APEX, N.C. -- On a rainy Wednesday morning in the thick of fall allergy season, Brian Forrest, MD, disappears into one of the plain, yet cheerful exam rooms at Access Healthcare with a longtime patient, Winston Goodwin. Half an hour later, the primary care physician emerges, heads to his office and types up a detailed treatment plan that includes specific meal suggestions -- leafy greens and salmon -- and other health tips.
All told, Forrest spends around 40 minutes on the patient encounter. Most primary care physicians would go bankrupt if they spent that kind of time on routine visits, yet Forrest says he's making two to three times the income of his colleagues while seeing only 16 patients a day.
All Goodwin pays when he checks out is $64 for the visit, $10 for the flu shot. And even though he has Medicare, neither the patient nor the practice will file a claim. "It's cheaper than going ... other places," he says, comparing Forrest's office to one where he'd used his insurance in the past. "You don't have to go through all that mess."
Without "all that mess" to manage, Forrest says he spends evenings and mornings at home composing music on his keyboard, and describes himself as "happy as a clam."
How can a primary care physician spend quality time with each patient, make it home in time for dinner every night, and still make upwards of $400,000?
The Business Model
Forrest attributes his success to cutting out insurance claims, which allows him to staff only one medical assistant, and receive cash payments daily.
About 10 years ago, Forrest designed his own brand of direct pay: either patients can pay a $40 per month subscription fee along with a $20 per visit fee, with some tests, like EKGs, included, or $64 per visit outright and additional fees for tests, which are listed in the lobby. There for a lipid panel? $34. Need a wart removed? $64.
Although Forrest says his is an egalitarian practice, one that provides access to low-income, uninsured families, this model works best where community members can pay a yearly membership fee. With average annual household incomes of $90,000 in this Raleigh suburb, Forrest has 1,200 patients on the subscription rolls, and more than 1,500 who schedule visits when needed.
Goodwin's nearby farm is a remnant of a prior, more rural age, but today's Apex is filled with wealthy residents for whom the $480 a year fee might not seem a burden.
The secret to both his happiness and his prosperity, Forrest says, is
Billing departments can easily use up to a third of a practice's financial resources -- so Forrest doesn't have one. Medicals staffs are often large and their work redundant -- so Forrest has a single assistant who weighs patients, prepares their charts, and handles scheduling.
Forrest's electronic medical records system is free, and his Web provider costs little. Although his physical office is well appointed and in a nice neighborhood, it is small -- just enough for Forrest and two other providers to see their daily roster of patients.
The result is a thriving practice with only 3,000 charts on the shelves and employees who are happy and fulfilled. The medical students and assistants even moved their break room into Forrest's personal office, setting up a microwave and conference table just feet from their boss's crowded desk.
"Our patients don't care if we have marble counter tops or leather chairs," explained patient care coordinator Susan Bavisotto, who has been with the practice since it opened in 2002. "It's about taking care of them."
It's more complex than that, though. Without the estimated $576,000 a year in subscription revenue, his business would run at a $100,000 yearly deficit.
Dysfunctional Medicine
During the late 1990s, as Forrest was finishing medical school at the University of North Carolina in nearby Chapel Hill, he became preoccupied with what he saw as a dysfunctional system that served neither doctors nor their patients. As a resident in family medicine, he questioned every doctor he encountered about what they thought was wrong with the healthcare system.
"The physicians were overwhelmed. It was treadmill medicine," Forrest says. "They were having to see 35 patients a day and they felt really burned out and like they couldn't take care of patients because they were so rushed."
Forrest was also frustrated by the higher costs self-pay patients were charged, while the negotiated rates insurance companies paid were often half the amount. He decided to invent : one that gave doctors more time with patients while keeping costs both low and fair.
Although there were several doctors prior to Forrest who practiced various forms of concierge or direct pay medicine, Forrest credits himself with inventing his model, which integrates the monthly payment alongside fees for appointments.
Several different permutations evolved during the early 2000s, but Forrest's was the first that combined the concierge approach with fee-for-service for those who couldn't afford the membership.
"My aim was to have a practice that was 90% uninsured people," Forrest says. "At the time, Wake County had 85,000 people [who] were uninsured. And I'm like, there are plenty of people who need a physician they can afford. Initially people [who] came were uninsured. But then they told their neighbors. And their neighbors who had insurance said, 'Hey, I want to try this out.'"
The Direct Pay Movement
Direct pay practices have been growing in popularity over the past decade. In 2002, when Forrest opened Access Healthcare, fewer than 0.05% of primary care offices were billing the consumer directly, and they were usually only accessible to very wealthy patients.
Today, according to the (AAPP), an organization of direct pay doctors, more than 9,000 doctors now work in direct pay practices, with hundreds more joining the fold each year.
At first, direct pay providers such as Forrest experimented with their models alone. But as Forrest's practice gained traction, he began to develop a strong network of contacts. He had labs who gave him and his patients discounts, drug vendors who provided medications at cost, and an increasing knowledge of the regulatory issues at play in this new model.
Then Forrest founded the , a group of physicians who take direct payment from their patients. They share resources and make deals collectively with drug companies, specialists, and other providers. Forrest has 503 doctors in his network, with more signing by the day.
A map of the United States hangs in Forrest's office crowded with thumbtacks marking each practice in his network. A wall calendar notes upcoming visits from interested doctors and trips to potential practices.
Nearly 50% of the weekdays are filled with plans to visit with doctors ready to make the switch. Bavisotto used to spend her days weighing patients and filing charts. She now manages his busy calendar and updates his consulting business's website during many of her working hours.
"Doctors love this model because it allows you to focus on the patients instead of worrying about what the codes are," Forrest says. "Who cares about the codes?"
Forrest earns a consulting fee for his visits to other practices, charges a network joining fee, and a monthly fee for access to low-cost labs and prescriptions. He travels to locations like Honolulu, Rochester, and Chicago, advising doctors on how to ditch insurance companies and change their entire business model.
The doctors also join the AAPP, of which Forrest is an officer.
Large companies have also taken up the private pay model. is an Amazon.com-backed company in Washington state that provides medical services to software company employees as well as private consumers. Instead of investing in insurance, companies such as Expedia pay a monthly fee for their employees to be seen in one of Qliance's many locations.
Other companies are developing similar models.
Improving Outcomes
Although Amazon founder Jeff Bezos and Dell CEO Michael Dell invested in direct primary care because they saw it as , another reason the model is gaining traction is because it appears to improve patient outcomes.
The Consortium for Southeast Hypertension Control in Winston-Salem, N.C., evaluated several years' worth of patient charts and data from Forrest's practice. Researchers found that his patients had 60% fewer ER visits as compared with traditional practices, and a 65% lower rate of hospitalization among patients who rely on Forrest to manage their chronic conditions.
Access Healthcare was designated by COSECH as one of only 33 Cardiovascular Centers of Excellence due to the results of the extra time spent managing patients' conditions.
Patients of Qliance and other direct pay practices have benefited as well. COSECH's research shows that, especially among patients with multiple conditions, the more time a doctors spends with them, the more positive the long-term outcomes.
For patient Melanie Williams, a retired new home sales agent from Apex, the extra time spent with Forrest, combined with a practice model she believes in, means she never worries about her health, despite experiencing a number of comorbid conditions.
"I love the fact you have time with the doctor and that he has time to listen to you," Williams says. "Even though we have insurance, it's worth it to me to stay here and stay healthy."