How this physician built a direct specialty care practice

Welcome to the “why is my appointment six months away?” era

If you’ve ever tried to book a specialist appointment and been offered a date that feels like it was scheduled by a sundial,
you already understand the emotional core of direct specialty care (DSC).
Patients want access, clarity, and a plan. Physicians want time, autonomy, and the ability to practice medicine without
spending half their day wrestling prior authorizations like it’s a competitive sport.

In the KevinMD podcast episode that inspired this article, a rheumatologist describes a scenario that’s painfully familiar:
a patient with severe inflammatory arthritis needs help now, not in “six months, give or take a season.”
The traditional system couldn’t deliver timely careso the physician built a model that could.
That model is direct specialty care: a specialty practice that contracts directly with patients, emphasizes transparent pricing,
and removes insurance billing as the center of the universe.

This is not a “how to get rich quick” scheme (if your business plan is “get rich quick,” medicine is a surprising hobby to choose).
It’s a “how to make care actually happen on time, at a known price, with fewer obstacles” storytold with the practicality of a founder
who’s already done the hard parts.

Direct specialty care, explained like you’re a busy human

Direct specialty care is a model where patients pay the specialist directlyoften through a membership/subscription,
sometimes pay-per-visit, sometimes a hybridwithout the practice contracting with insurance for routine specialty visits.
The goal is to strengthen the patient-physician relationship and cut out third-party payer complexity that drives overhead,
coding burden, and “surprise billing theater.”

What DSC typically includes

• Transparent pricing: clear costs for visits, procedures, labs, imaging coordination, and add-on services.
• Better access: faster scheduling, longer visits, easier communication (secure messaging, email, phone, telehealth).
• Membership value: predictable revenue for the practice and predictable costs (or discounts) for patients.
• Lower administrative overhead: fewer billing staff needs, fewer claims, fewer denials, less “coding gymnastics.”

What DSC is not

• Not health insurance: it doesn’t replace major medical coverage for hospital care, emergencies, or expensive meds.
• Not automatically “concierge”: concierge often implies higher retainers and may still bill insurance; DSC tends to emphasize affordability and transparent cash pricing.
• Not a magic wand: you still need clinical excellence, operations, compliance, and a real plan to reach patients.

What the podcast physician built (and why it resonated)

The physician featured in the KevinMD podcast is a rheumatologist who built a direct specialty care practice after seeing
how the traditional system can fail patients who need timely evaluation.
In her telling, a primary care physician couldn’t get a quick specialist appointment for a patient with disabling inflammatory arthritis.
In her direct practice, she was able to schedule the patient the next dayand the financial experience changed too:
costs were disclosed up front, and the patient avoided the “thousands (estimated) + surprise bills (guaranteed)” pattern.

The core idea: rebuild specialty care around trust and clarity

The physician’s argument is simple and sharp: patients are willing to “shop” for health care when pricing is transparent and the quality is clear.
And physicians can deliver better specialty care when they aren’t trapped in productivity systems that reward speed over thinking.
Direct primary care (DPC) pioneered this relationship-first, membership-based approach in primary care years earlier
DSC applies the same spirit to specialty medicine.

She also points out a practical challenge: direct care specialists can be hard to find.
That’s part of why physician-led networks and associations have formedto make it easier for patients to locate
specialists working in this model and for physicians to learn from each other instead of reinventing every wheel (and then billing the wheel).

The business case: why DSC can work for specialists

Let’s talk economicswithout turning this into a spreadsheet romance novel.
Insurance-based specialty practices often carry heavy administrative overhead:
claims, denials, coding, documentation for payment, contracting, credentialing, audits, and endless rules that change like a Wi-Fi password.
A direct model can reduce that overhead and reallocate time toward patient care.

What changes in a direct model

• Revenue becomes predictable: membership fees or packaged services can stabilize cash flow.
• Visits can be longer: when you’re not forced into rapid-fire volume, you can actually… think. With your brain.
• Prices become a feature, not a mystery: patients can plan, compare, and choose.
• Panel size and scope become intentional: you can decide who you serve and how you serve them.

Who benefits most as patients

• People with chronic or complex conditions who value continuity and access (hello, rheumatology, endocrinology, neurology).
• Patients with high-deductible plans who would rather pay a known cash price than gamble on “allowed amounts.”
• Employers with self-funded plans seeking predictable specialty access (in some markets, via direct contracts).
• Patients who have been bounced around the system and want one specialist to quarterback the plan.

How to build a direct specialty care practice

Here’s the playbookorganized so you can actually use it, not frame it on the wall as motivational decor.
While details vary by specialty and state, the core steps are remarkably consistent across successful DSC launches.

1) Pick a clear “who we help” lane

“We treat everything” is a great way to market yourself to… nobody.
Direct specialty care works best when patients understand the value quickly.
Examples:

• Rheumatology: rapid evaluation for inflammatory arthritis, second opinions, medication strategy, flare planning.
• Endocrinology: diabetes optimization, thyroid care, metabolic health plans, CGM interpretation.
• Neurology: migraine programs, movement disorder follow-up, long-form diagnostic reviews.
• Cardiology: prevention-focused consults, lipids, hypertension, post-hospital follow-up packages.

2) Choose a model: membership, fee-for-service, or hybrid

Many specialty direct practices use one of these:

• Membership/subscription: a monthly or annual fee that includes defined access and certain services.
• Cash-pay per visit/procedure: transparent pricing without membership (often with package discounts).
• Hybrid: memberships for ongoing care + transparent fee-for-service for one-time consults or non-members.

Hybrid models are common in specialties because some patients want a one-time expert consult,
while others want continuous access and care planning.

3) Build a simple, honest service menu

The most effective DSC pricing pages are boring in the best way:
no riddles, no “call for pricing,” no secret handshake.
A sample menu might include:

• New patient comprehensive consult (60 minutes): includes record review + care plan.
• Follow-up visit (30 minutes): targeted adjustment + monitoring.
• Second opinion package: records summary + recommendations + coordination note back to PCP.
• Care coordination add-on: labs/imaging navigation + prior record collection (where applicable).
• Membership tiers: “Essential,” “Plus,” and “Complex Care” based on visit frequency and access needs.

The podcast physician emphasizes upfront costs and patient choice. That transparency is not just nice
it’s the whole brand promise.

4) Design access like a product

Direct practices win on access. That means:

• Fast scheduling: offer rapid slots for urgent clinical questions.
• Asynchronous support: secure messaging for quick clarifications that don’t require an office visit.
• Telehealth: especially valuable for specialty follow-up and patients in areas with limited specialist supply.
• Longer visits: 30–60 minutes when needed, not when the calendar accidentally allows it.

Pro tip: if you advertise “direct access,” your phone system can’t sound like a 1998 escape room.
Invest in workflows that match the promise.

5) Build the operations stack (without buying every shiny tool)

Keep your tech simple and patient-friendly:

• EHR/notes: choose what fits your workflow, not what has the prettiest demo video.
• Online scheduling: let patients self-schedule with guardrails (appointment types, time windows).
• Membership management + payments: secure recurring billing, receipts, and clear terms.
• Communication: HIPAA-compliant messaging and telehealth options.

A practical truth: clinicians spend significant time in the EHR even in traditional systems.
Direct practice doesn’t eliminate documentation, but it can reduce documentation done purely “for billing theater,”
freeing time for actual care.

6) Contract smartly with labs and imaging (where possible)

One of the biggest “wow” moments for patients in direct models is discovering how different pricing can look when it’s negotiated
and disclosed upfront. Many practices coordinate cash-pay lab rates or imaging options so patients can compare:
cash price vs. insurance-covered price vs. deductible impact. The point is choice and transparency.

7) Market like a specialist, not like a coupon flyer

DSC marketing is education-heavy. Patients and referring clinicians need to understand:
what you do, who it’s for, what it costs, and how to use insurance alongside it (if they have it).
Effective channels include:

• Local PCP relationships: make it easy for primary care to refer patients who need timely access.
• Employer partnerships: especially in self-funded environments where access and cost predictability matter.
• Content: clear pages on conditions treated, what a new patient visit includes, and transparent pricing.
• Podcasting and speaking: the “trust accelerator” channelpeople hear how you think.

The podcast format matters here: it’s hard to fake competence for 30 minutes.
Patients and peers can hear whether you’re thoughtful, practical, and humanor just really enthusiastic about buzzwords.

Compliance and “don’t accidentally start a legal fire” basics

Direct care models are real medicine and real businesswhich means real rules.
You don’t need to become an attorney, but you do need an attorney who understands direct care.
Here are the big areas physicians commonly navigate:

1) State insurance and retainer laws

Direct primary care has been treated differently across states; some states explicitly exempt DPC arrangements from insurance regulation,
while others create registration requirements (and definitions of what counts as “primary care”).
Specialty models can fall into different categories depending on services and contract structure.
Translation: check your state rules, your contract language, and your scope.

2) Medicare rules and private contracting

Medicare is a special universe with its own gravity.
Physicians who “opt out” and use private contracts agree not to submit Medicare claims for covered services during the opt-out period,
and Medicare doesn’t reimburse those services. This can be relevant for direct practices that want a private-contract model
for Medicare beneficiaries.
The right approach depends on your practice design, patient population, and compliance guidance.

3) Private insurance contracts

If you’re still contracted with private insurers, you must understand what your contracts allow (and prohibit)
regarding membership fees and billing outside standard terms.
Some direct practices avoid these conflicts by not contracting with insurers at all;
others structure offerings carefully with legal guidance.

Bottom line: DSC is feasible, but you should structure it intentionallyespecially around memberships, covered vs. non-covered services,
and contract language. No one wants their grand opening to include a surprise “cease and desist” balloon arch.

Common pitfalls (and how not to faceplant)

Pitfall: “My pricing is transparent… if you call and ask three times.”

Transparency isn’t a vibe. It’s a document.
Publish a clear fee schedule or a clear membership structure with what’s included and what’s not.

Pitfall: Underpricing because you feel awkward charging for expertise

Many physicians launching direct models initially price as if they’re selling lemonade.
But you’re selling specialized clinical judgment, access, coordination, and time.
Price fairly, but sustainablythen deliver unmistakable value.

Pitfall: Building a “VIP lane” that accidentally narrows access

Critics worry that membership models can create a two-tier system.
Ethical DSC practices address this by:
offering non-member consult options, maintaining some reduced-fee options, providing transparent one-time visit pricing,
and partnering with employers or community programs where possible.

Pitfall: Doing everything yourself forever

The direct model reduces certain administrative burdens, but it doesn’t erase all work.
Build repeatable processes: intake, record collection, follow-up cadence, refills, prior authorizations (when unavoidable),
lab coordination, and patient education.

Why the direct specialty care story is bigger than one practice

The podcast physician frames DSC as part of a larger shift: patients and physicians “reuniting” around mutual accountability,
transparent pricing, and accessible care.
It’s also a response to specialist scarcity and the bottlenecks that happen when schedules are designed for throughput
instead of clinical reality.

Whether DSC becomes mainstream or remains a “highly effective niche,” its influence is already visible:
patients now expect clearer pricing,
more telehealth options,
and more human time with clinicians.
In a world where a patient can track a pizza delivery in real time, “we have no idea what this visit will cost”
is a tough customer experience pitch.

Experiences from the field: what it’s like after you launch (and after the honeymoon phase)

Once the website is live, the first memberships roll in, and your friends stop asking if “direct care” means you personally
deliver medication by bicycle, the real learning begins.
Physicians who move into direct models often describe a strange and wonderful sensation: time.
Not “I found 12 seconds between clicks” time. Real clinical time. The kind where you can ask a patient a follow-up question
without your schedule screaming, “Absolutely not.”

One recurring theme is how quickly patients adapt to transparency. In the traditional system, patients may treat medical pricing like weather:
mysterious, uncontrollable, and likely to ruin their plans. In direct practice, the conversation shifts to choices:
“Here’s what this visit costs. Here’s what labs cost. Here’s what imaging costs. Here are alternatives.”
Patients don’t always love paying cashbut they almost always love knowing the number before the bill arrives
like an unwanted subscription renewal.

Another common experience is that communication improves when it’s designed, not improvised.
In many direct specialty practices, patients can message questions, share symptom updates, or clarify medication instructions
without automatically triggering a bureaucratic obstacle course. That doesn’t mean the physician becomes a 24/7 hotline
(boundaries are healthy and should be built into the membership terms), but it does mean the “small stuff” gets handled early
which can prevent the “big stuff” later.

Physicians also report that the documentation burden changes shape. You still document because medicine is real,
but you can reduce the portion of documentation that exists mainly to satisfy billing codes, audits, or payer rules.
Many clinicians are startled by how much time traditional practices can pull into EHR work and non-face tasks.
In a direct model, the incentive can shift: document for continuity and safety, not for reimbursement gymnastics.
The result is often a more coherent clinical narrativeand fewer notes that read like a legal deposition written by a robot
with a caffeine problem.

The “hard parts” after launch are surprisingly human. Some patients want unlimited access but don’t want boundaries.
Some want specialist-level outcomes with primary-care-level pricing.
Some will compare you to their insurance copay and forget the deductible exists (deductibles are the plot twist no one asked for).
Successful practices handle this with clear expectations, tiered membership options, and transparent add-on pricing.
They also educate patients on how DSC can work alongside insuranceespecially for tests, imaging, medications, and hospital care.

Finally, direct specialty care founders often talk about professional identity restoration.
It sounds dramatic until you’ve watched a physician light up because they can finally practice the way they were trained:
listen, examine, think, explain, and planwithout the clock winning every round.
It doesn’t fix every problem in U.S. health care, but for many clinicians and patients, it fixes something foundational:
care becomes more direct, more understandable, and more human.

Conclusion: the “direct” part is the point

The podcast story isn’t just “a physician started a practice.”
It’s “a physician rebuilt a specialty experience around access and transparency.”
Direct specialty care won’t fit every clinician, every specialty, or every marketbut it’s no longer a theory.
It’s working in real communities, solving real access problems, and giving patients a clearer way to engage with specialty medicine.

If you’re a physician exploring DSC, the question isn’t “Can this work?”
The better question is: “What would it take for this to work ethically, legally, and sustainably in my specialty and state
while delivering undeniable value to patients?”