and proven models that are already working successfully.

  • Dave Chase

    Dr. Forrest may have his own perspective on this so let me just speak to what I’m doing personally. I wrote about this earlier which I call the Do-it-yourself Health Plan. I cobble together a few elements, get nice coverage and save a bunch of money.

    If you want more on the topic that I’ve published here, do a site specific search in Google (enter “dave chase” in the search box). Or you can read what I’ve written on TechCrunch/WashingtonPost by doing a similar search (i.e., enter “dave chase” in the search box).

    While it may *sound* more complicated to cobble together my own health plan, it’s a heck of a lot simpler than dealing with all the EOBs and other hassles of insurance for non-catastrophic items. I figured out how to pay for new brakes, a tune-up, etc. without using my auto insurance. I simply do the same for healthcare. It seems we’ve done everything imaginable to complicate something that needn’t be so complex. Medicine is complex. Medical pricing/payment shouldn’t be.

  • Nancy Beckmann

    I didn’t see anything mentioned about malpractice lawsuits or malpractice insurance costs.


    Does the doctor post a rate chart so that charges for all procedures are disclosed in advance? I love the concept of a cash system and would gladly raise the deductible on my catastrophic plan and move the saving to paying my primary care doctor in cash.

    • Brian

      Dr. Forrest has a sign in the lobby with the price for every service he offers.

  • Dave Chase

    My information is second hand but it has been consistent (I’d confirm directly with those who have 1st hand experience). That is, a primary care practice where patients are seen on average 7-8 minutes (traditional fee-for-service) versus 30-60 (typical of direct primary care) has clear implications for malpractice. Not surprisingly, someone assessing risk recognizes that there’s greater risk in shorter appointments as things get missed.

    The other factor is that patients who are more satisfied are less likely to litigate. Direct primary care practices such as Qliance have measured customer satisfaction (it’s been higher than Google or Apple by comparison). You can also see their Yelp reviews for anecdotal feedback – Impressive results to say the least.

  • Jarod Carter PT, DPT, MTC

    So glad to see articles about this for Medical Practices as well. The need for innovative ways to maintain both quality care AND profits spans the entire health care industry. I’m a Physical Therapist with a fee-for-service clinic and I can’t imagine going back to accepting insurance/Medicare. I get to spend a full hour with every patient, make a nice living, and don’t work more than 8 hours/day.
    Jarod Carter

  • Edward Rippel, MD

    I am Connecticut’s first solo provider recognized by NCQA as a Patient Centered Medical Home. While my outcomes measures are very good, I have seen a decline in office productivity in the last year and a half, mostly due to a surge in cancellations. More people have high deductible plans (> $4K), and they do not put anything away towards the deductible, forcing them to delay care. The Direct Primary Care Model intrigues me a lot. Where do I go about finding the so-called “wrap around plans” to cover the non-Primary Care needs that patients have?

    • Dave Chase

      Congratulations on the NCQA designation. That’s a great accomplishment. In response to your question on “wrap around plans,” this is an evolving situation. As a health plan consumer, I have to do it myself and it’s not a hand-in-glove fit. The expectation is that health plans will develop these wrap-arounds.

      I understand discussions are underway between some of the Direct Primary Care organization and insurance carriers on the wrap-around. My perspective is that the carriers will have to develop a baseline standard as models such as Drs Bliss, Forrest, Qamar, etc. are all different – this is great and there’ll always be some differentiation. However, the baseline standard would allow for a health plan to offer an employer a consistent offering that spanned geographies. If they know a certain set of services will be offered consistently, that will allow them to underwrite the risk of the wrap-around.

      Having been involved in industry standard efforts (outside of healthcare), it’s a very important step in the maturation of a sector. This is something that the key players should do in order to accelerate growth of the Direct Primary Care approach.

  • Brian Forrest, MD

    After having read most of the comments I would like to address a couple of common themes. First of all, I always get the question about “Well, this works great for primary care services but what about the specialty and hospital care for these patients?” We routinely get specialists in our area to give our patients discounts that are frequently over 80% off of their typical rate- Let me give you a quick example- a patient who normally has an 80/20 plan(like part B Medicare) might end up having to pay for 20% of their fee to see a specialist for a stress echo. If the cardiologist I use gives them an 85% discount to just pay cash upfront, then the patient actually spends less out of pocket by not using their insurance. I have shown many other specialists the same thing that I have learned about billing versus direct pay-$1500 billed to an insurer will only be collected at about 70%. The overhead associated with the procedure will be much more if it is billed to insurance so what actually makes it back to the specialist’s pocket for the procedure would be about $200(according to the cardiologist’s own practice manager). If my patient sees the specialist and pays him $250 upfront- he actually nets more for the procedure and the patient pays less than the $300 they would have had to pay as a 20% copay had the $1500 been charged. I have negotiated these discounts for my patients for gastroenterology, radiology, general surgery, ENT, podiatry, and others. Now, before someone comments that Medicare does not allow you to charge a rate lower than its allowable- this is true- so the patient is charged the Medicare rate and then given a cash paid-up-front discount to get the cost down-which is totally legal- a nice loophole that allows us all to give the uninsured a break on pricing.

    For the second issue, “what about hospitalization?” Only about 1% of the population gets hospitalized annually. Only about 5-10% of patients that seek care at a physician office cannot get the services they need in the outpatient setting. However, sometimes patients do need the hospital, and in those cases they should have some catastrophic insurance coverage which we encourage ALL of our patients to purchase if they have access to it. Premiums for plans with $2500 deductibles for catastrophic coverage tend to have much lower premiums. I still have some patients that cannot afford those and have told me that even with the new health care law they will simply pay the penalty and enroll “as they need it” because of the “no pre existing condition clause” The annual penalty is about 1/10th of what the premium would cost.

    Direct Pay does not fix everything wrong with the health care system. Like someone said in the comments “This does not help them if they go in the hospital.” Well, I think if we are all able to focus on quality patient care rather than the number of office visits per hour, hopefully there will be less patients having to use the hospital.

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