When Lexi Tabor-Manaker was a child, each summer her family would make the annual trek from Michigan to Montana to visit their relatives. At age 12, Tabor-Manaker decided she was going to become a doctor and practice medicine in northwest Montana. Her family would conclude the long road trip to visit her relatives in Hamilton with a vacation in Many Glacier, passing through Kalispell along the way. She recalls seeing the sign for the hospital’s emergency department and telling her parents, “When I grow up, I’m going to be a family practice doctor in Kalispell, Montana, where I’ve got a view of Glacier National Park.”
Her dream came to fruition in 2007, when Tabor-Manaker began practicing family medicine at a private practice called Family Health Care until it joined the sprawling regional hospital system now known as Logan Health. From 2015 through 2018 she worked at the Kalispell’s Veterans Affairs Clinic. However, in recent years she began to feel increasingly dissatisfied by the constraints of employed medicine, including having less time to spend with patients and devoting more time to navigate the convoluted health insurance system — problems she didn’t encounter as an independent doctor. She began to feel a strong sense of burnout but didn’t want to give up her life’s calling. Instead, in 2018, she took her career in a different and new direction and opened Glacier Direct Primary Care, her own private direct primary care practice.
Direct primary care (DPC) is a newer healthcare model started as a grassroots concept in the late 1990s by a group of doctors wanting to revamp the current healthcare system. They did so by bypassing the insurance regulatory system and focusing on what Tabor-Manaker said is “good, old-fashioned family medicine” with a focus on the physician-patient relationship. The model came into fruition in the early 2000s and relies on a direct agreement between the doctor and the patient, typically in the form of a membership. DPC eliminates the need for third-party billing, which is what the traditional healthcare system uses as a fee-for-service payment model. These types of third-party billings include commercial health insurance, Medicaid, or Medicare. Instead, for direct primary care, patients are billed an affordable flat monthly fee with access to that care provider’s services. It’s a subscription-based service in exchange for primary care services. Direct primary care is not the same as concierge care, which typically allows for unlimited access to providers but relies on the insurance model for billing. For Tabor-Manaker, the allure of the DPC model was its promise of more concentrated time with her patients while easing the administrative burden of insurance and hospital coding that took away from delivering the kind of care she wanted to provide. It also gives patients quick and direct access to their provider, she said, as well as her undivided attention. “I never have more than one person in my office at time. The office is completely private.”
While Glacier Direct Primary Care was the first one of its kind in the state, the model, while not yet mainstream, is quickly gaining popularity across the Flathead Valley as more providers open their own direct primary care practices. In June 2021, Dan Gragert, a physician with a varied medical background that includes biomechanics, physiology, gerontology, and family medicine, opened Bluebird Health in Kalispell. Gragert, who completed his undergraduate degree in Helena at Caroll College, had always wanted to practice medicine in small towns and rural areas. A series of pivotal changes in his medical career, health, and family led him to leave traditional employed medicine and carve a new path in direct primary care. Before arriving in Kalispell with his family, Gragert was on the front lines of the Covid-19 pandemic at the University of Oklahoma’s College of Medicine and witnessed how the global pandemic not only created a public health crisis but resulted in catastrophic consequences for hospitals and physicians. From a lack of critical resources and administrative support to being inundated with critically ill patients, Gragert felt like he couldn’t provide an adequate level of care, particularly when his workload involved meeting with 20 to 30 patients every day. To him, the system was the problem. After nearly a decade as a resident, he felt like he wasn’t present for his young family and wanted another option. Then, he was diagnosed with melanoma.
In January 2021, at 37 years old, he received a call from his dermatologist’s office that he had cancer. Alarmed at the news, his concern quickly shifted to desperation when he couldn’t speak directly to his primary care provider. “There are a few diagnoses in medicine that sends chills down your spine and melanoma is certainly one of them. I know all the risks and prognosis, but I wanted to talk to somebody,” he said. He had hoped, through his entire treatment for melanoma, for more compassion and sensitivity from his cancer team.
That isolating experience left him disillusioned and questioning his role within the established medical system. Between his experience working through the first year of Covid, his cancer diagnosis, and the death of his father during that same year, he wanted to realign his priorities, which included doing something that would make his children proud. He envisioned direct primary care as a solution to not only a way for him to practice medicine as he believed should be practiced but also as a legacy in hopes of making his children proud of him. In Gragert’s view, influenced by both medicine and economics, direct primary care is the “Fairest distribution of a resource — medical care, so we can actually spend time with people.”
Both Glacier Direct Primary Care and Bluebird Health offer comprehensive primary care services, which include wellness exams, urgent and acute care needs, chronic disease management, women’s health, treatment for minor injuries, laboratory services, preventative medicine, and more. Glacier Direct Primary Care accepts patients 18 years and older while Bluebird Health’s membership program includes pediatric patients as well. Both practices charge a monthly fee with pricing plans categorized around age ranges, and they offer plans for small businesses. Glacier Direct Primary Care offers a discount to veterans while Bluebird Health allows for one free child with each adult membership; each additional child costs $10, which is added to the monthly rate. In the fall of 2024, Bluebird expanded its service offerings with the opening of its imaging center. Billed as a direct access diagnostic imaging clinic, Bluebird Health Imaging offers CT and ultrasound imaging services without the requirement of a prior doctor’s approval. The cost is also lower compared to what many hospitals and traditional clinics charge. The imaging clinic is open to the public and patients don’t need to be a member of Bluebird Health to receive diagnostic imaging services.
The growing success of the direct primary care in the Flathead Valley is expanding into other fields of medicine beyond primary care, including areas of specialized medicine such as gastroenterology, with practices offering a similar cash-based service for care.
In the fall of 2024, Tom Flass, a pediatric gastroenterologist, and Brittany Coburn, a certified nurse practitioner in family medicine, started Functional Medicine Associates in Kalispell. Both Flass and Coburn have decades of experience practicing medicine in conventional clinical and hospital settings; however, independently, they found themselves wanting a different approach that would examine their patient’s whole health profile and provide a focus on preventative medicine. Functional medicine is a holistic approach to identify and treat illnesses or chronic diseases at the root cause. For Flass, functional medicine is ideal for “the patient who wants a more holistic, well-rounded, and personalized experience. They feel like traditional medicine has only taken them so far, something’s been missed, and they want someone to look into the root causes.”
Although Functional Medicine Associates is not a direct primary care practice, they have a similar approach to providing personalized medicine and spending more time with patients. As with Tabor-Manaker’s and Gragert’s practices, they don’t accept insurance. However, Functional Medicine Associates differs from DPC in that it does accept health savings accounts (HSA) or flexible spending account (FSA) payments as an out-of-network licensed medical provider, allowing patients to submit so-called superbills for reimbursement from their insurance carrier. DPC practices are, by law, not allowed to accept health savings account HSA or FSA payments, and their services are not eligible for reimbursement from an individual’s health insurance carrier. Both Glacier Direct Primary Care and Bluebird Health recommend that their patients retain their health insurance coverage as mandated by law and to cover catastrophic medical needs, hospitalization, or specialty care not provided by their practices.
Coburn and Flass believe they offer a unique perspective with their combined 30 years of practicing Western medicine in clinical and hospital settings alongside their training and certifications in functional medicine. Flass moved to Kalispell in 2015 to lead the pediatric gastroenterology program at what is now Logan Health Children’s Specialists. Coburn has worked as a board-certified family nurse practitioner since 2010 in area family practice clinics and is an assistant professor with the nursing program at Montana State University.
Functional Medicine Associates offers long-term wellness and nutrition guidance for children and adults, which also includes prenatal and postnatal infant nutrition, which is one of Flass’ specialties. Additionally, the two providers treat a wide range of digestive health issues like Crohn’s, Colitis, Irritable Bowel Syndrome, Celiac disease, and other autoimmune diseases. The duo also treats metabolic and brain health concerns like ADHD, anxiety, depression, chronic headaches, cardiovascular health and diabetes prevention. Unlike a membership subscription that direct primary care requires of patients, Functional Medicine Associates charges on an appointment basis. Coburn’s area of expertise is in family medicine, women and teen health.
For both Flass and Coburn, the transition from employed medicine to their private functional medicine practice allows for them to provide a blend of their medical training alongside the foundations of functional medicine, an area that they both tried to incorporate in their previous work, with an emphasis on nutrition and preventative medicine. Before Flass began his education and training as a medical doctor, his got his start in nutrition, larger stemming from his own experience with Celiac disease. The more he studied the connection between pediatric growth and development with nutrition he understood the critical relationship between the two, and this field of study has only expanded for him now that he’s trained in functional medicine.
The appeal of examining a person’s health from birth is one facet that drew Coburn to functional medicine. “It’s whole health care. We take the time to do a history from birth and really dive in and figure out where the symptoms are stemming from,” she noted.
The two caution that their practice isn’t designed to be a destination for a quick cure or magic pill and the path to wellness requires a comprehensive focus on lifestyle, habits and nutrition, as well as a patient’s environment, including social and emotional. As Flass said, its focus on identifying the root causes of illness and developing a holistic treatment plan is designed to keep people healthy, not simply to treat symptoms as they arise.
Coburn views this different approach to medicine as a way to move beyond a diagnosis and improving a person’s whole health: “Many times you start your healthcare journey after a diagnosis and you think, I finally know what’s wrong. But you’re not any better, you just have a label. This is a way we can work upstream and figure out what we could do better and without the label. We work on getting you to your true health.”
Across the country, Americans are spending more on healthcare than most comparable nations. These three practices are trying to shift the paradigm of how medical care is delivered by increasing affordability and access while placing an emphasis on preventative and more individualized medicine. With the direct primary care model used by Bluebird Health and Glacier Direct Primary Care, and the a la carte-care system adopted by Functional Medicine Association, alongside other similar practices opening across Montana and the Flathead Valley, new opportunities for patients and providers are on the horizon.
For all four of these providers, the goal is to improve the relationship between the patient and provider and the overall health care system. As Flass says, “The more we focus on personalized medicine, the better medicine gets.”
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