Why I Made the Leap to Direct Care as a Neurologist

In her first decade of practicing medicine, Dr. Jill Farmer, a New Jersey-based neurologist and movement disorder specialist, worked at a hospital, an academic medical center, and a large private practice. After “meandering through” different roles and treatment settings, Jill was itching to strike out on her own.

“I have always wanted to have my own practice,” she said. “When I decided I wanted to be a doctor, I liked the idea of being my own boss, having my own space, doing my own thing.”

Jill realized that she’d need to move into direct specialty care if she wanted to build a successful solo practice. So that’s what she did, about a year ago.

We talked to Jill about why she saw direct care as her best path forward, how she’s been able to retain Medicare patients, why insurance is still her biggest frustration, and what people get wrong about the direct care model.

Here’s our conversation, edited for length and clarity.

Offcall: Tell me about your journey from working as an employee, and doing traditional fee-for-service care, to opening your own direct care practice. What inspired you to make such a big career change?

Dr. Jill Farmer: Coming out of training, I was looking to move back to my area in New Jersey. The jobs available were really hospital-based, which didn't seem like a bad thing. I had access to resources that could round out clinical care. But there definitely was a push to keep things in house and focus on bottom-line efficiency, and I sometimes felt it came at the cost of practicing the way I wanted to practice.

I was never somebody who wanted to do primarily academic medicine. But when the opportunity then came to transition over to academics, my group was in a unique situation, where our entire group changed as a whole. So I didn't have to rebuild anything new. We all went to an academic institution, and I got the exposure of managing and teaching residents and looking at fellowship and research opportunities. But what was also obvious was that fewer resources were available in academics. Access to multidisciplinary clinics with physical therapy, occupational therapy, things like that. They were far more siloed. And then it just so happened that the hospital we were affiliated with closed.

We became a large subspecialty private practice with neurology and neurosurgery in an outpatient setting. I was still with the same people I had been with from the very beginning, but in a different practice setting. Neurology and neurosurgery just have different approaches to outpatient care. So when my contract was up, and I had the opportunity to look at a new physical practice space in my town, I was like, It’s a decade in the making. I think now is the time.

Having been in the insurance-based world, I also realized there would be no way I could open my own practice and accept insurance. The cost would be too high. So the only way to do it was to do direct specialty care.

Offcall: Would you have preferred to open your own practice and continue accepting insurance?

JF: Absolutely. I’m a Parkinson's doctor; I see primarily patients with Medicare. There’s an option with Medicare called “non-PAR,” where you can be paid at the time of the visit and then the patients have the ability to submit for reimbursement.

That sounds fabulous on paper, but you’re beholden to the rules and regulations, and the administrative hurdles and burdens, of Medicare and insurance, which make being a solo practitioner much more difficult. When I was researching this and asking people who had opted out completely, who were non-PAR, and who did accept insurance, the vast majority said that if they had to do it again, they would just completely divest themselves from all insurance. So that’s the advice I followed.

Offcall: It sounds like you did a lot of research before going out on your own — what did that entail?

JF: Talking to other people who had done it, speaking to practice administrators in my prior practice, and at other practices, about the workflows and overhead costs of offering a comprehensive practice with insurance and without insurance.

I looked into all the different models — direct specialty care vs. concierge vs. a blend. I’m lucky enough to be part of a Facebook group called the Women Neurologists Group. It’s a collection of women neurologists from residency through retirement. There are a few women in the group who’ve gone into various forms of direct specialty care, and they were instrumental in encouraging me — that this is not as hard as it seems — and providing practical roadmaps for how to go about doing it.

Offcall: Can you say a bit more about the Women Neurologists Group, and your involvement with it?

JF: It was an offshoot of a much larger Facebook group called the Physician Moms Group. Since that group got so big, it sort of naturally broke off into individual specialties. I got involved a couple of years after that split, because we were going to host our first in-person conference. I do work with pharma and industry, so I was tapped to help figure out funding. Then I became an administrator and have been one ever since. It’s been great. It's that classic thing where, like, women do work because it's the right thing to do. It actually is something that could be monetized, but that's not our goal. We just want it to be this free resource that people have access to, that's drama free, that they can use as a springboard to their own opportunities.

Offcall: Back to your practice — you opened it about a year ago. What’s been the most rewarding part of the experience so far?

JF: Feeling in control. I’m a first-born, Type A personality. I like doing things efficiently, the way I want to do them. That has translated to being able to do a renovation on my office space. It’s taking far longer than usual, which has to do with opening a small business in a small town with zoning boards, permits, and that kind of stuff.

But, because of that, I had to pivot to doing home visits. I couldn't have done that at a big institution. They wouldn't allow me to make that decision. From a clinical point of view, that has been the most rewarding — being in a patient's home and having a casual conversation with them, which is the majority of what my visits are with Parkinson's patients. It’s been eye-opening and rejuvenating, and it’s something I will not give up, even when my brick-and-mortar practice opens.

Offcall: And what’s been the most challenging part?

JF: Still, actually, insurance, even though I am not involved with insurance. That’s because the left hand doesn't know what the right hand is doing when it comes to insurance, particularly for Medicare and Medicare Advantage plans and these gray, nebulous areas of, are they private, are they not?

When patients submit for reimbursement, which they are allowed to do if they're not Medicare, they’re told by insurance that I'm still in-network, and I'm like, I am not in-network. It’s written clearly on the invoice. So, it's still a lot of back and forth because that is just the nature of insurance.

Offcall: You said you had a lot of Medicare patients. Have you been able to retain most of them? Or has the switch to direct care forced you to change your patient base significantly?

JF: Luckily, it has not. Despite all the changes in the practice models that I've had over the past decade, I've been in the same geographic area and I've followed some of these patients for that duration of time. So it's kind of been like a 10-year interview.

When I told them I was transitioning and planning to do this, I was blunt. And I said, “Well, hopefully you feel the care that I have provided you over the past decade warrants you feeling comfortable being able to pay for it out of pocket.”

I also had to explain — and this was a learning curve that I did not know I needed to address — that by having patients pay for the office visit, that's the only thing that is out of pocket for them. All medications, any referrals, any lab tests, imaging, whatever else I order or suggest is still covered by insurance. And once patients understood that, it became a far less worrisome prospect for them, and much less of a financial concern.

So, I was able to retain some of my patients. My goal was not to retain all of them because it’s just me and I wanted a smaller patient panel so that I would be able to spend more time and be more in depth.

The other aspect of it was that some of the patients — and I understood this completely — were like, I have paid into this system for my entire working career. I need to use it. I said I would help them find docs who are still in-network. I would say maybe one-third of those patients have found their way back to me. So, it’s a nice reinforcement that the care I'm providing is valued.

When I made my fee schedule, I tried to do it so that it wouldn't be cost prohibitive to most patients, and that was honestly the hardest part because I knew this practice model would exclude some patients. My goal was that if some patients were unable to afford the office visit, then, because it was my practice, I would have the authority to figure out either payment plans or adjustments in fee schedules for select cases.

Offcall: Have you had to do that a lot?

JF: Not often, but there were two patients I knew would not be able to pay based on their circumstances, but they were receiving a device treatment that I knew they would not be able to find another doctor to easily take over. So we figured out something that was reasonable for them. Because they did want to pay; they didn't want it to be like, I'm getting charity care.

Offcall: Are you marketing your practice at all?

JF: Right now, no, because I figured it was going to be too difficult to explain why I don't actually have an office, since it’s under renovation. I've been pulling from my own prior patient base, and then patients have found me by word of mouth.

By no means am I turning patients away, but I'm not actively advertising. When my new space opens, I intend to. But I've also been supplementing with other things like pharmaceutical consulting and participating in research; it’s helped maintain a good balance between clinical revenue and the other revenue streams.

Offcall: What's the most surprising thing you've learned so far about how direct care works?

JF: I do procedures, particularly botulinum toxin injections. The way that it works for a traditional practice is that for Medicare, they want you to buy and bill, meaning they want the doc to buy all the toxin and then bill Medicare on the back-end for reimbursement. I can't shell out tens of thousands of dollars to have stock on hand.

But Medicare does have a specialty pharmacy benefit, and that is how commercially insured patients gets their toxin. So I only inject Medicare patients through their specialty pharmacy benefit. I was expecting to not be able to do that — because that's how we're taught, that it’s just not done. But it can be done.

It doesn't work for every patient. Some will still have an incredibly high copay, but the majority don’t. It’s another way to be able to hold on to my Medicare patients and not have to send them out to other practices simply because they’re Medicare.

Offcall: What’s a common misconception about direct specialty care that you’d like to correct?

JF: I think the biggest misconception is that if you're a direct care model, patients have to pay a subscription fee. That’s concierge. Concierge is similar to direct care. It probably falls under the general umbrella, but it's a style of direct care. I explain to patients that they should think of me like a dentist from the ‘80s — when there was no dental insurance, you went, you paid, and if you could submit, you did. If you didn't submit, it was an out-of-pocket expense.

I didn't want the pressure of a concierge practice, because when you invest in something like that, there are going to be expectations of availability. I deal with a neurodegenerative disease, a chronic one. There are going to be times that we just don’t have the resources to manage symptoms, and we're going to have to look to other options. And I think that when you add a concierge fee on top of that, it can rub people the wrong way. So, I wanted to leave it as simple as possible, where you pay for the service that I provide.

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