Direct Care creates more satisfied pediatricians by allowing them to provide better care while enjoying healthier relationships with patients. With the time they gain from switching to Direct Care, pediatricians can research and provide cutting-edge medicine, in some cases even tailoring care to patients’ genomics.
Unfortunately, most pediatricians in the insurance system find their job inspires far less than childlike glee. Primary care doctors experience low job satisfaction due to long, exhausting, jam-packed hours and, in part due to low levels of insurance reimbursement, pediatricians have it even worse. Therefore, many have found their practices significantly improved by switching to a Direct Care model where, instead of being reimbursed by a patient’s insurance company for each visit, patients pay a subscription fee directly to their pediatrician to cover as many in-house visits as necessary.
Healthcare is the cornerstone of a physician’s job, so it’s frightening to hear a doctor describe the currently popular insurance-based healthcare model using the word “dangerous.” Unfortunately, that’s precisely how Dr. Julia Getzelman describes the current state of affairs. In her “Direct Care practice, two physicians and two pediatric nurse practitioners each see 8-10 kids on a busy day. In the traditional model, they would each see upwards of 30 kids, which is at best ‘poor care’ and at worst ‘dangerous.’” In her practice, however, Dr. Getzelman spends “an hour during wellness visits,” five times the national “average pediatrics visit of 12 minutes.”
Since these patients pay a subscription instead of a fee for each visit, they come in for appointments as needed. Practicing Direct Care in Chicago, Dr. Chris Donohoe  says, “in the fee for service model, families with frequent health problems like asthma would ration their visits, but now, when a kid has an issue, I can say ‘I’ll see you tomorrow’ and it works.” He focuses on the substance of his care without worrying as to the number of visits or any of insurance’s other financially motivated decisions.
Dr. Getzelman’s Direct Care pediatrics practice in San Francisco  allows her not only to return to old-fashioned, relationship-based care, but also to devote the extra time to dive into cutting-edge medicine. For example, she looks at genomic information “that allows me to recommend interventions to treat ADHD, anxiety, and other chronic conditions at their root,” a “totally personalized” and safer approach than “the traditional one-ill one-pill approach, where you make a diagnosis and figure out which medication” to prescribe. She enjoys practicing customized, 21st century medicine, but is well aware that she “wouldn’t have the bandwidth or the wherewithal to take on this self-education” if she were “seeing 30-40 kids in a day.”
It’s a foregone conclusion that health insurance companies are affecting patient care, whether by controlling the number of visits, covering only limited activities, or simply keeping doctors bogged down and exhausted. Direct Care, however, allows pediatricians to choose healthcare based on the medical situation, returning the power to the doctor’s hands.
Improved Patient Relationships
By avoiding insurance’s unwelcome intervention, Direct Care pediatricians enjoy deeper and more meaningful relationships with their patients. In the insurance model, children typically fear the doctor’s office since they associate their pediatricians with illness and shots. Many Direct Care pediatricians, however, find precisely the opposite.
Instead of fearing the doctor’s office, Dr. Donohoe finds that “sometimes siblings get upset that they’re not sick, because they want to go to the doctor too,” which arises from Direct Care’s personal touch. He often finds that “families are blown away by how the Direct Care model improves their overall healthcare experience.” Dr. Getzelman agrees, saying “parents that have transferred from other practices have said, ‘it’s more like a spa in here than a doctor’s office… we’re so thrilled that we switched!’”
For Dr. Getzelman, this enjoyment is notable on a day-to-day basis, with a marked impact on her happiness. “At my previous practice, I got used to [patients] crying every day . But in my practice we have plenty of time to establish rapport and help kids feel safe, so it’s a rare day that there’s crying. Now when I hear a lot of crying in the office, I’m reminded of the old days and am thankful that we provide a very different experience for children and their families.”
Dr. Donohoe admits that “there can be tough visits during the toddler years,” but “if you can have the kid play a little after getting a vaccine, that can change the timbre of the whole visit.” By spending more time with patients, these pediatricians find that they can even bring joy to administering shots. In the insurance-based medical system, a shot can be unsympathetic, bordering on mechanical. “In a traditional practice,” Dr. Getzelman describes, “after only 12 minutes with the pediatrician, the nurse comes in to give the shot. They say to the parents: ‘put the baby on the table and hold down the legs.’”
In addition to being more enjoyable for doctors and patients, these improved relationships can have a significant impact on healthcare. Dr. Cory Annis, a self-described “Unorthodoc” in Carrboro, North Carolina, points out an additional healthcare benefit to these improved patient relationships: “when I know a person… I know whether they are minimizers, hyper-vigilant, or plainspoken. That means I can gauge very quickly whether I have to pull info out of them or first address their anxiety before moving on. If I don’t know someone, I have to either guess or do the heavy lifting of figuring out who they are and then trying to solve the problem. In the end, relationships make my job easier.” Dr. Lissa Lubinski, currently setting up a Direct Care practice in Port Angeles, WA , finds her own benefits to developing healthy relationships with patients. “There’s a fair number of people in our community who don’t vaccinate,” she says, but “maybe through rapport, I can educate them and help them to make different decisions about vaccinations.” Medical problems can be difficult to solve, and knowing a patient can only help.
By combining improved medical care with stronger patient relationships, Direct Care naturally leads to higher levels of job satisfaction than the traditional insurance system. As Dr. Getzelman says, “at a big hospital corporation, I became disillusioned, fatigued by the churn-and-burn of mainstream pediatrics. I felt like I was a cog in a broken system.” Dr. Donohoe echoes her sentiment, adding his own fear about where this broken system leads. “My heroes in pediatrics were becoming angrier. Unhappy. I could see myself moving in that direction because of the medical system.” Dr. Getzelman “would have left medicine. The insurance medical model is so broken,” she laments, such that she “just wouldn’t be happy continuing in that realm.”
For many doctors, Direct Care can seem like a breath of fresh air, a return to the medicine they set out to practice. Dr. Annis promises, “I am not contributing to the ‘culture of crazy’ that defines the current healthcare system. Every day, I really live my oath to ‘First, do no harm.’” These pediatricians felt like the insurance system was doing them harm, but to Dr. Getzelman, Direct Care felt “like the clouds parting and the sun shining through.”
Just as Dr. Donohoe was able to see his asthma patients as often as needed, many Direct Care pediatricians use their newfound freedom to communicate with patients more, especially by using text or video-based messaging.
The communications technology serves to, as Dr. Annis puts it, “enhance the relationship.” She is able to have “a HIPPA-compliant video chat” with “a family on military assignment in the Balkans” as though it’s “just like any other appointment. This ability works well for kids away at college on chronic meds, too, and parents absolutely love having a back-up to student health.” To Dr. Annis, Direct Care’s flexible schedule allows her “to deliver ‘on-time’ care across platform[s]. Parents think that being able to text me anytime absolutely rocks. Sending me a picture or video that may mean no trip to the office: they say that’s priceless.” Her patients enjoy the accessibility, and it’s clear that Dr. Annis enjoys it too.
Dr. Donohoe has found that his patients so enjoy the ability to access him in-real-time that “communicating has turned into mostly (probably 90%) text messaging.” He admits, however, that this communication can sometimes be a bit overwhelming, as “there’s little filter for families. [To them] text = call = email, so everything comes in as ‘urgent.’”
Additionally, Dr. Donohoe has plans for improving his communication with patients. He is “currently looking into a service called ‘Spruce’… to organize and document the different ways in which families communicate.” While Dr. Annis admits it can be a difficult balance between being accessible and being too accessible, she says she has it solved. “It’s tolerable to be on 24/7 access [because] once I establish a personal relationship with parents, they are very respectful of how and when they ‘bother’ me.” She sets “proper limits, too… like [patients] don’t expect an immediate answer to texts, and never between 9pm and 7am.”
For these pediatricians, more communication has led to some atypical arrangements, though generally for the better. In addition to the family in the Balkans, Dr. Annis describes a family with two kids that showcases the benefits of the communication that Direct Care allows, writing:
“They weren’t sure they would benefit from the membership since physicals were their only visits. [The family] agreed to try for a year on condition that I wouldn't hold it against them if they stopped. Less than a week later, their youngest woke up with a fever and a rash. Both parents had mission-critical appointments that day at work and no alternate daycare option. Paging me in a panic, they wanted to be first on my office schedule today! I knew it was already booked (9 is a premium hour for fasting annuals). I was just getting out of the shower when they paged, but since my doctor bag is always with me now, I pulled up their address on my phone, saw they were literally 1 block off my route to work and said I'd be there in 30 minutes. Instead of a leisurely breakfast, it was an apple and almonds in the car, but when I walked into their house 30 minutes later, I felt as welcome as an unexpected inheritance. It was clear [the patient] couldn't go to school, and my presence made it possible for the parents to quickly problem-solve their day’s schedule. They updated me on her condition every few hours by text, the patient rallied, and the parents made their commitments without guilt. I did my job, and I doubt they will cancel their memberships.”
By communicating better with their patients, each Direct Care pediatrician is able to tailor their practice to their community’s needs.
After hosting a town hall with 2nd-6th grade students, Dr. Lubinski learned that the children in her community “really want fish tanks” and “an animal (be it real or stuffed) to hold while getting a shot,” along with “a rule that grown-ups had to turn off their cell phones.” Adults often assume they know what children want, but Dr. Lubinski discovered specific requests only because she spoke to her patients directly. From her adult patients, she learned that they were interested in a social element from her in addition to medical care, so she’s creating “monthly group encounters.”
With tailored practices also comes tailored pricing. As Dr. Lubinski says, “when I look at dozens of Direct Care websites, there a ton of ways to set prices and fees.” Many doctors offer discounted medicine to some patients or a family cap to prevent any one household from paying too large of a subscription. Dr. Lubinski plans to charge a “family cap of $150,” so if [a family] has two parents and two children… another child is discounted or even free.”
This sort of freedom of pricing is a far cry from the fee-for-service model that Dr. Getzelman describes, where pediatrics is “poorly reimbursed by insurance companies, so pediatricians have to churn through twenty or thirty or forty patients a day to pay the bills.” Instead, Dr. Donohoe provides free care to a few patients with financial difficulties and significant medical needs who he calls “scholarship patients.” He not only has time and energy to meet his practice’s costs, but a surplus which he donates to his community. To a doctor working ten-minute appointments just to make ends meet, Direct Care’s freedom seems like a dream.
Along with individualized medicine and the flexibility of fewer patients, however, comes one negative side effect: as Dr. Donohoe puts it, “the biggest roadblock to more people doing Direct Care pediatrics is the vaccine issue.” Children need vaccines, and, while vaccines aren’t an issue for most insurance-based pediatrics practices, many Direct Care doctors run into difficulties due to the high overhead costs that vaccines require.
Dr. Annis’ office, for example, “only has 350 square feet so the CDC mandated vaccine fridge/freezer is out of the question.” Dr. Lubinski also expects that she “won’t see enough kids to justify trying to do vaccines, especially given the variety of vaccines for the variety of ages.”
Each Direct Care practice has therefore developed its own individual approach to vaccinations. Dr. Lubinski will be “referring people to the department of public health.” Dr. Annis writes a prescription that her patients can take to a “drug store, health department, or another practice,” which works especially well for her situation since her Direct Care practice is “next door to [her] previous office” so patients frequently “walk down the hall to get vaccinated.” She also has “deals with local pharmacies” to sell her vaccines. As she describes, “it takes a personal relationship with the [pharmacy] manager, but that is what we are all about.” That said, even in the current situation, Dr. Donohoe feels optimistic, saying, “My wife and her friend are trying to get to the bottom of the vaccine issue. Give me another 1/2 year and maybe we’ll have a solution.”
For these pediatricians, even the highest hurdle isn’t hard enough to prevent their satisfaction with their practice. They’re elated with Direct Care and encourage other pediatricians to follow. Dr. Donohoe says his Direct Care pediatrics practice “scratched an itch” in Chicago. He “started small to make sure it would catch on,” and now is “starting to expand because it’s working.” Dr. Getzelman agrees, adding, “The appetite was in the community even if there wasn’t another [Direct Care pediatrics] practice in SF.”
In the throes of starting her own Direct Care practice, Dr. Lubinski is quick to share her advice for pediatricians suffering in the insurance system she recently left. She “found the Direct Care community (the Facebook groups, the Hint community, and Frontier ) to be really, really helpful.” Like Drs. Donohoe, Getzelman, and Annis, she’s excited to be a Direct Care pediatrician because she’s convinced Direct Care “is the right thing to do.” And maybe she’s right since, as Donohoe puts it, Direct Care “saves families both time and money” in addition to providing better care to children’s lives.
 Donohoe Pediatrics
 GetzWell Personalized Pediatrics
 Lissa Lubinski MD
 Hint Health Facebook, Hint Community Forum, DPC Frontier