For Durham’s direct primary care providers, it’s all about time

Dr. Kenneth Stone runs a primary care practice called Slower Medicine LLC. (Photo courtesy of Dr. Kenneth Stone.)

Monday, April 29, 2024

By Uma Bhat

Dr. Kenneth Stone serves a little more than 200 patients at his primary care practice off Highway 501. It’s a fraction of the more than 1,000 patients most primary care doctors serve.

As large hospital systems like Duke Health absorb private practices and insurance companies exert more control over what treatments patients can access, traditional primary care physicians say they’re spending less time with patients and more time bogged down in the business aspects of health care. 

And it’s causing these physicians – the doctors who handle everyday checkups and manage patients’ chronic conditions – to burn out

The answer for some, like Stone, is a model called direct primary care (DPC), which charges patients a regular membership fee for a certain number of appointments rather than payment through insurance.

The model isn’t an entirely new concept — it simply emphasizes a more direct relationship between doctors and patients, without the involvement of health insurance as a middle-man, an aspect that also sets the model apart from concierge medicine.

While there is no official registry of DPC practices, the DPC model has shown “considerable growth,” according to an article published in the peer-reviewed journal Population Medicine. An unofficial source showed “125 practices in 2014, 620 in 2017 and over 1500 in 2021,” according to the article. There are at least 22 DPC clinics in the Triangle, based on data collected by a DPC doctor who publishes a map with locations reported to him.

Though Stone sometimes still has to work with insurance companies, he said he has more control over the way he treats patients compared to past jobs at a small private practice in Maine and a Veterans Affairs healthcare facility in Mississippi.

Being able to spend more time with patients is one of the key aspects of direct primary care that Stone finds attractive. His practice’s name preaches his philosophy: “Slower Medicine.” The result is appointments that regularly last more than an hour.

“The whole thing about being a primary care doctor, if you don’t have that human relationship, it’s miserable,” Stone said.

It’s a common sentiment echoed by several DPC providers. Durham-based AccessiBull Healthcare founder Dr. Taineisha Bolden said she was tired of dealing with insurance paperwork and quality metrics while working at a traditional private practice in Roxboro, a city in nearby Person County.

“I found the things that I had hoped I would be able to fully address as a family physician increasingly became challenging to do because of the time constraints that were placed upon me,” she said. 

Bolden said that though she likely makes less money with the DPC model, she knows she isn’t a “corporate type of doctor,” meaning she gets to decide what quality care looks like for her and her patients instead of leaving that up to a larger entity.

Consolidations in the health care industry, including in primary care, are likely to continue, said Joshua Barrett, who helps direct research at the UNC Kenan-Flagler Business School’s Center for the Business of Health. 

He said health systems such as Duke Health and UNC Health are expanding their footprints to capture market size and power. There hasn’t been much regulation of mergers likely in part because of powerful lobby groups such as the American Hospital Association, which argue that bigger systems will provide patients cheaper services and expand access to care, Barrett said. 

“You’ll actually find some of the lit [literature] doesn’t really support that,” he said. “When these hospitals combine to make really giant hospitals, it’s not like a ton more people get access to care.”

A study led by researchers at Harvard and the National Bureau of Economic Research published last year also noted that “prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals.”

Michael Stillford, the practice administrator of Sentinel Primary Care in Brier Creek, said he believes access to health care is not improving. He worked as a health care administrator at multiple Duke Health practices before transitioning into direct primary care. He said that even with the expansion of Duke and other healthcare systems, patient needs in the area aren’t necessarily being met.

“We get that all the time from patients who are calling from around this area or moved to this area and are trying to find a doctor,” he said. “And they can’t.” 

Some patients in larger systems, he said, don’t even see a doctor.

“You may have a physician assistant or nurse practitioner assigned, and then there’s no doctor at all,” Stillford said. “Like, there might be one doctor, but that doctor you’ll never see, and you just have a constant turnover of these advanced practitioners.”

Even when patients do see a doctor, there’s not always enough time for all of a patient’s concerns to be addressed, he said. Physicians at large systems typically have to meet a quota for the number of patients they see in a day, Stillford added.

“You maybe, of that 15 minutes, have only truly about seven or eight minutes of valuable time with them,” Stillford said.

Barrett noted in an email, however, that there isn’t much research into the link between visit times and patient outcomes. Meaning some people may do just fine spending less time with a doctor, while others do need more.

While DPC is designed to offer a way for physicians to focus on patients, there are still caveats.

Most people still access health care through insurance and Bolden, who opened her practice in 2019, said some patients have only come to her as a temporary fix between jobs. As a family physician, Bolden can’t handle every special medical case either.

Bolden also noted that many DPC providers aren’t necessarily prepared for business ownership, which has its own unique stressors and requires a different set of skills.

“Hiring people, worrying about marketing, worrying about balance sheets,” handling and processing payments, are all things “you don’t learn about in medical school,” Bolden said.

Duke Health declined to comment for this article.