Pioneer Series: A Conversation with Dr. Steven Horvitz

Dr. Steven Horvitz understood the potential of the Direct Primary Care model before Direct Primary Care had a name. He’s been running The Institute for Medical Wellness as a Direct Primary Care practice since 2008, and his recognition of Direct Primary Care as the necessary solution to a backwards system precedes him. Before I even had a chance to ask him the question, “Why DPC?”, he asked me this: “If you’re going to work your butt off in school—high school to get into a good college, college to get into a good medical school, medical school to get a residency fellowship—do you really want to complete twelve years of training just to work in a system where high school graduates with one year degrees are telling you how to treat your patients?” The answer is pretty obvious, even to a writer like me: Hell no. 

Dr. Horvitz contends that DPC not only gets talented doctors out of a limiting, ineffective model, but also allows them to create their own. “It gives you the time and energy to hear what patients are going through, and to really think through things to decide the best way to help them. It’s not cookie cutter; you’re not following computer algorithms. Healthcare—and primary care in particular—shouldn’t be that way.” Among other virtues, Dr. Horvitz feels that the DPC model has allowed him to remain grounded, personable, and genuine in the office—something that’s not always possible in the more rigid, restricted, and regulated patient-doctor relationship that results from working under the hospital system. “I’m the same person inside the office as I am in the grocery store. I’m fairly good at talking to people, and the more I get to talk to patients, the more they open up. DPC puts you in a situation where you can shine.” 

Getting a Head Start

Dr. Horvitz realized he wanted to be a doctor at a young age, after visiting his father’s office and witnessing respectful, personal doctor-patient interaction. He saw the freedom and flexibility that owning a practice had afforded his father, and spent his childhood dreaming of a similar future for himself. “I liked that he could run things his own way. I liked that he set his own hours, that he could work an eighty-hour week or a twenty-hour week, that he could take a vacation whenever he wanted or work two years without one. I like that he took control of his practice, his profession, and his life--all while helping patients in his community.

“Following in his father’s footsteps, Dr. Horvitz attended medical school and then completed his three-year residency before joining a two-person practice to start his career as a primary care doctor. He worked with the owner in two different locations, and two vastly different socioeconomic areas. While he had great respect for his co-worker, he ultimately decided to leave the practice, knowing early on that he couldn’t work in a business where third parties were becoming increasingly involved. “I wanted to transition into a different style--one that would eventually morph into the DPC model. My partner was moving in the opposite direction, towards a managed care practice, and I was ready to forge my own path.”

Dr. Horvitz built up his practice for eight years, accepting all forms of insurance, before he realized that his revenues weren’t increasing alongside patient load and expenses. “I eventually determined that it wasn’t sustainable. I couldn’t continue as a solo doc in that kind of set-up. At the time, I belonged to an independent practice association where we had one contract with an insurance company, but even that was slowly falling apart. So I had to make a choice: I could continue doing what I was doing, join a group practice, or try to gather more doctors together to form a stronger IPA.”

Dr. Horvitz decided to continue running his solo practice while simultaneously searching for an alternative solution. Initially, he considered concierge medicine. “I heard about it first from a semi-retired doc, and then spoke a number of times with a concierge company. We went through the entire set-up process, speaking with patients and sending out surveys. At the end of it all, the company told me that my practice could do concierge very well. I decided against it though because concierge charges patients three to four times more per year than DPC.”

While he agrees that concierge can efficiently and effectively serve the economically advantaged, Dr. Horvitz knew the majority of his patient population would not have been able to afford it. “I didn’t want to dump 90% of my patients; I didn’t want them to force them to pay thousands of dollars a year or force them out.” Instead, he sought a cheaper solution that had the same benefits as concierge. “Back in 2007, I was already figuring out that DPC would work—even before DPC had a name. So, in June that year, I sent out termination to all the insurance companies other than Medicare, stating that—as of January 1st, 2008—I was out.”

Dr. Horvitz meant what he said. On January 1, 2008 he started charging his patients a monthly fee as well as a per-visit fee, around $25 for each. He retained fifty percent of his patient population through the switch. Some of those who wanted to continue seeing him annually opted out of the membership fee and just paid the single per-visit fee each year. After about six months in the new model, Dr. Horvitz surveyed his practice. “People said they were happy with me and didn’t want to leave. At the same time, they felt like I was nickel and diming them. Some patients said, ‘We pay you $25 a month just to be a part of your practice, and then we’re paying you an addition $25 every time we come in. My copay is only $10 and my premiums are paid for by my employer, so it seems like every time I come in to see you, I’m getting charged twice.’ They didn’t like that.”

Fully committed to patient satisfaction, Dr. Horvitz eliminated the per-visit fee and slightly increased his monthly fee. It served him well. “People started signing up right and left.” Since 2009, Dr. Horvitz’s practice has increased from fifty patients to four hundred and fifty. “We’re retaining about ninety to ninety-five percent of the people who join. The people who leave are either leaving because they moved or they lost their job. Very few people leave because they’re not satisfied.”

His early success maintaining both patient satisfaction and patient growth through a groundbreaking model makes Dr. Horvitz the perfect candidate to share his wisdom, values, and vision for practicing medicine under DPC.

Lessons Learned

Consult Your Practice

Successfully making the switch to DPC requires ample forethought, according to Dr. Horvitz. “It’s your business. You have to plan it out.” Preparing patients for the change—and keeping them in the process—is an essential ingredient for staying above water those first few months. “I recommend sending out a survey to get an estimate of the number of patients who will stay and the number who will go. Keep in mind that not everyone is going to give you an honest answer; a lot of people will say they’re going to leave to deter you from making a change.” Surveying the practice helped Dr. Horvitz make the decision to continue accepting Medicare as long as continued to be a minimal hassle. “My transition included Medicare, and at the time, Medicare was easy. It was fee-for-service, and it allowed me to retain 20% of my practice.” Tailoring the transition to DPC means considering the needs of both the practice as a patient community and the practice as a business. “You really need to figure out your income, where the revenue comes in, where your expenses go, and what’s going to change. Do you drop all your insurance providers at once and jump in? If fifty percent of your practice says they’ll stay with you, then sure, go for it! If it’s considerably less, then maybe take a more gradual approach.”

Stress the Positives--Without Giving a Sales Pitch

Dr. Horvitz believes that the increased visibility of DPC will facilitate patient retention for those primary care providers looking to make the switch. That being said, he still believes that patient conversion requires some educational conversations. “You’ve got to tell them why you’re doing it. I told my patients: ‘The present system doesn’t allow me to provide the level of care that I want to. I am switching to the Direct Primary Care model so that I can do a better for you.’” Emphasizing the ways in which Direct Primary Care benefits patients can reduce the knee-jerk negative reactions that often arise from fear of change. “You’ve got to stress the positives. It’s valuable to have your doctor’s cell phone number, to be able to text and email them, to able to get an office appointment the same day you call, to have the office staff available to schedule visits with specialists. It’s nice not to have to go to a lab and wait in line behind eighty people; it’s nice to have access to a staff that will draw blood for you whenever you need.” Shedding light on the value of Direct Primary Care, however, does not require that doctors perform a cost-benefit analysis for patients. “Don’t make it a sales pitch. Avoid saying, ‘It’s worth it for x amount.’ Keep it above water.” There are plenty of benefits for patients to get excited about when it comes to DPC—price doesn’t have to be one of them.

Respect Everyone—Including Yourself

For people considering joining his practice, Dr. Horvitz offers a free, twenty-minute meeting where potential patients can ask questions about DPC. “It’s an opportunity for both of us to share our stories--why they’re interested in my practice and why I started mine. People are always surprised that it’s free to come in, but I think it’s important for potential patients to get the chance to make an informed decision.” And this strategy pays off. “Three out of the four people who come in for meet-and-greets end up joining the practice.” While respecting patients may mean being generous with his time, respecting himself means valuing it, too. “I’m setting the price of what I think my services are worth to my patients and my community. I’m not signing a contract with Medicare or an insurance company that’s going to tell me what my value is. I’m putting my value you out there. I honestly believe that when I was priced too low, people didn’t respect me. I think they thought I was the McDonald’s of healthcare. Once I raised my price, people thought, ‘Okay, that’s not cheap, but it’s also not crazy.’ It piqued curiosity; people wanted to know firsthand the value of my services.”

Let Your Values Shape Your Practice

Dr. Horvitz considers investing in his values to be an underrated marketing strategy. Referrals from holistic health professions, recommendations from natural food stores, and advertisements in the local newspaper have been the next most effective ways to bring in potential clients, following his high conversion meet-and-greets. “Finding a group of like-minded people to network with can lead to a lot of growth. If you’re a DPC who loves sports medicine, then you should go to your local gyms and to the high school football practices to see if they need a team doc. It’s easier to attract a clientele that has similar values to your own.” Dr. Horvitz is committed to holistic, preventative care and wellness, and his practice reflects that. “Patients don’t want to be just treated for sick visits—they want to experience wellness. Focusing on wellness has brought a lot of people to my practice. I will probably see new patients two to three times in the first month because I want to get to know them. I want to do testing, to learn about family history, and come up with a plan of attack. I always tell patients, ‘You let me do the wellness, and I’ll throw in your sickness for free.’”

Maintain Connection, Build Community

Dr. Horvitz stresses the importance of keeping patients involved in the practice, especially among those who only visit infrequently. “You want your patients to feel like they are part of your DPC practice even when they’re not there.” To achieve a stronger sense of community around wellness, Dr. Horvitz sends out a monthly newsletter. “It usually has one or two tips or facts about wellness, but I also include something funny or weird that gets people laughing. I’ll say something about a diet and then make fun of it, and by making fun of it, it gets my points across even more effectively. People love it. It makes them feel like part of our Institute for Medical Wellness. It builds trust; it builds goodwill. I mean, who else is going to do that?”

It seems that no previous providers have been willing to go the extra mile for Dr. Horvitz’s patients, and his client testimonials prove they are all incredibly grateful that he does. A recent one reads: 

“Dear Dr. Horvitz, 
Choosing to become part of your Wellness Program was the second best step I took toward taking care of my health and well-being… Choosing you as my physician was the first.