This transcript has been edited for clarity.
Kathrin LaFaver, MD: Hi, and welcome, on behalf of Medscape. I am Dr Kathrin LaFaver, a neurologist in Saratoga Springs. We'll be talking today about the topic of direct-care neurology.
I have with me our wonderful guests, Dr Jill Farmer, who is CEO and director of Boro Neurology, a practice in Hopewell, New Jersey; as well as Dr Jennifer Werely, who's a neurologist and medical officer of Neurology and Headache Center of Greenwich in Connecticut. Welcome and thanks for joining.
Jill M. Giordano Farmer, DO, MPH: Thanks.
Jennifer C. Werely, MD: Thanks for having us.
Concierge Care vs Fee-for-Service
LaFaver: Maybe we should start off with some definitions. Some people might have heard of direct-care primary care offices, which have really been on the rise in the past decade, I would say. Some people are maybe familiar with the term "concierge medicine." I'd like to get both of your perspectives on what we're actually talking about. Jill, do you want to go first?
Farmer: Sure. For me, direct specialty care is just that. There is no middleman between me and my patient. It means that they have direct access to me and I have direct access to them without the gatekeeper of insurance.
It is basically, in my practice, fee-for-service. It's not concierge; they don't have to join my practice, pay a fee, or anything like that. They see me for an office visit, they'll get an invoice, and then they will submit it when they are able. Not everyone is able to submit an invoice.
LaFaver: Jen, how would you define direct-care neurology?
Werely: I would agree. My practice setup is similar to Jill's where, rather than have a large fee, the concierge fee, where you get care when and any time you need it, the framework of my practice is also fee-for-service.
Like Jill, at each visit, patients get a statement, and if they have out-of-network benefits or whatnot, they can submit it depending on their insurance plan.
LaFaver: I would say, probably 20 years ago, most physicians were working out of their own practice and in an insurance-based model. I think we've seen a huge shift, with big hospital systems over the years employing more and more physicians to the point that most neurologists in the US are employees.
Of course, physician burnout is at an all-time high. Many of the reasons have to do with increasing administrative burdens, and so much paperwork, and things to do with the interactions with the electronic medical record system rather than just spending time with our patients, which is what we set out to do as physicians.
I'd love to hear from both of you about what in your career trajectory really motivated you to make that switch. Jennifer, do you want to go first this time?
Fewer Patients, More Time, No RVUs
Werely: I've had this structure for my practice for about 8 years. Just to compare and contrast a bit, I have more time with patients, so I have less volume, which is nice. When I was in the insurance-based model, I was seeing probably double the number of patients that I do today and not having as much time to spend with those particular patients, which then meant more frequent visits. Often, patients would have to follow up in 6 or 8 weeks, which is sooner than they would with the structure I have today.
It's very helpful to have that direct access. There's no one answering calls for me, no nursing staff. I'm in control of everything. I like that. I like to know what's going on with people and when changes are made, which I wasn't so on top of in the insurance-based model, just because those tasks are often farmed out to other people. Until you follow up with a patient, you may be unaware if anything has changed in their care.
For me, it's the amount of time I can spend with patients, not having to deal within the framework of a system, being in more control over my life and my schedule — not just my needs, but my family's needs, which in other models is certainly not prioritized. It's more the needs of the practice. It's allowed me flexibility where I can work as much or as little as I'd like, but it also provides comprehensive care to people where, if anything comes up, they let me know and we can deal with it right away.
Conversations I've had with doctors over the years show that they just feel less valued in big systems. They don't have control over anything. Their RVUs change, their compensation structures change almost as if they're in sales now, where you reach a target and now it gets more difficult, and you have to see more patients and you have less time.
I think that's why you see a large amount of physician turnover. Where it used to be that folks would be in a practice and be there long term, it's really not the case anymore. Doctors are changing jobs much more frequently. Having control can be priceless, and that really is what motivated me to shift from the insurance-based model.
LaFaver: Jill, how did it look for you?
Farmer: I'm glad Jen went first because Jen was a big motivator for me to take this leap and do it, since her practice has been so successful. What resonates with me, from the very beginning — it was about a two, maybe two-plus‒year process for me to make this transition — she kept saying, "It's so easy."
People make it sound like it's so difficult, but it's really so easy to do this, particularly when you opt out of participating with insurance, and that is entirely true.
I had been one of those people who had some longevity. I was with the same practice for a little over 10 years. I had a very good working relationship with my colleagues and with administrators of the practice. It wasn't malignant; I didn't need to leave because I wasn't feeling valued or things like that.
For us, it was just the landscape and the context of how medicine is being practiced in New Jersey and Northeast Pennsylvania, where we were first hospital based, then academic based, and then we were a large subspecialty private.
Through each of those different practice models, I was losing more and more resources. When I initially started out in the hospital-based model, I had a multidisciplinary team, I had a large amount of administrative support, and I had a social worker. It was really the goal of what I would like a comprehensive clinic to look like.
As I moved from place to place, because of resources, COVID-19, and everything else, things started to get stripped away. I no longer had a social worker. I no longer had the access to the multidisciplinary team. Priorities were shifting, as you were saying with sales, like shifting patients over toward surgical interventions as opposed to medical interventions, even though our medical interventions were getting better.
I had kept my practice afloat through these three different model changes with the same patient base that I had, and at this point I had gathered enough clinical goodwill and clinical acumen with my patients that I felt I could do this on my own. I was now doing so much more myself anyway that I might as well be doing it for myself.
Home Visits and Cost Transparency
LaFaver: Maybe you could speak a little bit to some of the advantages for patients. There are upfront costs that they wouldn't have to pay otherwise with insurance-based models. What are they getting that they wouldn't have otherwise gotten?
Jill, you offer, for example, home visits, so I'd love to hear more about that.
Farmer: One of the things that I was looking to do when I transitioned was, obviously, to have my own space. It's been in renovation for 18 months. My husband's doing the renovation and we're working as quickly as we can. I ended up transitioning from my other practice before my office space was done, which was a happy accident because that meant that I started incorporating home visits into my practice.
That's something that, again, would not really be easily accomplished through an institution-based model, whether it's academic, hospital based, or whatever, because of the restrictions, rules, and regulations of what their liability is, what they're comfortable with doing. If you offer it for one, you have to offer it for all. You can't work outside your own box.
The home visits have been phenomenal. Patients are incredibly appreciative. They all ask whether, when my office is ready, I will still be doing home visits. I will, because it's been reinvigorating for me in the practice of medicine. It's been enjoyable to see patients in their own environment, and to have it be conversational and casual, but still incredibly informative and being able to provide the care that we need.
I should also mention that I'm a movement disorder specialist. I deal primarily with Parkinson's disease, so much of our exam and our time spent with patients is history-taking conversation — with a physical exam, of course — but I don't need any equipment or anything else. It lends itself to a home visit very nicely. That won't work for everybody.
LaFaver: Jen, do you have anything to add in terms of what patients really get out of this, in addition to the time aspect?
Werely: Absolutely. Jill, that's great. Home visits. I do them, but infrequently. I think, particularly in movement, it's good to see people in their home and see what space they're navigating. That's a huge benefit, absolutely, for that patient population.
The only way to explain it is the value of time. What's lost in medicine is time, and people think it's this big cost. I went to physical therapy for 45 minutes. They billed out to my insurance $1700 for one session. I'm still upset about it. Because of my deductible, a large percentage is falling upon me. Had I known that up front, I never would have gone for five sessions, which is now going to cost me thousands of dollars with an in-network provider.
With my practice, you know what the cost is up front. I can be flexible with it if needed. I try to be very reasonable and bill out less than what practices bill out to insurance policies. Although the cost up front may seem different, in many ways it can be a cost-savings long term because it saves you time. You don't have to come to my office as much. We can answer most of your questions by a phone call or an email. If you have one office visit a year, I can prescribe for you all year. I can think about things as they come up.
When I was insurance based, I had so many patients and I was so booked out that it was impossible to navigate every nuance of new problems, whereas in this particular model, because my volume is controlled, I just have more time. I think that time can be priceless when it comes to someone's medical care.
LaFaver: I love that. I think that transparency aspect is so true. Even for us as physicians, we usually don't know what kind of bill patients will get for our services. It can be very difficult to navigate as we have often learned, being in patients' shoes ourselves. That's a really great argument.
Farmer: I was just going to add to that. I actually came from a home visit this morning before doing this interview, and the woman I saw was so appreciative that when she called the office, I called her back. She was floored by that, that the doctor was giving her a call back. I said, well, that's exactly it.
To Jen's point, because I have a smaller patient population, I will be able to handle the calls that come in. You'll speak with me. There will be no buffer or barrier in between. Patients, I think, are incredibly relieved when they hear that because they get so turned around in the larger systems with the phone trees and the 14 hurdles that patients go through to get answers.
Once you explain to them, like we were saying about the upfront costs, that I have more time to deal with questions and triage things in between visits. I'm not looking to see you more. I'm really looking, at least in the movement world, to see patients maybe three times a year.
When you add up what that total would be for a year, over 12 months with the access in between, and they understand that it's just the office visit — all of their medications, all of their referrals, any testing that's ordered is still covered by insurance — it doesn't seem so financially daunting.
Advice on Starting a Direct-Care Practice
LaFaver: Before we close, what advice do you have for other physicians and maybe neurologists, specifically, interested in learning more about that business model or possibly considering that as an option? Are there any resources or other tips and tricks you can guide people to?
Werely: I didn't have any resources. I started from the ground up on my own, but people are welcome to reach out to me. It is actually an easy process. It does feel overwhelming, but you keep your overhead low and you keep your systems very simple. It's so much easier than these systems and such.
Starting a medical practice that's outside the insurance world, your needs are very basic, particularly because generally neurologists aren't doing procedures. We don't need hospital privileges. We don't have to cover stroke. What I suggest to people is that if you have an established practice in a geographic area, you may have some limitations about where you can go or for how long you can't practice.
Let's say it's a year in your contract where you can't practice near where you're currently practicing or within a certain radius. Then you have a year to set things up if, financially, that is something you can swing.
I didn't have many resources so I don't know what's out there, but I'm happy to help people. I've tried to put a service on my website so that if people need guidance, I can help collaborate.
LaFaver: Wonderful. Thank you for that. I know, Jill, you have learned from Jennifer, but I also know there are definitely resources out there geared more toward the primary care space. I was curious if that has been helpful to you or if there are any other thoughts you want to share with people.
Farmer: Jen is selling herself short. She is a wealth of knowledge, and it was not just helpful with the encouragement, but also with the practical pointers of what the basics are that you need to set up a practice. You need an electronic medical record, you need the ability to prescribe, and if you're going to have physical space, you need to set that up.
You can do all of this from your phone at this point. There is no need to have a large, integrated system. I have a Google workspace and my medical record is a therapist medical record because it already had telemedicine capabilities built into it.
What is marketed toward physicians specifically, you will see, it's like planning a party and saying it's a 50th anniversary vs a wedding. Once you say "wedding," everything gets marked up 1000%. If instead you say, "I need a medical record for any sort of provider," it's the same idea.
Once you go into the physician world, that gets jacked up 1000%. You need your liability, you need coverage. So you need your malpractice, your HIPAA compliance, and all of that. The range of costs was $750 to $17,000 for HIPAA compliance. If you're just a single person doing your thing, you don't need the $17,000 one. The $750 option works just fine to keep a binder on yourself where you can check a box to say "I'm compliant."
It takes a little bit of shopping around. There are many resources that are available for primary care. Much of it translates into specialty care. You don't have to necessarily reinvent the wheel, but there are plenty of ways to do it very economically.
LaFaver: Wonderful. It sounds like the time is ripe for a neurology practice startup guide from the two of you. Thank you so much for sharing your wonderful wealth of knowledge and experience. I'm very curious to see where this field is going as more and more physicians are looking for more autonomy over their time, their practice, and the way they want to practice medicine.
You both are pioneers. Thank you both for sharing your time.
COMMENTARY
Direct Neurology Practice: Cutting Out the Insurance Middleman
Kathrin LaFaver, MD; Jill M. Giordano Farmer, DO, MPH; Jennifer C. Werely, MD
DISCLOSURES
| January 02, 2025This transcript has been edited for clarity.
Kathrin LaFaver, MD: Hi, and welcome, on behalf of Medscape. I am Dr Kathrin LaFaver, a neurologist in Saratoga Springs. We'll be talking today about the topic of direct-care neurology.
I have with me our wonderful guests, Dr Jill Farmer, who is CEO and director of Boro Neurology, a practice in Hopewell, New Jersey; as well as Dr Jennifer Werely, who's a neurologist and medical officer of Neurology and Headache Center of Greenwich in Connecticut. Welcome and thanks for joining.
Jill M. Giordano Farmer, DO, MPH: Thanks.
Jennifer C. Werely, MD: Thanks for having us.
Concierge Care vs Fee-for-Service
LaFaver: Maybe we should start off with some definitions. Some people might have heard of direct-care primary care offices, which have really been on the rise in the past decade, I would say. Some people are maybe familiar with the term "concierge medicine." I'd like to get both of your perspectives on what we're actually talking about. Jill, do you want to go first?
Farmer: Sure. For me, direct specialty care is just that. There is no middleman between me and my patient. It means that they have direct access to me and I have direct access to them without the gatekeeper of insurance.
It is basically, in my practice, fee-for-service. It's not concierge; they don't have to join my practice, pay a fee, or anything like that. They see me for an office visit, they'll get an invoice, and then they will submit it when they are able. Not everyone is able to submit an invoice.
LaFaver: Jen, how would you define direct-care neurology?
Werely: I would agree. My practice setup is similar to Jill's where, rather than have a large fee, the concierge fee, where you get care when and any time you need it, the framework of my practice is also fee-for-service.
Like Jill, at each visit, patients get a statement, and if they have out-of-network benefits or whatnot, they can submit it depending on their insurance plan.
LaFaver: I would say, probably 20 years ago, most physicians were working out of their own practice and in an insurance-based model. I think we've seen a huge shift, with big hospital systems over the years employing more and more physicians to the point that most neurologists in the US are employees.
Of course, physician burnout is at an all-time high. Many of the reasons have to do with increasing administrative burdens, and so much paperwork, and things to do with the interactions with the electronic medical record system rather than just spending time with our patients, which is what we set out to do as physicians.
I'd love to hear from both of you about what in your career trajectory really motivated you to make that switch. Jennifer, do you want to go first this time?
Fewer Patients, More Time, No RVUs
Werely: I've had this structure for my practice for about 8 years. Just to compare and contrast a bit, I have more time with patients, so I have less volume, which is nice. When I was in the insurance-based model, I was seeing probably double the number of patients that I do today and not having as much time to spend with those particular patients, which then meant more frequent visits. Often, patients would have to follow up in 6 or 8 weeks, which is sooner than they would with the structure I have today.
It's very helpful to have that direct access. There's no one answering calls for me, no nursing staff. I'm in control of everything. I like that. I like to know what's going on with people and when changes are made, which I wasn't so on top of in the insurance-based model, just because those tasks are often farmed out to other people. Until you follow up with a patient, you may be unaware if anything has changed in their care.
For me, it's the amount of time I can spend with patients, not having to deal within the framework of a system, being in more control over my life and my schedule — not just my needs, but my family's needs, which in other models is certainly not prioritized. It's more the needs of the practice. It's allowed me flexibility where I can work as much or as little as I'd like, but it also provides comprehensive care to people where, if anything comes up, they let me know and we can deal with it right away.
Conversations I've had with doctors over the years show that they just feel less valued in big systems. They don't have control over anything. Their RVUs change, their compensation structures change almost as if they're in sales now, where you reach a target and now it gets more difficult, and you have to see more patients and you have less time.
I think that's why you see a large amount of physician turnover. Where it used to be that folks would be in a practice and be there long term, it's really not the case anymore. Doctors are changing jobs much more frequently. Having control can be priceless, and that really is what motivated me to shift from the insurance-based model.
LaFaver: Jill, how did it look for you?
Farmer: I'm glad Jen went first because Jen was a big motivator for me to take this leap and do it, since her practice has been so successful. What resonates with me, from the very beginning — it was about a two, maybe two-plus‒year process for me to make this transition — she kept saying, "It's so easy."
People make it sound like it's so difficult, but it's really so easy to do this, particularly when you opt out of participating with insurance, and that is entirely true.
I had been one of those people who had some longevity. I was with the same practice for a little over 10 years. I had a very good working relationship with my colleagues and with administrators of the practice. It wasn't malignant; I didn't need to leave because I wasn't feeling valued or things like that.
For us, it was just the landscape and the context of how medicine is being practiced in New Jersey and Northeast Pennsylvania, where we were first hospital based, then academic based, and then we were a large subspecialty private.
Through each of those different practice models, I was losing more and more resources. When I initially started out in the hospital-based model, I had a multidisciplinary team, I had a large amount of administrative support, and I had a social worker. It was really the goal of what I would like a comprehensive clinic to look like.
As I moved from place to place, because of resources, COVID-19, and everything else, things started to get stripped away. I no longer had a social worker. I no longer had the access to the multidisciplinary team. Priorities were shifting, as you were saying with sales, like shifting patients over toward surgical interventions as opposed to medical interventions, even though our medical interventions were getting better.
I had kept my practice afloat through these three different model changes with the same patient base that I had, and at this point I had gathered enough clinical goodwill and clinical acumen with my patients that I felt I could do this on my own. I was now doing so much more myself anyway that I might as well be doing it for myself.
Home Visits and Cost Transparency
LaFaver: Maybe you could speak a little bit to some of the advantages for patients. There are upfront costs that they wouldn't have to pay otherwise with insurance-based models. What are they getting that they wouldn't have otherwise gotten?
Jill, you offer, for example, home visits, so I'd love to hear more about that.
Farmer: One of the things that I was looking to do when I transitioned was, obviously, to have my own space. It's been in renovation for 18 months. My husband's doing the renovation and we're working as quickly as we can. I ended up transitioning from my other practice before my office space was done, which was a happy accident because that meant that I started incorporating home visits into my practice.
That's something that, again, would not really be easily accomplished through an institution-based model, whether it's academic, hospital based, or whatever, because of the restrictions, rules, and regulations of what their liability is, what they're comfortable with doing. If you offer it for one, you have to offer it for all. You can't work outside your own box.
The home visits have been phenomenal. Patients are incredibly appreciative. They all ask whether, when my office is ready, I will still be doing home visits. I will, because it's been reinvigorating for me in the practice of medicine. It's been enjoyable to see patients in their own environment, and to have it be conversational and casual, but still incredibly informative and being able to provide the care that we need.
I should also mention that I'm a movement disorder specialist. I deal primarily with Parkinson's disease, so much of our exam and our time spent with patients is history-taking conversation — with a physical exam, of course — but I don't need any equipment or anything else. It lends itself to a home visit very nicely. That won't work for everybody.
LaFaver: Jen, do you have anything to add in terms of what patients really get out of this, in addition to the time aspect?
Werely: Absolutely. Jill, that's great. Home visits. I do them, but infrequently. I think, particularly in movement, it's good to see people in their home and see what space they're navigating. That's a huge benefit, absolutely, for that patient population.
The only way to explain it is the value of time. What's lost in medicine is time, and people think it's this big cost. I went to physical therapy for 45 minutes. They billed out to my insurance $1700 for one session. I'm still upset about it. Because of my deductible, a large percentage is falling upon me. Had I known that up front, I never would have gone for five sessions, which is now going to cost me thousands of dollars with an in-network provider.
With my practice, you know what the cost is up front. I can be flexible with it if needed. I try to be very reasonable and bill out less than what practices bill out to insurance policies. Although the cost up front may seem different, in many ways it can be a cost-savings long term because it saves you time. You don't have to come to my office as much. We can answer most of your questions by a phone call or an email. If you have one office visit a year, I can prescribe for you all year. I can think about things as they come up.
When I was insurance based, I had so many patients and I was so booked out that it was impossible to navigate every nuance of new problems, whereas in this particular model, because my volume is controlled, I just have more time. I think that time can be priceless when it comes to someone's medical care.
LaFaver: I love that. I think that transparency aspect is so true. Even for us as physicians, we usually don't know what kind of bill patients will get for our services. It can be very difficult to navigate as we have often learned, being in patients' shoes ourselves. That's a really great argument.
Farmer: I was just going to add to that. I actually came from a home visit this morning before doing this interview, and the woman I saw was so appreciative that when she called the office, I called her back. She was floored by that, that the doctor was giving her a call back. I said, well, that's exactly it.
To Jen's point, because I have a smaller patient population, I will be able to handle the calls that come in. You'll speak with me. There will be no buffer or barrier in between. Patients, I think, are incredibly relieved when they hear that because they get so turned around in the larger systems with the phone trees and the 14 hurdles that patients go through to get answers.
Once you explain to them, like we were saying about the upfront costs, that I have more time to deal with questions and triage things in between visits. I'm not looking to see you more. I'm really looking, at least in the movement world, to see patients maybe three times a year.
When you add up what that total would be for a year, over 12 months with the access in between, and they understand that it's just the office visit — all of their medications, all of their referrals, any testing that's ordered is still covered by insurance — it doesn't seem so financially daunting.
Advice on Starting a Direct-Care Practice
LaFaver: Before we close, what advice do you have for other physicians and maybe neurologists, specifically, interested in learning more about that business model or possibly considering that as an option? Are there any resources or other tips and tricks you can guide people to?
Werely: I didn't have any resources. I started from the ground up on my own, but people are welcome to reach out to me. It is actually an easy process. It does feel overwhelming, but you keep your overhead low and you keep your systems very simple. It's so much easier than these systems and such.
Starting a medical practice that's outside the insurance world, your needs are very basic, particularly because generally neurologists aren't doing procedures. We don't need hospital privileges. We don't have to cover stroke. What I suggest to people is that if you have an established practice in a geographic area, you may have some limitations about where you can go or for how long you can't practice.
Let's say it's a year in your contract where you can't practice near where you're currently practicing or within a certain radius. Then you have a year to set things up if, financially, that is something you can swing.
I didn't have many resources so I don't know what's out there, but I'm happy to help people. I've tried to put a service on my website so that if people need guidance, I can help collaborate.
LaFaver: Wonderful. Thank you for that. I know, Jill, you have learned from Jennifer, but I also know there are definitely resources out there geared more toward the primary care space. I was curious if that has been helpful to you or if there are any other thoughts you want to share with people.
Farmer: Jen is selling herself short. She is a wealth of knowledge, and it was not just helpful with the encouragement, but also with the practical pointers of what the basics are that you need to set up a practice. You need an electronic medical record, you need the ability to prescribe, and if you're going to have physical space, you need to set that up.
You can do all of this from your phone at this point. There is no need to have a large, integrated system. I have a Google workspace and my medical record is a therapist medical record because it already had telemedicine capabilities built into it.
What is marketed toward physicians specifically, you will see, it's like planning a party and saying it's a 50th anniversary vs a wedding. Once you say "wedding," everything gets marked up 1000%. If instead you say, "I need a medical record for any sort of provider," it's the same idea.
Once you go into the physician world, that gets jacked up 1000%. You need your liability, you need coverage. So you need your malpractice, your HIPAA compliance, and all of that. The range of costs was $750 to $17,000 for HIPAA compliance. If you're just a single person doing your thing, you don't need the $17,000 one. The $750 option works just fine to keep a binder on yourself where you can check a box to say "I'm compliant."
It takes a little bit of shopping around. There are many resources that are available for primary care. Much of it translates into specialty care. You don't have to necessarily reinvent the wheel, but there are plenty of ways to do it very economically.
LaFaver: Wonderful. It sounds like the time is ripe for a neurology practice startup guide from the two of you. Thank you so much for sharing your wonderful wealth of knowledge and experience. I'm very curious to see where this field is going as more and more physicians are looking for more autonomy over their time, their practice, and the way they want to practice medicine.
You both are pioneers. Thank you both for sharing your time.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
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