The Doctor Is In
From same-day visits to house calls, direct primary care doctors offer New Hampshire residents a new health care model
You may feel sick today but quickly discover your health care provider can’t see you until next week.
If you decide to visit your local urgent care or walk-in care clinic instead, you may wait hours to see a provider you don’t know and pay a higher co-pay to use those services. Relying on the emergency room can result in long waits and quickly drain your savings, too. In New Hampshire, minor outpatient procedures at the ER cost an average of $386, according to New Hampshire Health Cost.
Patients across the country and in New Hampshire are becoming increasingly frustrated with the insurance-regulated health care system, and their doctors are, too, says Dr. Eric Kropp, a board-certified family medicine doctor who owns and practices at Active Choice Healthcare in Concord.
Active Choice Healthcare is a direct primary care practice that charges patients a fixed monthly membership fee. Patients in the practice can quickly get same- or next-day appointments for sick visits with Kropp.
Because most direct primary care practices only see between 400 to 500 patients (compared to the 1,200 or 1,800 patients insurance-based providers see), they can spend much more time with them.
“I found that, over time, my ability to care for the whole patient became limited by time,” Kropp says. “And then, I discovered a model which eliminates the middlemen that detract from the patient-physician relationship.”
The direct primary care model is a medical practice and payment model where patients pay their practice directly in the form of fees for primary care services. Rather than bill insurance, these practices charge patients a monthly fee, under terms of a contract, in exchange for access to a broad range of primary care and medical administrative services, according to the American Academy of Family Physicians.
At Active Choice Healthcare, adults over the age of 49 pay a $150 monthly fee. Younger adults (ages 19 to 39) pay $100 monthly, and children under 19 are charged $30 monthly. In exchange for these fees, patients can get physicals, be seen for sick visits, and even receive care for a number of infections and sports injuries. For an extra fee, Kropp can remove skin lesions and suture wounds in his office.
“There may be a time that I see people once a year, or I may see the same person three times in one week if there is something else going on,” Kropp says. “By simplifying the model, I can have fewer patients, spend more time with them and be available for them when they need me by whatever means is appropriate.”
Kropp, who opened Active Choice Healthcare in 2016, trained at The New Hampshire Dartmouth Family Medicine Residency and practiced for six years at Penacook Family Physicians before opening up his solo practice. He sees a wide variety of patients, and most of them choose to see him because they appreciate a personalized approach.
Direct primary care providers can also help patients save money on simple in-office procedures and blood tests, Kropp says.
Bridging the primary health care gap
In 2020, only 6.1% of the New Hampshire population was uninsured, which was lower than the national rate of 8.8%, according to the University of New Hampshire Institute for Health Policy and Practice. But, even patients with coverage are looking for better options — and are willing to pay extra for it.
“Some people have excellent insurance, and this may cost them more than what they might pay if they were to go somewhere else,” Kropp says. “But they really want that quality and approach that old-time, small health care offered. They want somebody they can call their doctor, not an institution that’s their health care provider.”
He estimates that about a third of his patients are uninsured, and that his fee structure allows them to better estimate their primary care costs for the year. About a quarter of his patients are on Medicare and prefer a doctor who can spend time with them and answer their questions.
“The other camp is underinsured. They have their insurance plan, but maybe they have a $3,000 deductible, and one ER visit will eat up their entire deductible right there,” he says.
Direct primary care for pediatric patients
If you’ve been the parent of a newborn or toddler, you might remember how often you visited the doctor and how inconvenient it could be to bundle up your child and go. In 2021, Dr. Kelly Parker-Mello opened Tailored Pediatric Medicine in Portsmouth to give busy parents a convenient, personalized health care option for their children up to 22 years old.
Like Active Choice Healthcare, Tailored Pediatric Medicine does not accept health insurance. Families pay a monthly fee for services. In exchange, children and teens can be seen anytime and can contact Parker-Mello via telemedicine calls and secure text messaging.
Before she opened her direct care pediatric practice, Parker-Mello spent seven years practicing general pediatrics in Maine, where she saw patients during the day and did newborn rounds in the hospital. She moved to private practice in Newburyport, Mass., but still felt pressured to see as many patients as possible quickly.
“Insurance-based medicine felt like I was on a treadmill, while my patients were on a conveyor belt going by me,” she says. “My well visits lasted 20 minutes, and my sick visits were 10 minutes, including the nurse check-in.”
Tailored Pediatric Medicine’s monthly fee structure varies according to a child’s age. The fee for newborns is $250 per month, which includes home visits for the first two months. Children ages 1 to 4 can be seen for a $200 monthly fee, and a $150 monthly fee will cover children over age 4. Families are capped at $500 a month. Her fees include sick and well visits and medication management for mental health and chronic illnesses like asthma.
Parker-Mello also offers a special $2,000 home visit infant package, covering children up to 6 months old. It includes a prenatal visit, a home visit within the first three days after the baby comes home from the hospital, and seven to 10 more home visits within the first six months. All of these services come with unlimited texting.
“Parents love it. And I feel so lucky to be able to go into their home, sit on their carpet, hold their baby, and chat,” she says.
The first newborn visit lasts two hours and Parker-Mello is able to spend time talking to parents and offering lactation support.
Direct Pediatric care is not only for wealthy families, Parker-Mello says. Her patients include uninsured families and those on Medicaid. She also uses a sliding scale when needed.
The beginning of a new approach
Kropp and Parker-Mello both encourage their patients to carry health insurance for services outside of the scope of primary care, including hospitalizations, X-rays and prescription drugs.
“We are not health insurance,” Parker-Mello says. “But by using us instead, you might be able to choose a catastrophic (less expensive) health plan. Your health care costs are predictable for everyday things (with direct care). I definitely encourage insurance, because health care can bankrupt people.”
People often ask how health care can be changed to provide patients with greater access to care and better cost transparency. The direct primary care model gives providers the breathing room to listen to patients and help them make decisions about their health care, Kropp says.
“I like to say that I’m doing my part one physician at a time and one patient at a time,” he says. “It’s the only way you can practice medicine really well.”