Madison-area patients seek new paths to health care (2025)

When Christina Pepper’s mother was put on a weekslong waiting list for a necessary imaging test, it wasn’t top of mind that Madison is one of the premier health care destinations in the Midwest.

When James Westring left primary care appointments after spending a few rushed minutes with his doctor, he didn’t think about his luck in living near a prominent research university that pumps out talented physicians and innovative medical technologies.

What matters most in each of those moments isn’t state-of-the-art facilities or top-10 designations, but being able to access quality, timely and affordable care. And even in a city flush with top-notch hospitals and innovative biotechnology and life science businesses, it’s a struggle. The patient experience is fraught with frustrations and disappointment: weeks spent waiting for appointments, hours lost to contesting claims or parsing shifting insurance coverage — all while health care premiums continue to climb.

Patient satisfaction isn’t the only thing at stake. Long wait times can delay critical diagnoses and impede treatment, leading to worse health outcomes. High costs can discourage people from going to the doctor’s office at all: In 2022, the CDC’s National Health Interview Survey found that more than one in four adults chose to delay or forgo care due to cost.

In Madison, some patients are taking matters into their own hands and seeking alternatives to traditional, insurance-based health care. The rapid growth of concepts like direct primary care (DPC) and independent, cash-pay medical treatment is a testament to the demand for options that cut down on wait times and out-of-pocket expenses.

For patients in need, accolades don’t matter. Access does, and many are done waiting for better care options.

A Real Headache

Health care horror stories (often having to do with staggering, unexpected medical expenses) aren’t uncommon: In fact, in 2019, GoFundMe’s CEO estimated that as much as one-third of the crowdfunding site’s donations went toward health care costs.

But even when experiences don’t end with a pile of medical bills, those related to quality of care and access are often rife with pain points and tangles of red tape.

Madison resident Laura Kaiser has struggled with migraines for most of her adult life.

In the early 2000s, she went to the emergency room or urgent care five or six times a month (with a toddler in tow). She tried everything and nothing worked — until she was accepted into a clinical trial for a medication (which she later found out was Emgality) in 2018.

“It made a huge difference in my migraines,” says Kaiser. Even with her use of a medication that helps prevent migraines, managing her pain isn’t easy. Kaiser is constantly orchestrating a complex concert of treatments and medications: Once a month injections of migraine medication, migraine Botox every 12 weeks, rizatriptan when a migraine first starts and Aleve as needed. That’s not to mention the many other interventions Kaiser uses to stave off the nausea and pain, including hot showers, cold caps and heating pads.

This past November, Kaiser’s insurance company notified her that Emgality would no longer be covered. When her doctor wrote her a prescription for the insurance-recommended substitution (Aimovig, a different monthly injectable medication) the coverage was denied. Kaiser appealed the decision, spending hours of the next month on the phone with the insurance company or exchanging MyChart messages with her doctor. On Jan. 31, the appeal finally cleared — just in time, since Kaiser had administered her last dose of Emgality on Jan. 1.

When she shared the experience on Instagram, her insurance company, Quartz, commented, encouraging her to call their customer support line.

“I took the brunt of ensuring [that] Quartz, my doctor, Walgreens and myself were all on the same page, and that really shouldn’t be my job, should it?” Kaiser says.

Her frustration strikes a familiar chord. Even for patients without chronic or complex conditions, the process of navigating the health care system can be difficult, impersonal and inefficient. Through years of experience, Kaiser devised a playbook that makes it work for her: She gets to her appointments prepared with a written list of changes she’s experienced since the last visit and a plan for what she wants to discuss — and she’s not shy about demanding the time and attention she needs.

“You have to be an advocate for yourself,” she says, “or you’re going to be frustrated.”

Kaiser’s successful appeal is the best-case result of an unfortunate scenario. But some patients are fed up with making the best of a bad system, and they’re finding different paths to care outside of the traditional insurance-based model.

The Doctor Will See You Now

The word Kaiser uses to describe herself — advocate — also appears in the name of Dr. Nicole Hemkes’ direct primary care clinic, Advocate MD. It’s intentional: Hemkes believes that patients shouldn’t have to fight for the basics of care.

Primary care is the most basic level of health care. Even the healthiest people typically head to the doctor’s office once a year for a checkup. For individuals enrolled in an insurance plan through a health maintenance organization, or HMO, a visit to a primary care provider, or PCP, is necessary to access additional care, such as a visit to a specialist’s office.

In the 10 years Hemkes spent practicing family medicine in traditional settings, though, she watched the value of these visits erode.

“I saw and felt like there was a progression, for doctors, toward less and less autonomy and being pushed to see more and more patients in less and less time,” says Hemkes. “In the bigger systems — and I think a lot of doctors would agree — the emphasis is not necessarily on time and quality but on productivity and how many patients you can see.”

It’s not a poor reflection on medical professionals, but rather on the system they’re in. The average primary care visit lasts 18 minutes, a period that leaves both patients and physicians feeling rushed and unsatisfied.

That’s how James Westring, a patient, felt.

“I come into an appointment and wait, then go to the exam room and wait some more. Then [someone] comes to take my vitals and disappears. Then I wait, then I talk to the doctor for five or 10 minutes,” he says.

For some patients, just getting to an appointment, which is often made weeks or months in advance, means taking off work or finding child care. And a game of red-light-green-light questioning — with a lightning round of “anything else bothering you today?” at the end — could have serious consequences. In a 2024 study, shorter primary care visits were associated with higher rates of inappropriate prescribing. Without time for an in-depth discussion of patient concerns, doctors are more likely to make a mistake or miss early indicators of a condition that may later become severe.

“I sometimes call [the traditional system] ‘factory-line medicine,’ ” says Hemkes. If a patient reports high blood pressure, a doctor pressed for time might default to prescribing a medication.

At Advocate MD — where, like at many DPC clinics, visits are booked for a full hour — Hemkes can have a comprehensive conversation with the patient about the lifestyle factors (diet, exercise, stress, sleep, substances) that might be causing or contributing to their health issues. In a day, a doctor at Advocate MD sees between five and seven patients. A doctor in a traditional practice sees, on average, 15 to 20 patients.

DPC practices operate on a membership model instead of a traditional fee-for-service model: Patients pay a monthly membership fee (typically between $50 and $100) that allows them to receive care directly from a primary care specialist. DPC clinics don’t accept insurance and patients are encouraged to “pair” their membership with some type of health insurance policy that would cover catastrophic or severe medical events exceeding a primary care doctor’s scope of practice.

Beyond the clinical value of covering more ground, extra time during an appointment allows for an experience that makes patients feel seen. When Hemkes opened Advocate MD’s flagship clinic in Middleton in November 2018, Westring was one of her first patients. Westring, who owns a construction business, now offers DPC to his employees, too — and admits to being “an advocate of Advocate” with friends and family.

“I’m not a number,” says Westring. “It’s very flexible and comforting. I feel valued. I feel listened to.”

In the six and a half years since opening, Advocate MD has added three more clinics in east Madison, Janesville and Fitchburg, as well as seven more doctors to the staff. In those same years, other DPCs have opened in the Madison area, including rootsMD in Verona in March 2021, Dedicated Family Care in Fitchburg in May 2021, Tallgrass Osteopathic Family Medicine in Madison in May 2024 and Adwuma Family Medicine in Madison in October 2024.

Suddenly, Madison-area patients don’t just have one alternative — they have several. Dr. Giselle Argento-Berrio, the physician at Adwuma Family Medicine, focuses particularly on creating a safe space for BIPOC (Black, Indigenous and people of color) individuals, and she currently conducts a high percentage of telehealth appointments. Dr. Angela Marchant of Tallgrass Osteopathic Family Medicine specializes in more hands-on treatment. With multiple DPC options, patients can take ownership of their choices instead of going to whichever in-network doctor has an opening.

When people find out that Argento-Berrio gives her patients her cell phone number, they’re usually shocked. That kind of access is a major departure from the online message portals some patients find cumbersome and confusing. Not all medical professionals are fans of that communication system, either.

In a traditional primary care practice, fielding messages on an electronic health record, or EHR, platform is a significant administrative burden for staff. In 2023, a study conducted in Massachusetts showed that PCPs were spending more time on each patient’s EHR than on their visit, which contributed to emotional exhaustion and burnout among physicians.

“If people are feeling heard and getting their questions answered, they’re not texting me or asking me questions after hours,” says Argento-Berrio. “They feel satisfied by the hour that I spend with them.”

The rapid growth in Madison of Advocate MD — and DPC in general — can be attributed to the appeal of a more relaxed, personal experience, but it’s likely that a lack of availability within insurance-based practices is a factor, too.

“What we hear from patients who are joining, or who were in the system previously, is [that it takes] six to eight months, sometimes a year, to get a primary care doctor’s appointment,” says Hemkes. “Access is an issue across the country, but in Wisconsin and Madison specifically, it’s a little bit worse in terms of wait time. We have a doctor shortage.”

The size and stature of Madison’s health care systems can’t insulate them from the national physician shortage. At the end of 2024, Wisconsin had over 150 designated Health Professional Shortage Areas, according to the U.S. Department of Health and Human Services’ quarterly summary, with only enough PCPs to meet 66.5% of needs in those areas. Forty percent of the PCPs currently practicing are projected to retire by 2035, while primary care demand is expected to increase around 20% across the state by the same year.

Going the DPC route doesn’t only mean you might get an appointment more quickly; it will likely be more cost-effective, too. By cutting out insurance, DPC eliminates a lot of overhead, like billing, coding, and dealing with claims and denials. Advocate MD members can access in-office diagnostic lab tests for around $5 to $10 each (for context, a typical thyroid function test costs about $50) and get discounted wholesale prices on medications.

For procedures or tests outside the scope of a primary care practice, Hemkes refers her patients to independent, cash-pay practices when possible. Those locations can offer lower prices due to reduced overhead. Until recently, though, that sometimes meant sending patients an hour or two away.

“In Madison, we should have lots of independent specialists, but they’ve all been gobbled up by the hospitals,” says Hemkes, referring to hospitals’ or health systems’ frequent purchases of independent practices. An analysis of data collected by the American Medical Association between 2012 and 2022 revealed that the percentage of physicians in traditional, insurance-based private practice shrunk by 13.4% between 2012 and 2022 — and that needing to raise payment rates and struggling to manage administrative requirements were the top two reasons for putting up the “for sale” sign.

“But I think there’s a shift happening … as physicians and patients become more and more unhappy,” says Hemkes. “The bubble has to burst at some point.”

Establishing a Presence

Independent specialists do seem to be developing a lasting foothold in Madison: Orthopedic & Spine Centers of Wisconsin opened in February 2023 and grew to eight clinic locations across Wisconsin by 2024. MH Imaging, an independent, Wisconsin-based outpatient medical imaging company, opened a Middleton location in May 2023. That August, another independent outpatient facility, Smart Scan Medical Imaging (founded by UW medical school graduate Jeffrey Rosengarten) opened a location in Middleton, too.

Going through the hospitals, it might take months to schedule a common screening test like an echocardiogram, mammogram or bone density test. Christina Pepper, the co-founder and chief operating officer of MH Imaging, has seen the problem firsthand. During the pandemic, her mother, a Sun Prairie resident, was diagnosed with cancer.

“It was a nightmare to get anything she needed as far as imaging,” Pepper says. Her mother, an HMO member, was restricted to “in-network” radiology practices, which delayed both her diagnosis and other tests she needed.

Pepper and her MH Imaging co-founder Malcolm Hatfield (a radiologist) had already been considering opening a location in Madison, since Madison-area physicians had been sending patients to MH Imaging’s other locations in Milwaukee, Racine and Kenosha.

“This was the straw that broke the camel’s back,” says Pepper, referring to her mother’s experience. “Madison needs MH Imaging. Madison needs independent outpatient medical imaging, because these patients are just getting screwed.”

MH Imaging offers options for patients to pay with or without insurance. The latter option creates opportunities for what Pepper calls “a self-referred, self-pay patient.” Instead of waiting to get a referral for a certain scan, patients can call MH Imaging, make an appointment, and pay in cash.

At an outpatient facility — without the overhead and volume that’s inherent to a hospital — patients can get the same diagnostic tests faster and cheaper. (An MRI of the knee, for example, might be billed as much as $4,000 at a Madison-area hospital; at MH Imaging, the same MRI costs $650 without insurance.)

“Being sick isn’t easy. Not feeling good is not easy,” says Pepper. “We’re trying to make it as easy as possible.”

A Step in the Right Direction

Even just a few years ago, changing Madison’s health care landscape seemed impossible.

In 2014, when Argento-Berrio — then a first-year medical student at UW–Madison — first heard of DPC, she was told it would never succeed here. “My mentor at the university said, ‘This isn’t possible in Wisconsin. It won’t take off here. The HMOs are too powerful,’ ” Argento-Berrio says. Ten years later, Argento-Berrio opened Adwuma Family Medicine (Madison’s seventh DPC clinic, by her count). Within four months of opening, she had signed up more than 70 patients despite doing no marketing or advertising.

In September 2023, just four months after MH Imaging opened in Middleton, Quartz agreed to contract with the company and opened the network, just a little, to give their insurance-based patients access. (Dean Health Plan Inc. also has a contract with MH Imaging, but currently patients at the Middleton location can only get open MRIs — as opposed to closed-bore MRIs, which sometimes cause claustrophobia — since no in-network providers offer them.)

Pepper had been working to establish partnerships with local HMOs for at least a year before the Middleton clinic opened. What solidified the Quartz partnership? She can’t say for sure, but she guesses that patients pushed for the change — and got it.

There are no simple fixes for issues like the rising cost of health care, the national doctor shortage or Madison’s HMO-dominated health care environment. And working with the system, for now, is a necessity. DPC remains a supplement, not a one-stop shop for all health needs and procedures; MH Imaging (as well as other independent clinics) offers both cash-pay and insurance-based options.

And that’s the key word: options. The growing network of health care options outside of Madison’s large health systems puts some power back in patients’ hands — and maybe puts some pressure on insurance companies, too. Before local alternatives existed, a patient on a six-week wait list for a CT scan had no choice but to wait; a patient unsatisfied with lightning-speed primary care visits had no choice but to swallow their complaints and make the best of it.

Not anymore. Patients and physicians alike are pushing for change — for new pathways that could make Madison’s wealth of health care resources feel like a bounty and not a bitter irony.

Every patient and medical professional who steps off the well-traveled but often frustrating path opens the door further to a better way — and better care.

HMO-nopoly

In the 1980s, health maintenance organizations, or HMOs, in Madison got really big, really quickly, thanks to the city’s large proportion of state employees.

On Dec. 31, 1983, only about 22% of state employees in Dane County were enrolled in an HMO. On Jan. 1, 1984, that number jumped to over 80% due to a change in the state’s policy for employee health plan contributions.

It was a dramatic transformation — and one that seems to have stuck around. In 2021, 44% of Wisconsinites were enrolled in a large national insurance carrier. In Dane County, that percentage was just 19%. HMOs typically have lower out-of-pocket costs than other health insurance plans. Two Wisconsin-based HMOs — Dean Health Plan Inc. and Group Health Cooperative of South Central Wisconsin — ranked in the top 20 in the National Committee for Quality Assurance’s 2024 report card, which measures patient experience, caliber of treatment and more.

The cons? Each HMO has a defined network of providers, and out-of-network visits might not be covered at all. Also, every HMO member is required to have a primary care physician, or PCP, who directs follow-up care by referring patients to specialists. Having to go through a PCP — and stay in-network — can restrict patients’ options for specialized care.

Anna Kottakis is digital editor at Madison Magazine.

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