In 2017, an overworked Dr. Anna Kendrick was considering leaving the practice of medicine. Instead, she found a new, more personal practice model: direct primary care.
“It kind of gets back to the old-school model of care where you know your doctor,” said Kendrick, a Little Rock native who had been working part time at a UAMS Neighborhood Clinic and juggling a thousand patients before making the switch in 2018.
Her friend and business partner, Dr. Siobahn Hruby, shared Kendrick’s frustration with the workload. They had only 10 to 15 minutes to spend with each patient, “and then just lots of paperwork after hours just to catch up,” Hruby said. “We were unhappy enough that we probably would have left clinical medicine.”
But after Hruby learned in November 2017 about direct primary care, which cuts out insurance companies to deal with patients directly, she and Kendrick opened their own clinic, Pinnacle Internal Medicine, in September 2018. The west Little Rock clinic charges patients a monthly membership fee of $125, or $1,200 annually, giving them access to the doctors 24/7. The services include an annual physical, chronic disease management or stitching up a wound, for example. The fee, however, doesn’t cover a trip to a specialist or emergency room, which is why the doctors encourage their patients to maintain catastrophic insurance coverage.
The direct primary care model and the similar concierge medicine, which accepts insurance, are growing nationwide, said Keith Elgart, chief operating officer at Concierge Choice Physicians of Rockville Centre, New York. He said interest is growing from physicians, from health groups and from large health systems as well as patients.
The American Academy of Family Physicians’ 2019 Practice Profile Survey found that about 3,000 of its 72,600 active members were in direct primary care practice, with another 435 moving to direct primary care, according to the AAFP.
“There’s an excitement among physicians when they get into this model,” said Dr. Sterling Ransone, a family physician in Deltaville, Virginia, and an AAFP board member.
“I think a lot of us are stuck on this hamster wheel, and a lot of us are looking for a way to get out from under a lot of the regulatory and administrative burden that we have to do. And this is certainly a very viable way to do it.”
The model also is growing in Arkansas. In November, Drs. Lillian West and Caryn Pendleton opened Bear Fruit Direct Primary Care in Little Rock.
West, an internal medicine physician, said she started researching the business model in 2018, and was attracted to the prospect of being able to spend more time with her patients. Her patients like the model because they don’t feel rushed in their visits with their doctors and can get an appointment either the day they call or the next day.
West said that after being in business for only a few months, she enjoys the DPC model even more than she thought she would.
“Most of us go into medicine to really help and spend time and develop a rapport with our patients,” West said. “This allows that.”
Another reason for the surge in direct primary care is that doctors who are “now entering the workforce in primary care don’t expect to work 80 hours a week,” Hruby said. “They want to have a life and contribute to society in other ways than just through their clinic.”
Several doctors have asked to join Pinnacle Internal Medicine or quizzed Hruby and Kendrick about the model. But Hruby said they aren’t looking to add another doctor.
“We did not get into this to dominate the marketplace or to open expansion clinics,” she said. “What matters to us is that we have a fulfilling job, and are able to still be moms and wives and enjoy our lives. And feel like we’re rocking both of those.”
‘It Didn’t Feel Appropriate’
When Hruby moved to Little Rock about six years ago, she was looking for “the best internists in town” and found Kendrick, she said.
“In our first visit, we immediately really liked each other,” said Hruby, who also is an internal medicine primary care doctor. Kendrick asked Hruby to go into practice with her.
Hruby, though, was wary of going the traditional route of taking insurance, which would mean hiring several employees for just the two of them.
Meanwhile, Kendrick said she felt like the path she was on at the UAMS Neighborhood Clinic wasn’t sustainable. She didn’t feel that she was able to give her patients the level of care they deserved.
Hruby, who also worked at a UAMS Neighborhood Clinic, was unhappy with the business of medicine and didn’t plan on staying.
In November 2017, Hruby was on a flight to New Orleans for a conference and sat next to a doctor from Texas. That doctor said he practiced using the direct primary care model and praised the work.
As soon as Hruby landed, she contacted Kendrick. “This is what we’re doing,” Hruby said she told Kendrick. “And I think we should make a two-year plan.”
They got their business up and running in less than a year.
Cheaper, Better Outcomes
Hruby said she and Kendrick received advice from Direct Care Clinic of Northwest Arkansas, a practice that opened in 2015.
Dr. Dan Weeden, one of the three primary care doctors at the clinic, supports the expansion of direct care, saying the model is cheaper and provides better patient outcomes.
“We feel strongly that primary care, the first doctor you go see, is routine, basic and predictable, … and doesn’t need to be under the umbrella of insurance,” he said. “And when you insure something that doesn’t need to be insured, you’re going to pay more for it.”
Hruby, 39, and Kendrick, 38, spent about $270,000 on startup costs, which included renovating office space at 1400 Kirk Road, Suite 210, and equipment.
The renovation included a room for children, so if a school is closed, the doctors’ children can stay at the clinic, allowing the physicians to continue seeing patients.
In addition, the doctors also hired Kevin Norton, a CPA, at the accounting firm Rasco Winter Thomas Group of Little Rock and attorney Sam Baxter at the Little Rock firm of Baxter Jewell & Dobson for legal help.
The doctors didn’t spend money on advertising, however. Patients aren’t “going to come based on a radio ad or a print ad or anything else,” Hruby said. “It’s all word of mouth.”
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Some expenses were reduced under the direct care model, such as malpractice insurance. “The insurance companies know that we know our patients better, and we have a deeper relationship with them,” Hruby said. “And your relationship is the main determinant of whether or not you get sued.”
Kendrick said the malpractice insurance is about 60% less than what she paid when she was in private practice 10 years ago in Denver.
The doctors initially thought they would have 300 patients each, but then decided to keep the patient load at 200 each.
“We’ve had a lot of patients sign up that are very sick, and have been very time consuming, which honestly is very fulfilling from a professional perspective,” Kendrick said. “But to really give patients the time and care they need, we’ve had to limit the amount of people that we see because there’s only a finite amount of time.”
Hruby said it’s “probably a weekly occurrence” that someone is kept out of an urgent care center or emergency room because the patient contacted Pinnacle Internal Medicine “at the very beginning of their symptoms.”
Success Stories
One of Hruby’s patients was going to the emergency room once or twice a month for about six months. And the four specialists the patient was seeing were stumped.
“I sat down and had a one-hour-long visit with the patient and their spouse,” Hruby said. “We figured out all of the dietary triggers for this problem and the medication trigger.”
Together they addressed the problem’s triggers, and the patient hasn’t been back to the emergency room for that issue.
The model is also convenient for patients who can consult with doctors over the phone, unlike at a typical clinic, where the patient needs to be seen by a doctor for insurance to pay the claim, Hruby said.
Hruby said she and Kendrick work more now on patient care than they did before, but they aren’t complaining. “The work is so much more gratifying,” Hruby said.
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