Pioneer Series: Harnessing the Power of DPC with Dr. Lisa Davidson

Lisa Davidson had never envisioned attending medical school as part of her life’s trajectory—at least that’s what she believed at the age of twenty-two when she applied. After being accepted, however, her mother dug out a box from storage and pulled out a handmade book that Davidson had made in Kindergarten. In it, a five-year-old Davidson had written down two dreams for her future: becoming a doctor and becoming a mom. Today, as founder of Insight Primary Care and mother of two, Dr. Davidson has realized them both.

Despite her underlying disposition towards a career in medicine, Dr. Davidson spent her undergraduate studying to become a biochemist. The summer following her junior year, she landed an opportunity that tested her interest in the field. Both her sister and her brother-in-law worked as biochemists, and they offered her an internship helping out in the lab. She quickly discovered that it wasn’t for her. “I found it excruciatingly boring. I loved science, but I still desperately wanted to work with people.” It wasn’t until the start of her senior year that Dr. Davidson realized that she didn’t have to abandon either passion for the other. “My brother-in-law suggested that I apply to medical school, and it immediately struck me as the place I needed to be.”

Dr. Davidson’s instincts did not lead her astray. By 2000, she had completed her residency and joined a private practice. By 2004, she had successfully opened her own. “I believe deeply in the value of surrounding myself with incredible people, and, luckily, my nurse and physician’s assistant followed me from my previous practice to our new one.” Early on, Dr. Davidson and her team experienced remarkable growth, taking on a large patient load comprised of diverse populations within the metro-Denver area. “We maintained a booming business for nearly eight years--but it wasn’t easy. I was responsible for a running a full staff, keeping up with charting, and seeing twenty patients a day, four days a week.” When Dr. Davidson arrived home at the end of a long day, she only had a few hours to eat dinner and play with her young children. After that, she remained stationary on the couch until ten o’clock, finishing her charting while her husband watched television next to her. “In retrospect, it was kind of pathetic. The burden of charting kept me from doing much of anything else.”

Then, in 2012, Dr. Davidson found herself at a crossroads. The lease was up on their office space and the owners had decided to increase the rent by double. “We could no longer afford to stay there, and I struggled to find comparable spaces in the area that would allow us to keep our private practice open. I desperately wanted to avoid having to join a hospital system.” Dr. Davidson remembers the night she stumbled upon an alternative. “I couldn’t sleep, so I got up at four in the morning and sat at our dining room table, combing through pages and pages of online medical websites and forums.” Eventually, Dr. Davidson found exactly what she didn’t know she was looking for. “I ended up on Qliance’s homepage, reading about the Direct Primary Care model and how they had implemented it. I emailed them as soon as the sun came up.” Over the following days, Dr. Davidson contacted more than twenty people across the country who had opened direct care and hybrid practices. One aspect of their conversations surprised her more than the model itself: “All of the people I spoke to sounded unbelievably happy, and that--perhaps more than anything else--compelled me to give it a shot.”

Dealing with “I don’t get it”

“It certainly challenging to explain DPC to someone who has never heard of it, but once that light bulb turns on, the excitement is contagious.”

Not many people understood Direct Primary Care back in July of 2012, not even the marketing expert Dr. Davidson hired to sell it. “Picture your dog when she tilts her head to the side and looks at you funny--that’s exactly how everyone responded when I started telling them about my plans to implement this model.” Soon after she pitched the idea to her staff, Dr. Davidson purchased an office condo less than half a mile away from her home in Denver. Her husband, an architect, designed and furnished the office space and within two months they had opened their doors.

In the meantime, Dr. Davidson and her team sent out emails, created a website, and held numerous Q&As in an attempt to build more understanding of the direct care model and its benefits. “We explained the concept again and again, trying to make clear what we were trying to do and why we were trying to do it, but at the end of every conversation, email exchange, and town hall meeting, we still received our fair share of ‘I-don’t-get-its’. I couldn’t figure out how to make it click.” Despite this seemingly enormous roadblock, the Insight Primary Care team still managed to bring 200 patients over from their previous practice’s panel of 6000. But with no available DPC data to compare it to, a 3% conversion rate seemed dismal. “I assumed we had failed miserably. There were moments where I wondered if I had made the wrong decision.”

Through bouts of fear and overwhelm, Dr. Davidson found resolve in her gut sense that Insight Primary Care would ultimately succeed. “I knew we were doing the right thing for the right reasons, so I waited--sometimes impatiently--for others to see that, too.” A month later, emails began flooding in. Patients who had transferred to larger practices wrote that they constantly found themselves lost  in the shuffle, that they missed having a doctor who actually bothered to get to know them. “When I explained the practice model a second time, I could tell they were really listening. The circumstances had changed. They had seen what else was out there and they didn’t want it. They wanted us--whatever the model. After that, we got a lot less “I don’t get it” and a lot more “How do I sign up?”.

Finding the Good Folks

“If you surround yourself with people who know what they’re doing, you’re going to end up looking smart and capable--even if some part of you still feels like you aren’t.”

Getting patients onboard with DPC means getting them excited, not just about the model or their primary care doctor, but also about the other people who make care possible. According to Dr. Davidson, attracting and maintaining a sustainable patient load almost always requires attracting and maintaining an efficient, dedicated, and likable staff. “Don’t go cheap. Don’t hire somebody because you don’t have to pay them very much--it never works. The formula is simple: take care of your staff members and they’ll dedicate themselves to your practice.”

Dr. Davidson attributes the growth of Insight Primary Care to the sense of mutual ownership that shapes everyday operations as well as the process of long-term decision making. “The women I work with would bend over backward to keep us up and running. My PA and I split the time. I work three and half days in the office each week and, with her around, I feel comfortable leaving town whenever I need to. She’s an amazing practitioner and an amazing person. I trust her with my patients completely.” Dr. Davidson also employs an MA who manages patient populations and another employee who works remotely answering the phones after hours. “Our former receptionist’s husband is in the Navy and they recently moved to Hawaii. I didn’t want to lose her, and my first thought was ‘Why do I have to?’ Now, when we close the office for a slow day or when my MA needs a day off, we forward all of our calls to Chelsea. It allows us to maintain the appearance that we’re always open--even when I’m sitting in my backyard reading a book in the middle of the week.”

Having additional employees with unique strengths and skill sets makes it possible for Insight Primary Care to provide more holistic care to a more diverse patient population. “Melissa, my PA, has a background in social work and a lot of psych experience. We’ve been able to find help for patients with depression, anxiety, and ADD and manage their medications.” Having additional time to meet with patients allows Dr. Davidson to dive deeper and give more accurate diagnoses. “Many mental illnesses have physical symptoms. The limitations of the six-minute office visit pushes doctors to diagnose people with a stomach condition or a sleeping problem when they’re actually suffering from an anxiety disorder.”

The combination of an equipped team and a liberating care model have given Dr. Davidson the tools to close the gap between herself and her patients. That being said, she knows hiring extra help is not always feasible or the right decision for everyone. “Really think it through. Ask yourself: ‘Can I manage my patient memberships? Can I answer my the phones? Can I put in orders for my supplies? Can I greet my patients at the front desk? Can I draw patient blood? Can I write the prescriptions?’ For me, it all felt like too much.” For doctors who do want to hire additional staff, Dr. Davidson has this pearl of wisdom: “Never undervalue employees with a passion for DPC. The payoff for the practice hugely outweighs the cost of keeping them.”

Surfing the Sea Change

“Any Direct Primary Care practice that survives the first few years eventually reaches a point where it begins to coast. Most docs don’t prepare for it. We spend so much of our time focused on making it that we aren’t entirely sure where to go once we do.”

The Insight Primary Care team considered fifteen different price models before finalizing their membership fees. Dr. Davidson had to work backwards, first assessing their overall expenses and then figuring how large of a patient panel they would need at each rate to get by.  “We had very little to go on. The workshops, conferences, and networks that the Direct Care community has built in the past four years didn’t exist back then, so it was entirely up to us to think through what we wanted for ourselves, what we thought was fair to our patients, and what we deemed sustainable for the practice.” Dr. Davidson ultimately decided that she valued flexibility in her schedule more than a potentially large increase in income. “I didn’t care as much about the money. If I didn’t have a PA, I would make her salary on top of mine, but I would have to work twice as hard. Personally, that bump in pay wouldn’t be worth a decrease in my overall quality of life. Everyone weighs it out differently and some don’t need to weigh it out at all.” Dr. Davidson knows that even now, with information about direct care more widely available, most doctors still price their memberships arbitrarily. “I’ve spoken with doctors across the country and many say they just kind of made it up. The monthly fees tend to vary somewhere between fifty to eighty dollars nationally. I haven’t seen any practices trying to charge anything outrageous.”

The first patient to onboard at Insight Primary Care actually didn’t think Dr. Davidson charged enough. “He was shocked by the amount of care we were able to provide at such reasonable price point. That seems to be the general sentiment among DPC patients, even among those with lower incomes.” Dr. Davidson reports that her patient panel runs the gamut in respect to income, profession, gender, age, and drive for obtaining a DPC membership. “Our practice is 65% women and 35% men. 7% are over 65 and 10% are under 13. We have patients on Medicare and Medicaid, though we don't bill either. We have small business owners, self-employed folks, people with great insurance, and people without any. We serve waiters, hair stylists, massage therapists, lawyers, and CEOs. We see people with multiple degrees and people who stopped their education after high school.” Despite this diversity, one universal trait seems to define the group of people who choose Insight Primary Care: “Across the board, our patients are in the know. They’re curious about the latest innovations in the world and they’re willing to give them a try. I love those kinds of people, and those kinds of people love DPC.”

Dr. Davidson doesn’t necessarily think Direct Primary Care memberships make sense for every person at every stage of life, though some of her patients disagree with her. “We had a man in his early-thirties sign up before we even opened. He sent in his payment, and then two years went by without seeing or hearing from him. I decided to give him a call--I wanted to know why he was paying for a service that he didn’t use.” The patient’s explanation stuck. “He wasn’t paying to sit in a doctor’s office unnecessarily. He was paying for the assurance of knowing that he could on a day’s notice if he needed to. I realized in that moment that motivations for joining a DPC practice vary in tandem with people’s wants, needs, and priorities.” Young, healthy males certainly haven’t been the only cohort to surprise Dr. Davidson by joining Insight Primary Care. “We also have a number of active members who live outside of Colorado. I just saw one of my patient’s yesterday who splits her time between Canada and Florida, but comes to Denver for check-ups and physicals. It still strikes me as counterintuitive, but, for her, it’s worth the investment. She values our doctor-patient relationship over convenience.”

Whatever the reason--loyalty to Dr. Davidson, excitement over the DPC model, or a desire to expedite quality care--patients have onboarded at Insight Primary Care in droves. “We eventually had to cap our practice and open a waiting list. In retrospect, it’s remarkable how much we’ve grown. I spent the first few years so focused on bringing in a sustainable patient load that I didn’t have a chance to imagine what I would want in the future once we finally did.” As a glass-half-full kind of person, Dr. Davidson recognizes that growing pain is a good problem to have. She’s still figuring out the best way to harness it. “I’ve pushed myself to think carefully about my next move, and I encourage DPC docs in a similar position to do the same. Ask yourself: What would the you that didn’t think you would make it want for the you who has? More locations? More employees? More services? Whatever it is, let yourself have it. Be proud of making it to the point where you can. Remind yourself of how far you've come and then share that journey with other doctors so that they can succeed too.”

Spreading the Word

"The Direct Primary Care model renders the concept of competition irrelevant. Someone could open up a DPC practice down the block from Insight and I would be thrilled. There are more than enough patients to go around.”

Dr. Davidson receives at least three phone calls a week from doctors across the country considering making the switch to DPC. Of all the perks of practicing under the model, she finds the opportunity to mentor other people most rewarding. “The docs that contact me are totally excited and totally terrified--I remember the feeling well. Some of them just want reassurances that it’s possible. Some of them want answers to specific questions. Either way, it feels good to be able to offer the comfort and insights that I wished I had when we started out.” Recently, Dr. Davidson had the opportunity to provide that support on a massive scale. “The American Academy of Family Physicians invited me to speak at the Direct Primary Care Summit in Kansas City. It gave me the chance to share my knowledge and experience with the newbies and swap war stories with the tight-knit community of veterans. All of us can learn so much just by gathering together.”

Organizing for legislative change has created another touchpoint for Dr. Davidson and the other DPC doctors in her area. “Currently, only 16 states have legislation with language that addresses DPC. In a few weeks, a group of us will meet with the Colorado Academy of Family physicians and the Colorado Primary Care Collaborative to try to build a framework for legislation that would allow patients to use funds from their Health Savings Account to pay for their DPC subscription fees legally. The community has actively invested in helping write the legislation because we know how much patients and practices will benefit. The direct care movement has always been self-governing and grassroots--I don’t envision that changing anytime soon.”