Concierge medicine and direct primary care: Alternative models for health care delivery

LACONIA — For those increasingly frustrated with their options for primary medical care, there are several alternatives. Concierge medicine services and direct primary care are two health care models which offer patients a more personal relationship with their provider.

Vanessa Hahn, APRN, is a nurse practitioner with vast experience in the local health care industry, and she’s struck out on her own to build Hahn Health, a concierge service providing in-home health care to residents of the Lakes Region. 

Hahn previously worked as a registered nurse in a local primary care office, where she became increasingly frustrated by what she described as a “broken health care system” that prioritized quotas over compassionate care for each patient. 

What if, as a patient, you could expect a call back from your primary care provider within 12 hours? What if you were able to secure an appointment with your provider within a week of connecting with them? 

“Nurse practitioners can operate in New Hampshire independently, providing primary care,” she said, noting they’re governed by the board of nursing, not of physicians. NPs can prescribe, refer and order tests, just as physicians can. “We pride ourselves on holistic care.”

The legacy health care system works for some, but others who have experienced long wait times to get an appointment, difficulty reaching their primary care provider, difficulty finding a provider willing to do in-home visits or who experience transportation or parking difficulties may find concierge services interesting. The traditional system is tough on providers, too — the excessive documentation required to justify billed services to insurance companies plus having no control over the size of their patient panels can cause high stress, burnout and, ultimately, allowing the provider less time with those they’re meant to serve. 

“I can’t see patients every 15 minutes, it’s not how I’m wired,” Hahn said. “We no longer spend time with patients. The focus really is on getting numbers.”

The concierge medicine model

Concierge medicine combines both a membership fee and the ability to bill insurance for covered medical services. Through working with a concierge provider, a patient may find they’re better able to develop a personal relationship with their primary care provider and may find accessing medical services this way is more convenient.

While physicians employed by large health care systems may have more than 1,000 patients on their panels, a concierge provider is generally working with far fewer patients, allowing that provider to develop personal relationships with their patients. 

“I was burned out, depressed, and I was becoming toxic,” Hahn said of working in the traditional model. “We are in a broken health care system — I felt there has to be a better way.”

In her new concierge service, Hahn brings the knowledge and network built over a career in the health care industry with her. 

Pursuant with the concierge model, Hahn bills insurance for covered services rendered. Patients on her panel pay a monthly membership fee, which grants them a personal relationship with their primary care provider and greater convenience in accessing covered services. Explicitly, Hahn does not operate a pain clinic. Her practice is much like any primary care clinic. 

So far, patient feedback has been quite positive. There are numerous positive reviews of her services online. But running her own practice isn’t easy, and adapting to take care of many administrative tasks has been a learning curve for her. 

“I just want to keep taking care of people, it’s what I do. As an owner of Hahn Health, I wear a lot of hats,” she said, pointing to her new roles as secretary, nurse, biller and keeper of records in addition to NP. “It’s been wonderfully eye-opening. I don’t have to see 20 patients a day — that’s a beautiful thing.”

There are many benefits to a patient to being included on a smaller panel. For example, if an individual lost their primary care provider and called Hahn for consultation, that person may be able to secure an initial appointment in just a matter of days, not weeks or months. 

“If you want something you’ve never had, you’ve got to try something you’ve never done,” she said. “I’m trying to empower people.” 

The direct primary care model

In addition to the concierge model of care, the direct primary care model offers patients an alternative. Dr. Eric Kropp of Active Choice Healthcare in Concord is one of the founders of the Direct Primary Care Alliance, a network of DPC providers. He pointed to a few key differences between the models.

“The key with both concierge medicine and direct primary care is that there’s a fee that’s paid directly to the physician,” he said, adding those fees are outside of any existing insurance premium. “For direct primary care, that fee is the payment for the care we provide.”

Kropp said the national average for DPC fees is about $100 a month, about on par with a cell phone bill or other subscription services commonly used by consumers. In concierge medicine, that fee is a sort of access fee, which allows practices to provide heightened services and facilitates direct access to providers.

“That’s the same thing we strive for in direct primary care,” he said.

In Kropp’s experience, a large portion of his patient panel are uninsured or underinsured, patients who make too much to qualify for Medicaid but not enough to afford private insurance. He recommends patients with insurance keep it. Outside of his office, a patients’ insurance works the same way.

“I’ve got people from all walks of life,” he said.

Noting that in American culture, people expect health insurance to pay for every aspect of health care services, Kropp said he’s found success in purchasing medications outside of insurance, and strives to help patients navigate the system to their best advantage. 

Kropp said patients seek direct primary care for two main reasons.

The majority do so because it provides greater access to their physician. He’s a solo practitioner, so his patients enjoy a direct relationship and greater access. Patients can often secure same-day appointments in his office and they’ll always be seen by him, personally, almost always for more than 30 minutes. 

“When they call the office, we pick up the phone,” he said. “There’s no six weeks waiting to get an appointment.”

The second reason is direct primary care offers an affordable option, always looking for discounts on services to drive the price down for consumers. They negotiate on their patients' behalf and Kropp said he’s found it’s often cheaper for patients to pay out of pocket than to bill insurance under those conditions. 

But direct primary care is not without its own challenges. Kropp said he’s before run into issues when health maintenance organization “gatekeepers” influence the restriction of access to specialists within an institution unless the primary care provider is in network.

“There have been issues in some instances,” he said.

Striking out on their own to offer direct primary care is not without risk to the physician themselves, either. To participate in that model of care, a provider must opt out of Medicare for a two-year period, forgoing Medicare reimbursement and restrict them from billing services to insurance. 

Ironically, Medicare patients are those who best remember having a relationship with their primary care provider.

“They appreciate the value of having an individual that they get to know over time,” Kropp said. 

And Kropp said the notion that direct primary care is only for the rich is not true.

“No, it’s not. You, too, can have that,” he said. “That copay will have paid for a year or more of direct primary care.”

The DPC movement is growing steam, he said, but it’s relatively unknown and many may not look into it until they’re forced to by circumstance.

“It takes, often, something dramatic for patients to make that decision,” he said. “The DPC movement is really growing in New England.”