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Opening a Direct-Pay Membership Medical Home


Alternatives to traditional fee-for-service practice come in all shapes and sizes. Here's one physician's unique approach.

One common concern among physicians considering concierge medicine is that many patients may not be able to afford it, and therefore, they will need to receive care elsewhere. After all, concierge care, in which patients pay a fee for additional services, such as improved access to physicians and more personalized attention, can come with a hefty price tag. But internal medicine physician Michael Freedman may have found a way around that.

In July, he began accepting patients at Evolve Medical Clinics in Annapolis, Md., which he describes as a "direct-pay membership medical home." Just like any other Patient-Centered Medical Home, Freedman and his partners embrace a team approach to patient care. The main difference between his model and the traditional medical home model, however, is that Freedman's practice does not accept insurance; patients pay his practice directly for care. They can also opt to pay a monthly membership fee for perks such as virtual patient visits and access to providers via secure e-mail and text messages.

Freeman's intent was to reduce the cost of patient care, improve care quality, and boost customer service. "... I had the vision of what I wanted to do, what I wanted to provide," says Freedman, who declined participation in a national concierge practice chain due to concerns about the small number of patients who could afford to join such a practice. "... I started with a goal of, 'How can I provide really excellent care to a much greater percentage of [patients]?'" Evolve, says Freedman, was the answer.

Here's more on how he opened the clinic, how it works, and how it's affecting patient care.


Freedman, who previously practiced in a large medical group in Annapolis, says planning for the opening of his new clinic took about one and a half years. Much of that included determining what to charge patients for care, securing financing and legal advice, and planning for the new facility, which features hardwood floors, high ceilings, artwork from local artists, and a coffee, tea, and water bar.

The planning process also included recruiting three NPs who would serve as Freedman's partners and practice co-owners. These NPs, says Freedman, will play a critical role in the practice's future."For complicated people, an internist is the right person to go to, but for the vast majority of primary care where you've got high blood pressure, high cholesterol, thyroid [problems], diabetes, even COPD, there's just a lot of stuff where [NPs] do a great job and their clinical ratings are better and their patient satisfaction outcomes are better," says Freedman. "... The folks I have working with me are extremely active in helping us to build the practice. We have a weekly meeting [and] everything is very transparent as far as all the dollars and cents, and they contribute as far as what decisions are made and what direction we go. I think it's going to be a big part of our success: Treating nurse practitioners more like doctors have traditionally been treated, with the respect that they are due."


Patients who choose to join the membership side of Freedman's practice pay a monthly fee of $35 and $25 per visit. They also pay out of pocket for certain procedures, such as a skin biopsy or an EKG. Still, Freedman says, he tries to keep those costs down, typically charging about 80 percent less than the prices for services that are listed in the Healthcare Bluebook.

One of the biggest perks of membership is access to virtual care, says Freedman. Rather than having to travel to the practice when routine health problems arise, Evolve members can access Freedman and the NPs online through secure virtual visits (for which they pay $25 per visit), e-mail, and text messages. "... With a fee-for-service model, physicians don't want to get themselves tied up answering e-mails, texts, etc., all day long because it's all free care," says Freedman. "But with a membership model, you just price it so that all of that service is part of what's included [in the membership]."

Evolve also accepts patients on a non-membership basis, charging $105 per visit and slightly higher fees for services. To view a fee schedule for Evolve members and non-members, visit bit.ly/evolve-fees.

Though the practice does not accept insurance, it does refer patients to specialists through their insurance when necessary, says Freedman.


Four months after opening, Freedman's practice had accumulated about 150 members, and he is predicting large growth in the coming months. "It was definitely a little slow at first; July and August tend to be slow months [in general], but it took a little while to get word out," says Freedman, acknowledging that his payment model can be difficult to explain to patients. Still Freedman says, "... Everyone who comes through the door is just blown away. It's extremely rewarding. Normally people are frustrated with their doctor's office, people come in here and they're just thrilled. They're thrilled with the facility, they're thrilled with the staff, they're thrilled with the provider, and they're thrilled with their experience. A lot of people who come in just for urgent care needs end up signing up as soon as they hear about the program."

While patients are responding well to the practice, so are Freedman and his partners. "... It's just like working in heaven, Nirvana," says Freedman. "We come in to work and there are hardwood floors, and there's artwork hanging on the walls. It's clean, it's pleasant. We've got a hand-picked A-list team [of providers] ... Everyone just loves coming in."

Aubrey Westgate is senior editor for Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the February 2015 issue of Physicians Practice.

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