On the economy of attention.

The single most useful number in primary care is also the one most clinicians never see: the average length of a primary-care visit in the United States, in actual minutes, from "knock" to "wrap." The number, depending on which survey you read, sits between thirteen and twenty minutes — but the figure that matters is not the average; it is the one in front of you. In the medical group I worked in until October 2022, the answer was twelve minutes. Twelve minutes, of which roughly four were eaten by the templated note. Eight minutes of looking at a patient. Eight minutes to take a history, examine a body, decide what to do, explain what to do, and document it.

The math of the seven-minute visit is the math of attention. There is a fixed quantity of clinician attention available per day; let us approximate it as eight clinical hours, or 480 minutes. The institutional question, in a fee-for-service economy, is "how do we maximize billable encounters per 480 minutes?" The clinical question, which the institution does not ask out loud, is "what is the longest visit a clinician can compose in 480 minutes such that the encounter rate still pays the institution's overhead?" The answer to that second question is a function of the price of an encounter and the cost of a minute. In 2022 the math, in our practice, came out to twelve minutes.

I do not think anyone designed this. The system that produces the seven-minute visit is the rational assembly of small decisions made by people each of whom was acting locally in good faith — institutions accepting RVU contracts they did not write, payors paying RVU rates that had drifted from any underlying notion of value, clinicians taking productivity bonuses tied to RVU output because the alternative was a smaller paycheck. Each decision is locally rational. The aggregate is what it is.

An attempt at the alternative math

A direct primary care practice runs the math differently. The unit of revenue is not the encounter; it is the membership. The institutional question becomes "what panel size sustains the practice's overhead at a given membership fee?" The clinical question becomes "what visit length does the panel size permit?" The math is straightforward at the membership-fee end: $95 per adult per month, times an average panel size of around 380 paying members (we cap at 480 because not every panel slot is a paying adult; some are dependents at $45), works out to roughly $36,000 per month. From that we pay rent, utilities, two staff salaries, malpractice, electronic records, lab supplies, vaccine inventory, dispensary inventory, and three clinician salaries scaled to the panel.

What that buys, in clinical-time terms, is the inverse of the seven-minute visit's math. A 480-minute clinical day, distributed across the panel-cap-at-cap of 480 members, is a minute per member per day on average. But not every member needs a minute every day; most members touch the practice every six weeks or every three months. Concentrate the daily 480 minutes among the members who need them on a given day, and you can build a 90-minute first visit, a 60-minute follow-up, and a 30-minute acute visit without breaking the math. We tested it for a year. It works, with margin.

What attention actually costs

The argument I find myself making most often, with members who are deciding whether to enroll, is not about the price; it is about what the price is for. The price is for attention. Attention is not "more time." Attention is the willingness to look at the actual person in the actual room, with the actual chart, on the actual day, without being mentally scheduled into the next encounter. Attention is also, more bluntly, the willingness to read the literature on the question the patient just asked. The seven-minute visit cannot afford either of those things. The 90-minute visit can.

What the 90-minute visit is not is more careful in some heroic, clinician-as-monk way. The clinician at the 90-minute visit is the same person they were at the 12-minute visit. They have not become more attentive by an act of will. They have become more attentive because the math of their day no longer requires them to spend most of it not paying attention. The change is structural, not moral.

Where the math stops working

The DPC model has limits. We are five clinicians and a panel of 480 — comfortably below the 1,500–2,500 panel sizes considered standard in primary care^[1], but well above the boutique concierge ratios of 200:1 or so. We do not solve the cost of hospital care, surgical care, oncology, complex specialty care, or the hundred clinical situations that outrun a primary-care practice's scope. We are an alternative for one specific layer of the system; we are not an alternative for the system. Members keep a high-deductible insurance plan for the rest of it.

What the DPC model also does not solve, candidly, is the politics of access. A direct primary care practice that asks members for $95 per month is not affordable for every patient who needs primary care. We have tried to address this at the margins (we run a sliding-scale slot-set; see membership), and we recognize the larger limitation. We are not the system. We are one practice. The system requires structural reform we cannot deliver from Suite 211.

What we are willing to say

The seven-minute visit is not a clinical question; it is an economic one. The members of our panel are not getting better attention because their clinicians are wiser; they are getting better attention because the math of the day permits it. The practice's job is to keep the math honest — to keep the panel small enough, the prices posted clearly enough, the schedule structured enough — that the attention remains available. The chronograph metaphor, here, is not romantic. The clock is what we are accountable to.

If you are reading this because you are considering joining the practice, the question to ask yourself is not whether $95 per month is affordable in the abstract. The question is whether $95 per month, replacing the copays you currently pay and replacing nothing else, ends up cheaper or dearer for your year of care. For most members in most years, the math comes out cheaper. For some it comes out neutral. For a small number it comes out a little dearer. We will tell you, at the first visit, which group you are likely in.

— EM