“I’m really sick of what the drugs are doing to me,” Tighe told Palmer, his primary care doctor. “I’m sure that the reason I’m alive is because of these drugs, but it’s awful what they’re doing to me.”
The patient, Kevin Tighe, a retired businessman, recently had cardiac surgery following a heart attack. He was taking at least seven drugs, including atorvastatin for high cholesterol.
HOLLAND — Dr. Deborah Palmer sat at the cherry wood dining room table in the home of her 71-year-old patient, trying to understand why he kept waking up in the middle of the night with a headache, indigestion, and feelings of anxiety.
Palmer took Tighe’s blood pressure, listened to his heart with a stethoscope, and discussed his feelings of depression. After spending 45 minutes with him, she kept him on his other medications, but halved his dosage of atorvastatin, suspecting it was causing the side effects.
“It’s a rough medicine for a lot of people,” she told him.
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Palmer’s lengthy house call was possible as a result of an unusual career change she made in 2022 from a traditional primary care practice in Brimfield, where her roster of 3,500 patients necessitated 15-minute appointments, to an emerging model called “direct primary care.”
She now has about 200 patients who pay her $80 to $145 monthly to see her as often as they need. She no longer accepts insurance, which she says did not pay her enough while overwhelming her with administrative work.
Palmer is one of about 15 direct primary care physicians in Massachusetts using the new business model, which could become more popular under the Trump administration. Robert F. Kennedy Jr., the controversial new secretary of the US Department of Health and Human Services, mentioned direct primary care as a promising approach during his Senate confirmation hearing in January, when he also criticized government-run health programs.
Project 2025, the Heritage Foundation’s conservative policy blueprint published ahead of the second Trump administration, trumpeted direct primary care as well, saying it is “improving patient access, driving higher quality and lower cost, and strengthening the doctor-patient relationship.” The blueprint also warned against “overly exuberant attempts at regulation” of the model. Proponents herald it as a free-market approach to providing medical care, one that bypasses traditional insurance intermediaries.
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But critics say direct primary care, like so-called concierge medicine, could widen health care disparities between haves and have-nots by requiring patients to pay membership fees.
Dr. Deborah Palmer sat with her patient Kevin Tighe in his home trying to help him address drug side effects he was experiencing. Suzanne Kreiter/Globe Staff
There’s one thing both sides agree on: the model has emerged because the primary care system is broken, with a dire shortage of doctors, physicians complaining of burnout, and patients waiting weeks or months for appointments with a practitioner — if they can even find one.
Palmer, 34, calls her practice “Freedom Doctors,” the name emblazoned on the back of her black jacket. (She’s the only doctor in it so far but hopes to expand.) She has no staff since she doesn’t need employees to charge for visits or file insurance claims. She doesn’t have an office and instead makes house calls, driving around south central Massachusetts in a black Toyota 4Runner.
She also keeps in touch via texts, phone calls, online appointments, and messages on a web portal. She typically sees patients within a day of receiving a request for an urgent appointment and within a week for a routine one.
“The goal is to emphasize quality personalized care without dealing with the middleman, aka the insurance company,” she said.
There are about 3,000 such doctors nationwide, said Dr. Phil Eskew, a direct primary care physician in South Carolina who started DPC Frontier, a website that tracks them.
Similar to concierge medicine, direct primary care is built on fees, but there are key differences. Doctors with concierge practices typically also receive reimbursements from health insurers and copays from patients. Direct care physicians rely entirely on monthly subscription fees, prompting some proponents to call it “Netflix for medicine.”
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Concierge practices also typically charge considerably more, usually annually: often between $2,000 and $10,000, but as high as $30,000 or $50,000. In contrast, Palmer charges monthly fees of $80 for children, $115 to $130 for adults, and $145 for seniors, which works out to $1,740 a year for patients paying the highest amount.
Even though direct primary care doctors don’t accept health insurance, their patients still must buy coverage for treatment of major illnesses and prescription drugs and to comply with the federal Affordable Care Act.
Detractors say direct primary care may appeal to some people, but it’s beyond the reach of many patients.
These doctors are “leaving behind patients who can’t afford to pay the monthly fee as opposed to taking advantage of their employer’s insurance or whatever insurance they have,” said Dr. Russell Phillips, director of the Center for Primary Care at Harvard Medical School.
Dr. Deborah Palmer returned to her car after seeing a patient in his home. Suzanne Kreiter/Globe Staff
He also said the business model could worsen the shortage of primary care physicians by siphoning off doctors who treat large numbers of patients at traditional practices. Direct primary care may improve the lives of its practitioners, Phillips said, “but it just contributes to the primary care shortage.”
“Unfortunately, it’s a response to what’s going on [in] primary care generally,” he said.
Amy Rosenthal, executive director of Health Care for All, a Boston consumer advocacy group, said everyone should have access to affordable care regardless of their ability to pay. “Relying on high-cost options for patients to be able to see primary care providers will not solve our primary care shortage challenges,” she said.
That shortage is particularly acute in Massachusetts, according to a report by the state Health Policy Commission in January. While Massachusetts has the highest number of physicians per capita in the country, the vast majority are specialists; the state has the fifth lowest share of primary care physicians. New patients wait an average of 40 days in Boston for an appointment, double the average of 15 other cities studied, the commission reported.
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Several direct primary care doctors parried criticism of the monthly fees, saying they are a small price to pay to ensure patients can quickly get an appointment.
“You have access to your personal physician who knows you and takes care of you all the time for the price of a cup of coffee every day,” said Dr. Marguerite Garofalo, who has a direct primary care practice in Mansfield called Hydrangea Family Medicine. Her monthly membership fees are $85 for children, $135 for adults, and $325 for families of four.
Other defenders say patients should reserve their health insurance for emergencies and major medical expenses, not for routine physicals and sick visits. Dr. Kimberly Legg Corba, a direct primary care doctor in Allentown, Pa., and member of the board of the nonprofit lobbying group DPC Action, draws an analogy with car insurance.
“My car insurance doesn’t pay for me to replace windshield wiper blades and do tire rotations,” she said. “It pays for the big stuff.”
Dr. Wendy Cohen, who has a direct care practice in the same building as Garofalo, said the business model enables her to provide the kind of care that drew her to medicine in the first place. When she previously worked at a traditional practice in Easton owned by the now-defunct Compass Medical, she said, she was admonished for spending too much time talking to patients.
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“It was just all about productivity and how many feet [came] through the door,” said Cohen, who cofounded a direct care practice in 2016 called Infinity Family Care. “I didn’t ever have any slots in my schedule to see sick patients, so sick patients went to the urgent care.”
“Then I thought, ‘Oh, I really do not want to be in a system that thinks that talking to the patients is a negative,’” Cohen said.
While Cohen and Garofalo both have offices where they examine patients, Palmer’s lack of one and reliance on house calls appears to be a selling point.
Dr. Deborah Palmer with her patient Kevin Tighe in his home. Suzanne Kreiter/Globe Staff
Tighe, her patient who was waking in the middle of the night, loves never having to sit in a waiting room. “It’s wonderful,” said Tighe, who has been seeing Palmer since August and pays $140 a month. “I don’t have to go hang around with a whole bunch of sick people.”
Palmer’s patients use their insurance to cover the cost of lab tests obtained wherever they want or pay out of pocket to Palmer to use Quest Diagnostics, with which she has negotiated discounted prices. (A test to measure cholesterol levels costs $8 at Quest, while a basic metabolic panel to assess general health costs $4.03.)
“You pay me for the labs, and I pay Quest,” she said. Her patients use their insurance for their prescription drugs.
Palmer declined to share how much she makes as a direct primary care physician. Although it’s less than she did at the Brimfield practice, she said, she hopes to eventually make as much through membership fees. (The US Bureau of Labor Statistics puts the average family doctor’s annual earnings at about $240,000.)
And because she treats far fewer patients, she enjoys a better work-life balance, typically working four nine-hour days, and spending more time with her family. At Brimfield, she said, Palmer worked at least 70 hours a week, including a full day on the weekend to catch up on record-keeping and administrative tasks.
After making house calls one recent day, Palmer said she sometimes feels like a throwback to an earlier era of family medicine. She showed up at Tighe’s house carrying her stethoscope, blood pressure monitor, and laptop in a bag, although it was a red-and-black plaid backpack, not the classic black leather bags doctors carried generations ago.
“I’d like a nice leather old-school bag,” she later said.
Dr. Deborah Palmer arrived at one of her patient’s homes for a house call. Suzanne Kreiter/Globe Staff
Jonathan Saltzman can be reached at jonathan.saltzman@globe.com.
‘Direct primary care’ offers doctor on demand for a monthly fee
