When Dr. Nicole Hemkes opened a solo practice called Advocate MD in Middleton in 2019, the idea seemed like a long shot. As a direct primary care physician, she would be charging patients a monthly fee for her services and not accepting insurance. Other doctors had tried similar practices in the Madison area in the past and failed.
“When I started the practice five years ago,” says Hemkes, “I was told by people ‘Don’t do this, it can’t work in Madison, there are too many HMOs, and everybody wants to go to UW.’ But it does work.”
This year, Hemkes opened her third Madison area-clinic, in Fitchburg. The original Advocate MD office in Middleton Hills and a second on Fair Oaks Avenue are also joined by a fourth clinic in Janesville. Hemkes now has five more doctors working with her in the practice. And Advocate MD is no longer the only direct primary care option in the area.
“Even more today than five years ago, people are unhappy with their health care experience,” says Hemkes. “The insurance keeps getting more expensive, and the care you actually receive goes down.” That’s where direct primary care steps in.
“The joke is, if you’ve seen one direct primary care practice, you’ve seen one direct primary care practice,” says Dr. Wendy Molaska, who opened Dedicated Family Care in Fitchburg in 2021. “We’re all a little bit different.”
Direct primary care practices provide preventive care, manage chronic diseases, treat colds and flu, sprains and other sports injuries, lacerations, strep throat, and other conditions. They perform procedures including X-rays, ultrasounds, cardiac monitoring, prolotherapy and even vasectomies, though available procedures vary from practice to practice.
The idea is that the direct care doctor can see patients more often, know them better, and keep them healthier. Most people who opt for direct primary care also take out a high deductible or “catastrophic” health insurance plan in case of serious illness.
Direct primary care is not insurance. These practitioners see insurance as one of the factors getting in the way of patient care and increasing its cost. Instead, doctors charge patients a monthly fee after an initial enrollment fee, as at a health club or yoga studio.
Primary care doctors also refer patients to specialists or help set up other procedures with private labs or smaller hospitals, negotiating more reasonable costs and shorter wait times than patients increasingly encounter in a large health plan.
When Molaska opened her practice in 2021, “it was just me seeing patients in one room,” she remembers. Then things “kind of exploded,” she says. In less than a year she’d moved to a larger office that functions more like a clinic, with four exam rooms, a procedure room, an office, and a reception area.
Her practice now includes a nurse (who is also a certified medical interpreter) and a medical assistant/receptionist (who is also a nurse in training). Molaska is about to hire an assistant who will work remotely on the administrative end. She’s also looking to hire a second physician: “I’m full and we have a waiting list.”
Before opening Dedicated Family Care, Molaska says she was on the verge of quitting healthcare altogether. “Most people call it ‘burnout.’ I prefer the term ‘moral injury,’ because it implies that it’s the system that is broken — and I really believe our healthcare system is broken.”
Now, Molaska says, she couldn’t be happier as a doctor and believes she is providing better care than she ever has. She started her clinic with the aim to reach underserved communities, especially Spanish speaking, and it serves many Black, Latino/a and LGBTQ+ patients. Clinic outreach has included going to health fairs to provide diabetes and blood pressure screenings as well as “to get the word out there to the people who fall through the cracks” that direct primary care is an alternative.
Her patients vary widely. Members include people who have money and think of her more as a “concierge doctor”; those who have health insurance but feel they can’t use it effectively and are “fed up with lack of access”; those with high deductible plans who would otherwise have to avoid doctor visits because they can’t afford them; and the uninsured. She found it “heartwarming” when one of her wealthy patients donated to pay for monthly memberships for some of those less well off. She’s now considering creating a nonprofit arm to take contributions to fund care for those without means: “We’ve never yet turned anyone away.”
The number of area direct primary care options is increasing. Dr. Amanda Preimesberger opened her direct primary care practice, rootsMD, in Verona in 2021; in 2023 the clinic added a second practitioner, Dr. Traese Kuhl. Our Lady of Hope is a faith-based direct primary care clinic in Middleton. And this year Dr. Angela Marchant opened Tallgrass Osteopathic Family Medicine, integrative medicine on the direct primary care model.
As direct primary care has grown, so has direct specialty care.
In the past year “the options for where we can refer patients have expanded a lot,” says Hemkes of Advocate MD. MH Imaging, an independent radiology facility, opened in Middleton; another, Smart Scan Medical Imaging, is also in Middleton. “Smart Scan also does infusions, so patients who require IV infusions for rheumatoid conditions can have it done there,” says Hemkes. These independent radiology clinics advertise state-of-the-art equipment yet charge much less than the same procedure in a hospital. Some accept insurance plans.
The Orthopedic & Spine Centers of Wisconsin, comprised of a dozen doctors who left other local health care systems, opened an office off the Beltline in 2023. They’ve been performing surgeries at area regional hospitals and plan on opening their own surgery center. This would be a less expensive option for patients needing joint replacement or any orthopedic surgery.
Hemkes also cites Solstice Health, a direct primary care practice that started in Oconomowoc in 2012 that now also has a surgery center. Solstice’s slogan on its website — “It’s your money. It’s your health care. Take it back!” gets to the heart of current dissatisfaction with the health care system.
“They will do any surgery,” Hemkes says, noting the practice contracts with different specialists. It’s all cash-based. All prices are listed on its website — a diagnostic colonoscopy is $1,599; a single mastectomy is $9,193.
Direct primary care doctors know options for sites where operations and procedures can take place at more reasonable costs, from independent surgical centers to smaller regional hospitals. Or they might point a patient to the Wisconsin Well Woman Program for a mammogram or other screening.
Another change Hemkes has seen since she started Advocate MD is that businesses are more interested in figuring out ways to help their employees opt in to this care model, both to improve access to doctors and to save money themselves.
“Five years ago, very few people had heard of direct primary care,” Hemkes says. “Now businesses are coming to us.”
