When a Waterville hospital closed, physical therapist Mason Liberatore had a plan.

Most of his patients didn’t.

During his five years working at Northern Light Inland Hospital, Liberatore said he watched health insurance companies stick his patients with tighter restrictions and higher bills. In the months before the hospital shuttered, he laid the groundwork for a more direct way to provide care.

“There was a widespread urgency for patients to line up their following care,” Liberatore said. “And they realized: ‘Wow, I can actually save money paying out of pocket with my credit card by coming to see you, rather than choosing another hospital-based, insurance-based physical therapy practice.”

A growing group of Maine’s primary care physicians have come to the same conclusion.

Doctors are abandoning struggling hospitals and traditional offices for direct primary care, a fee-for-service model that cuts out insurance by charging patients subscriptions for primary care. Satisfied patients tout accessible appointments and easy rapport with their doctors, but experts caution that the model leaves Maine’s aging and working-class residents behind.

There are at least 46 direct primary care clinics in Maine, and that number is growing. Some offer traditional primary care services while others wax holistic, offering osteopathic and wellness services. Patients pay a flat membership fee, charged monthly or annually, for unlimited access to their doctor — without going through insurance.

Doctors say cutting out insurance gives them more time to focus on their patients. One study of typical clinical work days in 2016 found that for every hour physicians spent with patients, they spent an additional two hours on electronic records and desk work, plus up to two more hours of personal time after work.

“The current model is broken, and people are seeing opportunity to do it this way,” said Steven Michaud, president of the Maine Hospital Association. “A lot of it is driven by extreme aggravation with Anthem and commercial health insurance companies, for sure. Patients have had it with the denials.”

Michaud, 63, of Durham said he’s found it increasingly difficult to book doctor appointments and get a human on the phone, let alone the “rigmarole of getting called back.” He started seeing a membership-style doctor in Yarmouth and said he now enjoys longer appointments and the ability to text his doctor at any time.

Started as a grassroots movement in the early 2000s, direct primary care has rebounded across the country during a time of uncertainty for health care and coverage. It’s especially taken off in Maine, where health systems have already announced two primary care clinic closures in the new year.

The model doesn’t work for everyone, though. Direct primary care membership fees can range from several hundreds to thousands of dollars a year, with varying rates for individuals and families. In Maine, prices often fall between $1,000 and $1,800, not including a one-time startup fee.

People without that kind of cash on hand still need health insurance, but that’s proving costly, too. A 77% average increase in Affordable Care Act premiums in Maine this year has led thousands to drop their plans, with many saying they couldn’t afford the higher monthly premiums.

And primary care, while a crucial preventative health tool, doesn’t cover hospital visits, tests, screenings and other procedures that are associated with aging. In Maine, where more than 23% of residents are 65 and older, experts say those needs will only increase.

Direct primary care doesn’t make sense for most older adults, said Isaiah Meyer, a nurse practitioner who provides in-home primary care visits to older people across central Maine.

“They can’t afford it, and it wouldn’t be a cost-effective thing for them, because they’re at risk for ending up in the hospital,” Meyer said. “They don’t have that emergent care piece, and then they’re really stuck.”

“It might work for healthier, younger folks, but it’s not really a sustainable option for these folks.”

‘WORKED FOR ME’

Maine has one of the highest rates of direct primary care doctors per capita in the country, according to analysis of national direct primary care data by Mending Health Insurance, a small health insurance company based in Maine and Oklahoma that tailors health insurance to direct primary care. One plan allows enrollees to join a DPC doctor at no cost.

Direct primary care is a rare chance for doctors to set their own rates and get paid upfront, often while reducing their previous patient volume by hundreds or even thousands. Now that he has autonomy over his schedule, Liberatore says he meets patients for physical therapy after work, on weekends and “just about any time.”

Some worry that doctors who leave for direct primary care worsen staffing shortages at traditional primary care practices. They may only take a fraction of patients with them, adding extra work to the remaining doctors who are then more likely to leave, too, said Zirui Song, Harvard Medical School researcher, in an interview with Harvard Medicine News last year.

Though there is no data available on direct primary care’s impact on health worker shortages, researchers say that climbing interest in fee-based practices could reveal what pain points physicians are facing in traditional settings.

Maine’s physicians are among the oldest in the country, with only 11.8% under age 40, according to the most recently available Association of American Medical Colleges workforce data. A growing number are on the cusp of retirement.

But Kevin Kenerson, an osteopathic physician in Freeport who runs Be Well My Friend family medicine practice in Augusta, says direct primary care can actually extend career longevity for burned out doctors. Whenever he calls a friend who switched to DPC, he says they’re rarely in their office and often “doing something healthy and fun.”

Kenerson plans to make the switch this year.

“We’re doing good work here, but I’m switching because it’s not worth it,” Kenerson said. “The amount of my personal time that I’ve sacrificed, the amount of time I haven’t spent with friends and family.”

Michael Stadnicki, a Lewiston family medicine physician who spent years recruiting for primary care in Maine, says younger doctors are increasingly going into DPC right out of residency, realizing it’s better to be “part-time from the start.”

Direct primary care will continue to grow in Maine, Stadnicki predicts, until federal players push to regulate costs or invest more in traditional primary care. No matter where patients get their primary care, though, he says the biggest priority is continuity, so patients don’t miss screenings and tests for chronic issues that had gone undetected.

Michaud says he’s lucky to be in good health. He doesn’t need regular checkups, but if a health concern does crop up, he feels better knowing his doctor is only a text or call away.

“I like this more direct, kind of mom-and-pop thing,” he said. “It worked for me.”