What Is Direct Specialty Care? How Cardiologists, Neurologists, Rheumatologists, and Endocrinologists Run Membership Practices
What direct specialty care is, how it differs from conventional specialty care, and how cardiology, neurology, rheumatology and endocrinology run membership practices.
Direct specialty care (DSC) is a model in which a specialist, such as a cardiologist, neurologist, rheumatologist or endocrinologist, is paid directly by patients through a membership or transparent cash prices instead of billing insurance. It applies the direct primary care model to specialty medicine: fewer patients, longer visits and direct access to the physician between appointments.
Most specialists who go direct are not trying to escape a fee schedule. They want the long, longitudinal visit that chronic specialty patients need and that a 15-minute insurance slot cannot hold. This guide covers how direct specialty care works, how four specialties structure it, and what the practice needs to run it.
What is specialty care?
Specialty care is medical care from a physician trained in one organ system, disease group or patient population, usually after a primary care physician identifies a problem that needs deeper expertise. In the conventional model the specialist sees the patient on referral, bills insurance per encounter and returns the patient to primary care.
How is direct specialty care different from conventional specialty care?
In direct specialty care the patient, or sometimes an employer, pays the practice directly, and the practice does not contract with insurers for its visits. That removes per-visit billing and most prior authorizations for the physician's own services. Practices typically use one of three payment structures:
- Membership. A recurring monthly or quarterly fee covers visits, messaging and care coordination. This fits specialties with years of follow-up.
- Pay per visit. A published cash price for each consult or procedure. This fits one-time second opinions and consults.
- Hybrid. A membership for established patients plus cash-priced consults for new referrals.
Labs, imaging and medications are usually billed separately at cash prices the practice negotiates. Many patients keep insurance or a high-deductible plan for hospital care and catastrophic events.
Why are specialists moving to direct care?
Specialists go direct mainly for time and clinical control. A patient with lupus, heart failure or multiple sclerosis needs a long first visit, frequent adjustments and a way to reach the physician when symptoms change. Insurance scheduling rarely pays for any of them.
Prior authorization adds to the pressure. According to AMA survey data, practices complete about 39 prior authorization requests per physician each week. Specialties built on biologics and advanced imaging carry more than their share. Direct care takes the physician's own visits out of that loop, though drugs billed to insurance still need authorization.
Specialists building these practices also share what works. The Direct Specialty Care Alliance is a physician-led network for specialists running or starting direct-care practices.
How do cardiologists, neurologists, rheumatologists and endocrinologists run membership practices?
All four run on the same base of a small panel, long visits and direct access, so their days look more like a direct primary care day than a hospital clinic. Each builds the membership around its own visit cadence and lab load. The ranges below are typical, not prescriptive.
| Specialty | Visit cadence | Lab and imaging intensity | How patients usually arrive | Typical membership shape |
|---|---|---|---|---|
| Cardiology | 60-minute new evaluations, 30–45 minute follow-ups; quarterly to annual for stable disease | Moderate: lipids, metabolic panels, BNP; imaging such as echo and stress testing | Primary care referral for chest pain, AFib, heart failure or risk evaluation | Monthly membership for the relationship; studies billed separately at cash prices |
| Neurology | 45–60 minute visits, roughly 8–12 a day; quarterly for MS, epilepsy, Parkinson's and migraine | Low to moderate labs; MRI, EEG and nerve conduction studies drive cost | Referral for new-onset symptoms, then long-term management | Monthly membership; imaging and studies ordered at negotiated cash prices |
| Rheumatology | 45–60 minute established visits; monthly during treatment changes, then every few months | High: CBC and liver panels every 8–12 weeks on methotrexate, more often when starting a biologic | Referral for joint pain, abnormal antibodies or a known autoimmune diagnosis | Monthly membership built around years of follow-up |
| Endocrinology | Visits paced by lab results; thyroid and diabetes follow-ups every 3–6 months | Highest: four to six draws a year for a thyroid patient alone | Referral for diabetes, thyroid disease, or patients seeking hormone care directly | Membership plus labs priced by the practice, often as a revenue line |
Each specialty has a deeper guide:
- How cardiologists build memberships around long visits and complex patients
- The neurologist's guide to direct care
- Rheumatology direct care for complex chronic patients
- How direct-care endocrinology practices order, price and track diagnostics
What does a direct specialty care practice need from its EMR?
A direct specialty practice needs membership billing, cash-priced diagnostics, referrals and between-visit contact in one place, without insurance billing at the center. SigmaMD is an EMR built for direct primary care, concierge and direct specialty practices, and handles each part.
How does SigmaMD handle memberships and cash pricing?
In SigmaMD, a practice builds its own membership plans with a name, a billing cycle from monthly to multi-month, an optional minimum commitment, auto-renewal and enrollment fees, and SigmaMD invoices each cycle automatically (Steps to Create a Retail Membership). Pay-per-visit consults and procedures go on invoices as charge items, so a hybrid practice runs both models side by side (Guide to Creating Retail Invoices).
How does SigmaMD handle labs and imaging?
In SigmaMD, clinicians order labs and imaging from the patient chart, electronically or by fax, and choose whether the clinic collects payment, the patient pays at the draw site, or insurance is billed (How to Create and Submit a Lab Order). Practices build their own lab panels, for example a methotrexate monitoring panel or a thyroid panel, and set their own markup on cash-priced tests (Creating Lab Test Panels). Results go to the ordering clinician's review list with a notification.
How does SigmaMD handle referrals and outside records?
Specialty practices live on referrals. In SigmaMD, a clinician builds a referral PDF from the chart, choosing which problems, medications, vitals and results to include, and faxes it from the same screen (Creating a Patient Referral). Incoming records land in the Documents inbox, and Sigma AI summarizes a long fax or scan, including critical or abnormal results and requested follow-ups, before the physician reads every page (Summarizing Documents with Sigma AI).
How do SigmaMD Scribe and Sigma AI support long visits?
SigmaMD Scribe records the visit with the patient's consent, in the exam room or on a SigmaMD telehealth call, and drafts the note in whichever template the practice builds, whether that is a cardiology follow-up or a rheumatology joint exam (How to Use Scribe for Telehealth). The physician reviews and signs the note.
Sigma AI, SigmaMD's in-app assistant, answers plain-language questions about one patient's chart or across the whole panel (Sigma AI Overview). A rheumatologist can ask which patients on methotrexate have no liver panel in the last 12 weeks. An endocrinologist can pull a patient's TSH history before the visit starts. Practices that track specialty measurements, such as grip strength or body composition, can add them as custom vitals and trend them over time (Using the Vitals Trends View).
How does SigmaMD support access between visits?
Between-visit access is the core of a membership. In SigmaMD, members chat securely with the care team from the patient app, and clinicians start video visits from the chart (Quick Guide to Telehealth). A new AFib episode or breakthrough seizure gets a same-day answer instead of an emergency visit.
FAQ
Is direct specialty care the same as concierge medicine?
Not quite. Concierge practices often charge a retainer and still bill insurance for visits. Direct specialty care usually does not bill insurance for the physician's services at all. See concierge medicine vs. direct care.
Do patients need insurance with direct specialty care?
Usually, yes. The membership covers the physician relationship; insurance covers hospitalization, surgery and many medications.
Which specialties work best as direct care?
Specialties with long-term chronic patients fit best, because a membership pays for an ongoing relationship. Cardiology, neurology, rheumatology, endocrinology and psychiatry are common examples. Specialties built on one-time procedures more often use pay-per-visit pricing.
Can a specialist run both memberships and per-visit pricing?
Yes. Many direct specialty practices run a hybrid. In SigmaMD, memberships and charge-item invoices sit in the same billing system, so one patient can be a member and another can pay for a single consult.
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