About the practice.

Suite 211, 03:14 CDT — the morning we signed the lease.

01 · Origin

Elin Marek and Jules Armitage had worked together at Essentia Health's Lakeside primary-care clinic for five years when, in late 2021, the medical group rolled out an automated visit-template that capped a routine follow-up at 12 minutes from "knock" to "wrap." It wasn't malevolent. It was the rational response to the way primary care is paid in the United States: a fee-for-service economy where a clinician's revenue is the count of distinct billable encounters, and where the underwriter's idea of value is what shows up in an ICD-10 code. The math is the math. We didn't want to fight the math. We wanted a different math.

By the spring of 2022 we had read enough on the Direct Primary Care Frontier wiki to know there was a working alternative; by August we had a draft business plan; on October 14, 2022 we signed a one-year lease on Suite 211, above the East Hillside post office. We brought our patient list, with consent. We brought a borrowed photocopier — Aldo, a 1997 Xerox 5915 that still works. We did not bring an electronic-health-record vendor, an insurance contract, or a billing department, because the model does not need them.

02 · The model

Direct Primary Care is what it sounds like. Our patients pay us a flat monthly membership fee — currently $95 per adult per month, $45 for dependents under 22 — and in exchange we provide unlimited primary-care visits, direct phone access to their clinician, and labs and generics at our acquisition cost. We do not bill insurance. We do not file claims. We are not in network with anyone, by design. Members keep their high-deductible health plan or HSA-eligible catastrophic plan for the things primary care can't address — surgery, ICU, oncology, complex specialist care — and we are the part of their care that should not require a pre-authorisation phone call.

The model is small in two important senses. It scales poorly: you cannot run a 4,000-patient panel under it without becoming what you left. And the unit economics are unromantic: a fully-loaded panel of 480 members pays the salaries of three clinicians and two operators and the rent on Suite 211, with about four months of operating runway in the bank. There is no exit. We do not plan to be acquired. We plan to keep doing this until one of us retires, at which point the most senior nurse practitioner buys in, and the cycle repeats.

03 · The panel cap

Our hard cap is 480 members across the panel. Standard primary-care panels in the United States run between 1,500 and 2,500 patients per full-time clinician¹. We carry a panel that is roughly one-fifth the size of the average. That is the entire trick — and it is a trick that does not work without the membership model, because nobody pays us per visit. We are paid to keep the panel small enough that we can hold it in our heads.

What that buys, concretely: a 90-minute first visit; a 30-to-60-minute follow-up; a 19-minute median reply time to text messages during business hours; same-day or next-day acute appointments 94.6% of the time over the past quarter; and a clinician who has read your last visit note before walking into the room. What it does not buy: free hospital care, free imaging, free specialty care, or any kind of magic on the part of the clinicians.

04 · Posting prices

Every price we charge is on the wall in the waiting room and on this website. The membership fee. The cost of a CBC. The cost of ninety lisinopril. The cost of an IUD insertion. The cost of an in-office trigger-point injection. There is no encounter, lab, medication, or procedure for which our price is not knowable in advance.

This is uncontroversial in any other small business in Duluth. You can know what a sandwich at Northern Waters Smokehaus costs. You can know what a haircut at the Lake Superior Trading Post barber chair costs. You can know what an oil change at our local Jiffy Lube costs. American healthcare is the only sector in which not knowing the price has been treated as evidence of seriousness. We don't think it is evidence of anything except the difficulty of billing payors. We don't bill payors.

05 · Why "chronograph"

We named the practice for the instrument because the instrument is honest. A chronograph does not produce time; it records it. It cannot make a slow lap fast. It cannot wish a heart attack into a viral pharyngitis. What it can do is write down, accurately and at a known scale, what happened — so that you can look at the splits afterward and figure out what to do differently next time.

That is, more or less, what we are trying to do with primary care. Each protocol is a lane: a body of medical knowledge we have rehearsed enough that we can call its splits — what is supposed to happen at minute three, at week six, at year one. Each visit is a lap. Each member is a runner whose times we know well enough to flag when something is off. The ambition is not heroic. It is a chronograph's ambition: name what just happened, accurately, at a known scale.

06 · What we aren't

We are not a concierge medicine practice. Concierge practices typically charge an annual retainer and continue to bill insurance for visits; the retainer buys access. Our membership replaces the visit fee entirely.

We are not a wellness clinic. We are not a hormone-optimization clinic. We are not a longevity clinic. We do not sell IV vitamin drips, peptide injections, exosome therapy, or any treatment whose evidence base lives mostly on Instagram. If you want those things, the internet is full of them. If you want primary care, we are primary care.

We are not a hospital. If you are having chest pain, dial 911 and go to St. Mary's Medical Center or Aspirus St. Luke's. If you are having a stroke, same. If you are bleeding heavily, same. We will visit you in the hospital. We will not be your hospital.

The people who built this practice are listed on the clinicians page, and the things we know how to do are listed on the protocols page. The price for joining the panel is on the membership page, and the way to do so is on the begin page. Everything else is a matter of which lane your question belongs in.