Sarah Smith holds her daughter Delaney, 1, surrounded by her older children Charlotte, 9, and Carter, 13, at their home in Biddeford on Friday. The family has been under the care of Dr. Alison “Ali” Kopelman since Carter was a baby. When Kopelman switched to offering direct primary care services, the family followed her. Brianna Soukup/Portland Press Herald

BIDDEFORD — It is not unusual to see kids blowing bubbles, running around with toys and sprawling out on the rug in Dr. Alison Kopelman’s pediatric office – all things that are seldom seen in the offices of doctors who work within hospital systems.

Kopelman is a one-woman show, operating Personalized Pediatrics of Maine in Portland, a direct primary care practice. She is not affiliated with or beholden to any large hospital system, giving her the freedom to practice her own way and write her own office rules.

“I feel so truly lucky to be able to do this,” she said. “When you’re an idealistic teenager and you know what you want to do with your life, you envision being a doctor where you really get to know families. So, I have hour-long appointments, frequently. I really know families. I’m really able to provide care and to build trusting relationships in a way I was never able to before.”

Kopelman is among a growing number of doctors going into private practice after decades of doctors being employed by hospital systems, and often breaking ties with insurance companies in the process.

The growth, while still modest in Maine, is fueled by patients frustrated by a system that can overwhelm doctors with an onslaught of patients every day, often only having time for 20-minute visits, making it more difficult for patients to make appointments and have their concerns adequately addressed.

Despite acknowledged shortcomings in the current direct primary care system that make it not the best system for everyone, direct primary care practices grew from 125 nationally in 2014 to more than 1,500 in 2021, according to an article published on the National Library of Medicine’s website.

There are at least 27 direct primary care practices in Maine, including a few that are hybrid — insurance is billed in addition to the monthly fee, according to DPC Frontier, a website that maps direct primary care practices across the United States. In Maine, most practices are located in the southern and midcoast areas.

The direct primary care model does not rely on insurance payments; rather it is a system in which patients pay a flat monthly fee for primary care services. Patients are often able to see providers faster through direct primary care. And many direct primary care providers come to people’s homes and are available by phone at all hours.

Because she has no staff, all patient-related responsibilities fall on Kopelman’s shoulders. It can be stressful, but she prefers it that way, she said. She is basically on call for her patients all the time, though most of them only call her at night and on weekends if it’s an emergency, she said.

When she was working for one of the big hospitals in southern Maine and billing insurance companies to get paid, she saw a minimum of 20 children a day and upward of 35 kids on a busier day, she said. On top of that, she had to do administrative work to comply with insurance billing requirements.

It became too much, Kopelman said. Despite her best efforts, she was always running behind, working extra hours and not giving patients what she felt was the best quality of care. She worked that way for nearly two decades before deciding to leave the system.

Now, she doesn’t spend substantial time at her desk fulfilling insurance requirements, allowing her more time with patients in appointments, she said. She is building trust and relationships with families in a way she was never able to while working for a hospital.

Harrison Smith of Biddeford followed Kopelman as a patient when she established her own direct primary care practice in 2021, and has not looked back since.

“She has the time to actually spend with them (his children), to do more than just check a couple of vitals and head back out the door,” he said. “She’s got the benefit of time to talk and observe.”

Kopelman said she can spend upward of an hour with patients, giving her time to observe them in the office. It’s the reason Smith said he would never return to seeking primary care services from a hospital-based physician for his children. Despite also having family insurance, he said the monthly fee is worth what he considers to be a better quality of care. He has barely had to use his kids’ insurance.

“Honestly, like, I would never go back,” he said. “I would never take my kids back into a traditional doctor’s office after this.”

The conflicting aspects of medicine

Dr. Michelle Garcia, who practices in Scarborough, said she found herself rushing through visits with patients when she worked in hospitals. She was not able to do all of the things she had envisioned when she dreamed of being a family doctor when she was younger.

Hospital administrators often made decisions that resulted in patient care that was not as good as it should have been, and created a stressful environment for providers and staff providing care, Garcia said. When she tried to advocate for ways to make things work better, she felt like what she said was not considered.

“I was very active in all the offices I worked in, trying to make systematic changes to make things better for everybody and there was just so much pushback,” she said. “There’s a big disconnect, I think, between the business of medicine and the taking care of people part of medicine, and they’re not — the two things are not always in line. And unfortunately, the thing that’s going to prevail in a for-profit type of system like that is going to be the business side, and that’s not always the best thing for patients.”

Dr. Allison Kopelman, left, sits in her Portland office with a patient Jan. 4. Her dog provides support to children. Submitted photo

Insurance payments reimburse for primary care poorly, she said. It is one of the reasons why providers are required to see an excessive number of patients each day. Hospitals often hire whole teams of people just to process insurance payments and fulfill requests from insurance companies before they get reimbursed or care is approved.

“So in order to continue to fund all of that, you have to have a really full schedule all the time,” she said. “So a lot of times they won’t give you spaces in your schedule to be available for patients for acute visits. So if someone calls and says, ‘Hey, I’m worried. I’ve got this cold and I’m worried.’ It might be progressing or something. You’d like to say, ‘Oh, yeah, come on in. We’ll see you today or we’ll see you tomorrow.’ But most of the time you don’t have availability for like weeks. So it’s really hard to get people in.”

The health care industry is starting to see a staff retention issue that is largely driving a push for seeking other forms of health care funding, according to Jason Harkins, executive dean of the University of Maine Business School.

All of this industry pressure is what ultimately pushed Garcia to throw up her hands last summer and leave that system behind to start Horizons Direct Primary Care in Scarborough, in which she only bills patients’ insurance for certain services. Now she controls how her office operates and can make adjustments as needed.

Since largely foregoing insurance reimbursements for a monthly fee-based system, she spends more time with fewer patients and only works nine hours a day, she said. It is a much better balance for her and she is not feeling overwhelmed.

A solution for some but not all

University of Maine Professor of Finance Pankaj “Pank” Agrrawal thinks that while direct primary care is a solution for some patients, the model does not address numerous issues including emergency care, surgeries and specialists — services most people still need insurance to cover.

Direct primary care is likely supplemental for a niche population, he said, though it does seem to have a rather diverse group of patients, from “gig” workers (such as Uber drivers) to rural farmers who live geographically far from large hospital systems.

“Patients with the predictable and chronic conditions favor (direct primary care) for its personalized attention and preventive care focus,” he said. “… The minute you have an emergency event, the minute you have surgery, the minute you have an important out-of-network consultation required, the cost becomes so high that there is no way that … monthly premium can cover that.”

Kopelman and Garcia both said more accessibility to primary care doctors tends to result in fewer visits to the emergency room, reducing people’s use of insurance. Both of them have saved their patients visits to the emergency room or walk-in care just by being accessible by phone, they said, access that many providers in hospitals struggle with.

Dr. Michelle Garcia sits in her Scarborough office March 21. Submitted photo

Kopelman will draw her patients’ blood in office and dispense some basic medications, such as amoxicillin, for just the price she pays pharmacies for them, which tends to be much cheaper than what her patients themselves would pay out of pocket.

She charges $100 a month for children 7 and up, $125 for kids ages 2 to 6 and $175 for children under 2, she said. She also has a sliding fee scale that lets her accept patients who have a hard time affording the fee. There are some services that she does still bill patients’ insurance for, though those instances are minimal.

Garcia can give discounted prices to her patients for lab work and medications, she said. Her patients will pay for labs directly through her and then she pays for those labs at a lower price than what patients are typically charged through the labs themselves, she said.

The average monthly cost for direct primary care tends to be $75-$150, she said. However, she still encourages patients to have some kind of catastrophic health insurance.

She has heard the criticism about direct primary care mostly being utilized by wealthier people, but that is not her experience, she said. Her patient panel is mixed, with about a third paying with cash, a third have private insurance and a third have health plans that cover her monthly fee. Some of them are lower income, some of them are rural and some of them live a distance from her office.

“There’s just a ton of people that have really high-deductible health insurance plans or are uninsured,” she said. “… This is actually a more affordable way for them to get their health care.”

Pressure to innovate

Direct primary care has become a popular option to some in the Trump administration as a way to address some of the country’s struggles with health care and health care funding.

However, the majority of people still tend to rate their health care insurance plan as good, Harkins said. Insurance tends to become an issue for people when they experience a barrier to coverage, such as a when a request is denied, questioned or replaced with some other care suggested by the insurance company. Costs can be another issue for people with high-deductible plans.

Despite these issues, Harkins does not see insurance plans going away any time soon, he said.

“(The direct primary care) model is interesting and it remains to be seen if it will stay separated out, with people being OK with paying for primary care interactions but still needing a high-deductible plan for catastrophic coverage,” he said.

Agrrawal wonders if the rising popularity in direct primary care will have an influence on how insurance companies continue to offer plans.

“Dissatisfaction with traditional insurance has grown,” he said. “And so (direct primary care) may put pressure on insurers to innovate and offer more patient-centered (care).”