On most mornings, the waiting room of Dr. Joshua Brown’s medical clinic off Hospital Drive in Santa Fe has the feel of a village gathering spot — packed with about a dozen chattering walk-ins. Sick or well, his patients are likely to run into someone they know.

“They can walk in if they are sick, and I can get them to whatever they need, by and large,” Brown said. “I take care of a large part of the community.”

Since he began practicing in Santa Fe 16 years ago, Brown has become known as one of the few doctors in the city whose door is always open. He accepts nearly every form of health insurance, including Medicare and Medicaid coverage. His practice employs a diabetes educator, a part-time psychologist, a social worker and a trainer who offers exercise classes most evenings. He also has ultrasound and echocardiogram machines for diagnostic scans.

Brown said he will almost always see a patient rather than send them to the emergency room — short of a knife in someone’s chest.

“I have always felt very strongly about seeing my patients when they are sick and taking ownership,” he said. “The bad news is I am chronically running sometimes very late, and that is really hard and drives people nuts — and you can’t do both.”

So Brown will embark in April on a burgeoning medical trend: subscription-based — or concierge — care. The method is also referred to as direct primary care.

His patients will be given an option of enrolling in a program in which they pay $180 per month to ensure on-time and more thorough appointments. He expects the switch to concierge medicine — a patient-centered style of practice that focuses heavily on prevention — will reduce his patient load from several thousand people to just a few hundred.

Brown will continue to accept a wide range of insurance policies, he said, but some of his nonsubscription patients might be seen by a physician assistant instead of him.

“The fundamental problem,” he said, “is across the country and particularly in Santa Fe, we have lack of primary care. … It is a bit of a broken system, with financial pressures and pressures to see lots of patients in a short period of time.”

New Mexico has struggled with a doctor shortage for years, even before the federal Affordable Care Act and a an expansion of the state’s Medicaid program to more low-income adults increased the demand on primary care physicians. A Health Data Summary by the University of New Mexico in 2017 reported that 40 percent of the state’s residents were living in areas with severe shortages of primary care; though, Santa Fe County was among four in the state with more doctors than the national average.

Brown expects the new style of service to appeal to people who are frequently sick and those who see subscription-based care, allowing more quality time with a doctor, as a smart way to spend their money.

One couple who have been seeing Brown since they retired to Santa Fe in 2011 are planning to pay $2,000 each annually for on-time visits with the doctor that last around 45 minutes.

Their desire for a higher level of medical care in Santa Fe is what motivated John, who asked that his last name not be published, and his wife to sign up.

“It was a difficult decision,” John said. “The final conclusion was, for me, that to get very high-quality medical care, this was the way the system was moving.”

He added that he and his wife have been “fortunate financially and we can afford it.”

Santa Fe has such a bad reputation for health care access, John said, that several friends encouraged him to move to Albuquerque, instead of Santa Fe, after his retirement.

“The received wisdom among people that I know and have had experience with medical services in Santa Fe is that it is quite weak,” he said.

Concierge health care began nearly two decades ago as an elite service, providing in-depth and specialized care for wealthy clients. Specialized doctors in big cities can charge more than $5,000 or $10,000 for annual memberships. But more middle-class models have since emerged, and the subscription-based service is even used as an alternative to traditional insurance in some primary care practices.

While the concierge-care trend has been slow to take off in smaller medical markets like Santa Fe, thousands of doctors in the U.S. offer specialized subscription-based services, including around 950 who offer the care through MDVIP — the largest network of concierge providers in the nation, serving 300,000 patients, according to the organization’s website.

Bret Jorgensen, the chairman and CEO of MDVIP, said the network grew out of physicians trying to find an alternative to “turnstile” care. Too frequently, he said, modern medicine requires doctors to shuffle through a huge patient load, with time only to assess symptoms and offer referrals and medications.

The company was born out of the realization that “if we could reduce the practice size, charge an annual membership fee, it would allow [doctors] to be much more proactive and preventative,” he said, and “patients were hungry for more time with their doctor.”

The model prevents doctor burnout and improves patient outcomes, he said, reducing ER visits and unnecessary procedures.

MDVIP won’t sign up a physician if his or her patients who can’t afford to subscribe don’t have access to other primary care doctors in their area, Jorgensen added.

The New Mexico Department of Health does not track subscription-based private doctors, but several advertise the service online, and the MDVIP network includes two New Mexico physicians.

Brown is unaffiliated with the network; developing his own model gives him the flexibility to continue seeing all of his patients, he said.

Albuquerque Dr. Tom Pascuzzi has been operating an independent direct primary care practice for about three years, charging a $150 monthly membership fee for his services instead of taking insurance. He also offers urgent care services for nonmembers for $175 per appointment.

“I saw the need and the opportunity to do something different and to solve some of the issues happening around primary care,” Pascuzzi said.

His fee allows his patients to see him as frequently as they need to, he said, and for as long as they’d like. They can call or text him 24/7, he added, eliminating the need to go to a hospital emergency room simply because a primary care doctor is unavailable.

Some of his patients use subscription care as an alternative to insurance, he said, while others subscribe and use their insurance only for emergencies or major surgical procedures.

“It is a more efficient way, it is the right way, to practice medicine,” Pascuzzi said.

He compared this setup of combining concierge care with health insurance to the use of car insurance — which covers costs of repairs following accidents but isn’t used to buy gas or complete basic maintenance.

Pascuzzi began his career in aerospace medicine, stationed at the Cannon Air Force Base near Clovis. There, he had a group of 50 families — pilots and their wives and children — that he was in charge of caring for, often visiting patients in the middle of the night with his little black bag.

“Having a small practice that you can really take care of was always in the back of my head,” he said.

After working at what is now Christus St. Vincent Regional Medical Center in Santa Fe in the 1990s and running urgent care practices in Albuquerque, Pascuzzi said direct primary care has allowed him to return to a more intimate model of health care.

With around 350 patients, he sees four patients each day — compared to the 40 he’d see daily if he worked for a large hospital or busy clinic.

Pascuzzi also believes the pricing model is much more transparent and allows people to know what they are paying for up front. He said he can address about 90 percent of patients’ problems in his office, even offering blood tests and X-rays at a fraction of the insurance price.

And the additional time he is able to give patients makes his care more preventive, he said.

“I tell people for $5 a day, you have a doctor available all the time. For [the cost of] a cup of coffee a day, a doctor will pick up the phone and talk to you and not just treat you like part of the system,” he said.

“This is breathing the private practice back into the life of medicine,” Pascuzzi said, “and giving people more control over their lives.”

Reporter

Rebecca Moss has covered the environment and Los Alamos National Laboratory for the Santa Fe New Mexican since j2015. In 2018, she was selected to participate in the ProPublica Local Reporting Network.