Dr. Lorna Shanks said she became a primary care doctor because she wanted to care for patients. Instead, she found herself overwhelmed by rushed patient visits, endless paperwork and constant staff turnover.
After 14 years working for large health systems and practices, she decided to walk away. Last September, Shanks left a large practice in Tigard to open her own primary care practice.
She doesn’t take insurance. Instead, she charges each patient a flat fee of $125 a month for unlimited access to a range of primary care services, including office visits, basic lab work and discounted medications. She exchanges texts with patients — and doesn’t have to assign billing codes or correspond with insurance companies.
“This lets me be the kind of doctor I wanted to be,” she said. “It restores the human aspect of medicine.”
A growing number of Oregon doctors are ditching an insurance-centered health care system that many have come to loathe as much as their patients do. Instead, they’re offering primary care as a subscription service, a model they say leads to better quality of care and reduces the provider burn-out that’s left the entire medical system short staffed.
Critics, however, see the potential for a gaping divide between patients who can afford concierge care and those who can’t. Many patients can’t afford both monthly fees on top of premiums for health insurance to pay for specialist treatment or hospitalization.
Meanwhile, Oregon lawmakers last month passed a law that could help bridge that gap.
House Bill 2540, since signed into law by Gov. Tina Kotek, requires certain health insurers to count direct payments to providers — like those monthly fees — toward a patient’s deductible. The law is aimed at reducing out-of-pocket costs for people who choose to pay for care outside their insurance network.
Primary care crunch
According to the self-reported Direct Primary Care Frontier database, there are now roughly 55 direct primary care clinics in Oregon, up from fewer than 20 five years ago. Many are run by doctors who left hospitals or group practices in search of a more sustainable way to practice medicine.
Shanks said she sees fewer than 50 patients, sometimes spending up to 90 minutes with them during an appointment. (She said her goal is to eventually reach 250 patients.)
She said she tries to lower the cost of services like basic labs and imaging for her patients by negotiating discounts with imaging centers and laboratories. For example, she said, an MRI might cost $1,000 or more through insurance, but Shanks said her patients can usually schedule the diagnostic procedure for $700 or less.
Shanks said referrals to specialists — which often rely on large, in-network health systems or insurance company directories — are a frequent challenge, particularly for patients without insurance or with limited provider networks. She said other direct primary care doctors have been trying to develop a network of specialists willing to take their referrals.
The subscription model can be jarring for patients.
Guadalupe Gabba, a Portland resident and longtime patient of Shanks, said she stayed with her doctor last year — and started paying the monthly fee — because she worried about finding a new primary care provider.
“It’s brutal out there,” she said. “You have to find which providers take your insurance, and there are so many that have closed panels and can’t even accept new patients at all.”
But Gabba said she values the consistent, personalized care she gets from Shanks, which she likened to the “old-fashioned” doctor-patient relationship. Gabba, who manages diabetes and a history of obesity, credits the consistent care and coaching she received from Shanks with helping her lose 100 pounds and get her blood sugar under control.
Cascade Family Practice in Milwaukie is a father-and-son operation that is shifting to direct primary care over the next year.
“This is how we practiced in the ‘80s,” said Dr. Carl Erickson. “You see the patient, diagnose the issue, and treat it — without having to justify everything to an insurance company.”
The family physician with more than 40 years in practice said he has resisted offers from hospital systems and private equity groups to buy his clinic. “Corporatized medicine,” he said, has led to worse outcomes and higher costs.
“You get more overhead, more rules, and less time with your patients,” he said. “Direct care cuts through all of that.”
Affordability concerns
Still, concerns about equity and access persist.
Because direct primary care doctors see fewer patients, critics argue the model could strain an already tight workforce, particularly in rural areas.
Others point to affordability: with insurance premiums already rising, asking patients to pay additional monthly fees may leave lower-income patients behind.
Dr. John Santa, a retired physician and former member of the Oregon Health Policy Board, acknowledged that the model appeals to disillusioned doctors and offers potential for streamlining care.
But he said direct primary care practices’ lower volume of patients limits access and raises concerns about scalability. The model, he said, might not work in areas with many Medicare and Medicaid patients.
“I don’t think that this is a viable solution for a large number of people, particularly if you’re in rural communities,” he said.
Dr. Neal Goldstein, an epidemiologist at Drexel University who studies health care availability and access, co-authored — with a physician who operates a direct-care practice — a study that found direct primary care practices are less likely to be in locations with provider shortages. They were, the study found, more likely to be in rural or partially rural areas.
“If we see more people choose primary care, then perhaps it can fill some of those health professional shortage areas,” Goldstein said.
Still, Goldstein said, there is little conclusive research on the model’s impact on quality of care. Many direct primary care practices don’t track traditional quality metrics, and the impact on workforce capacity remains unclear, he said.
Hayden Rooke-Ley, a research fellow with the Brown University School of Public Health, said interest in the direct primary care model is a symptom of a broken health care system.
But while it might appeal to physicians and some patients, he warned that it may deepen inequities.
“I understand why physicians are doing this, and it’s a real signal to how broken the current system is and how corporatized it’s gotten on the provider side, leading physicians to burn out,” he said. “But it’s not a good or systemic solution.”
Dr. Paul Yerkes, a direct primary care physician in Delaware and co-author of the study with Goldstein, acknowledged the affordability concerns but said practices like his often provide a better value for patients with high-deductible health plans who are already paying out of pocket for most care.
He also rejects the idea that doctors seeing fewer patients means reduced access overall.
“In my mind, it’s better to take really good care of a smaller patient population than to take mediocre, less-than-par care for a larger population just to say they have a primary care physician,” Yerkes said. “And if we make primary care more sustainable, more doctors may choose it as a career, which would help address shortages in the long run.”
Charlie Fisher, state director at consumer advocacy nonprofit Oregon State Public Interest Research Group, said patients who sign up for a direct primary care service should be cautious.
“I’d be worried about people thinking this is all they need and discontinuing their insurance. That’s when they could end up in serious financial trouble,” he said. “If someone were to go into this, they would have to be really sure that it’s the right choice and well informed.”
Fisher said consumers can check whether the practice is licensed at the Department of Consumer and Business Services’s website. Direct primary care clinics are required to list in a contract the services they provide and fees they charge, as well as the refund policy for business closures and cancelations.
Shifting landscape
Dr. Andrew Chang, a primary care doctor, opened a direct primary care clinic in North Portland, where he doesn’t take insurance and charges monthly rates as low as $19 for children and $79 for adults for unlimited primary care services.Kristine de Leon
Doctors like Dr. Andrew Chang, who opened Bayberry Clinic in North Portland in October, believes the direct model can help retain primary care physicians who are burning out under the pressures of fee-for-service medicine.
Chang’s clinic offers monthly rates as low as $19 for children and $79 for adults, with discounts for families. He’s also formed a regional direct primary care networking group to support new physicians entering the model.
Chang said many members of the group had left traditional systems due to burnout and a desire to reconnect with patients. He himself left his role as a hospice physician for Providence Health & Services, which he said involved more time doing administrative work and less time with patients.
“When we eliminate insurance from the primary care equation, we keep it focused on patients and doctors only,” he said. “For me, this approach lets me focus more on patient care, delivering higher-quality service while avoiding the administrative hassles that often inflate costs in traditional health systems.”
Chang said the model isn’t for everyone, especially those needing frequent specialty care. But for the majority who simply need consistent, affordable primary care, he said he believes direct care can be especially appealing for those patients.
“There’s a real hunger for this kind of care,” he said. “We’re not actively looking to undo the current system that exists. We’re trying to provide something meaningful for our patients.”