Direct primary care and health insurance seem to be at odds with each other, but is that really the case?
About a year ago, I was diagnosed with a chronic medical condition that changed the course of my life in many ways. The early days of my illness were filled with specialist visits, lab draws and imaging studies. Thankfully, I had a direct primary care family doctor that could help me navigate this new landscape.
And even though I'm a physician myself, our traditional medical system is so broken that I had many days that I wondered if I could receive the medical care that I needed.
Additionally, I was thankful that I also had a traditional health insurance plan that initially covered my very expensive medication. Even though, I normally dislike insurance providers, insurance coverage for a $20,000 monthly medication was necessary if I wanted to continue to live a full life.
How do primary care physicians provide care under DPC?
Although specialty care is outside of the scope of the medical services that my family doctor provides, my PCP was able to call in prescriptions when it seemed impossible to get a hold of the specialist. As my primary care provider, she has lots of experience with managing chronic conditions, acute conditions like colds and minor urgent care needs that her patients have.
I'm also a primary care physician for children. Five years ago, I opened a pediatric practice using the direct primary care model. As I surveyed the scene in my large metro area, there was very little choice when it came to pediatric care. Families could choose between a hospital owned pediatric clinic where they felt like a number or seek the advice of a non-medical practitioner that often led them astray and away from evidence based medical practice. As a result, I opened a direct primary care pediatric medical practice in order to provide personalized care and evidence based medical care for children in our community. I wanted to provide families with a viable alternative for pediatric care and selfishly, I disliked feeling like my patients were just a number or RVU. My approach to patient care is more like a trusted advisor.
In the past few years, direct primary care has exploded as a model that benefits both the doctor and the patient. But is it right for you? And do you still need health insurance if you choose a DPC doctor? In this article, we will look at how the model works and how to obtain affordable health insurance so that you can get the care that you deserve without the risk of losing your assets if a catastrophic medical condition enters your life.
How Direct Primary Care Works
At its inception, direct primary care provided an alternative model for burned out physicians and patients alike. In this model, your doctor charges you a monthly membership fee that allows you to access primary care services for you and often your family. In some ways, it is a return to the old model of medicine where patients paid doctors directly for health care services.
So instead of asking your insurance company permission to be paid for the medical care they provide for you, your doctor charges you directly. As Americans, we are no strangers to membership models. We pay monthly for our gym membership or our Netflix subscription. Primary care practices have adopted this primary care model in order to be able to offer direct access and more personalized care to a smaller subset of patients.
For most practices, this monthly membership fee allows you to access the doctor via text messaging for questions and in order to schedule visits. DPC doctors provide preventative care as well as management of chronic diseases. Unlike primary care visits in the "traditional" insurance based system, DPC physicians are able to follow up on health conditions and maintain an ongoing relationship with their patients.
Some DPC practices will charge an additional visit fee, but most allow specified primary care services that are covered by the monthly fee. Additionally, certain things like stitches or lab draws may incur an additional fee, but often these services are much less expensive at your DPC doctor's office than they would be in an urgent care or ER setting.
Benefits of DPC for patients
While many complain about our current model of the delivery of healthcare, the patients who use a direct primary care model have numerous benefits. They get more time with the doctor, more transparency and more convenience because they are willing to partner with their physician directly. Let's break down these three categories that greatly benefit both patients and physicians.
Time with the doctor
Time is our biggest commodity. We are never going to get back time that we have lost. In our traditional medical system, often people need to plan well in advance to take the time that they need in order to visit their primary care physician. And even with that sacrifice, you will often spend at least half of the day at the doctor's office as you walk through the layers and layers of people between you and your physician. If you are lucky, you then get to see your physician for 10 minutes, maybe 15 minutes if you are very fortunate.
In direct primary care, time with patients is one of the cornerstones of the model. In this way of doing healthcare, often the doctor works alone or with a small staff. You come in for an office visit, maybe talk with the nurse or medical assistant and then spend the majority of the visit with your primary care doctor. Often these visits can be anywhere from 30 minutes to an hour depending on your needs and your doctor's office structure. Frequently, you will get in on time and leave on time. This allows you to take less time off work in order to take care of your health.
Transparent pricing
Another cornerstone of direct primary care is transparency. As rebels against our traditional health care system that operates with hidden fees and large surprise bills and extra costs, direct care doctors offer transparency in pricing. Often you can find the prices for the practice on the doctor's website or easily receive a price list via email.
Due to the low overhead model of direct primary care, DPC doctors offer an affordable alternative to large insurance premiums and out of pocket costs that come in the traditional healthcare system. Even though, you won't receive your "free" wellness visit that your insurance company promises you every year, you will receive true primary care that helps you to live your best life.
Direct access to the doctor and convenience
What would your life look like if you could text your doctor and get a quick answer to your question? As a privilege to members of my practice, parents will often text me a picture of a rash or a question about constipation. I can answer them quickly and give them guidance at the moment.
In addition to texting questions directly, DPC doctors offer convenient scheduling. Since my practice is small, I am able to work pediatric visits around a parent's work schedule, a child's daycare schedule or even sometimes a baby's nap schedule. Also, I remain available to see your child in a timely manner if they come down with an acute illness.
Drawbacks of DPC
For families that are more familiar with a traditional health care model, you may be questioning how DPC works and if it will benefit you if you have traditional health insurance.
Do you still need health insurance?
While full scope family medicine doctors can take care of you in a lot of ways, you still need to carry additional insurance for catastrophic medical conditions. If you are in a car accident, get diagnosed with cancer or require ongoing specialty care for a chronic medical condition, you will need insurance to protect you from financial devastation.
While traditional health insurance premiums can be large, there are many other alternatives to this type of insurance that pairs easily with direct primary care.
Deductibles and membership fees
Unfortunately, at this time in history, your membership fees will not count towards your deductible. There is no provision for your healthcare provider to file insurance paperwork with your carrier that will allow for the fees to be credited towards your benefits.
However, direct primary care benefits families who have high deductible health insurance plans in other ways. DPC is especially beneficial when they don't meet their deductible each year. Often a year's worth of DPC membership is less than the deductible for many high deductible health plans. Where it becomes less of a cost benefit is for families who meet their deductible and therefore have "free" healthcare visits after that. Sometimes, the cost savings is not there for those families.
Even though, that was my case last year, I didn't want to give up the relationship that I had with my PCP. We probably paid a little extra last year for healthcare, but each year is different and this year, we have no hope of meeting our deductible.
How the payment structure works
As a member of my DPC pediatric practice, a parent keeps a credit card on file. I charge a set membership fee each month on the first of every month. This covers the primary care for that child each month and allows access to me as the child's physician. Prior to initiating a relationship with the practice, a family signs a contract that gives full transparency for the care provided as well as the membership fee.
How does insurance work with DPC?
Families are able to use their health insurance whenever they want for other aspects of their medical care. For my practice, I partner with a vaccine provider that will allow parents to use their health insurance for vaccines. Additionally, many families choose to use their health insurance for expenses such as imaging or lab studies and certainly for most specialist visits.
Most DPC doctors are well versed in helping patients to navigate the health care system and find health savings by offering discounted cash pay for labs, steering families towards imaging centers that offer reasonable cash prices for certain studies and community resources such as the health department for low cost cash pay vaccines.
One thing that many families have begun to do is purchase purely catastrophic health insurance. Many think it means big deductibles, but the marketplace for that coverage has changed. You can now buy a set of policies that can cover up the financial risk that comes with major health events that would be beyond a DPC relationship. These health insurance plans come with much more manageable deductibles and premiums. But that is an explanation left for the professionals at Insurance For Texans.
DPC is worth it for most families
I know that I am biased, but the direct primary care model has been life changing for me, both as a doctor and as a patient. While I know that cost can be a barrier for some families, often DPC practices are less expensive than concierge care. Even though most of us offer this level of care, your cost of care will frequently be less with a DPC doctor. Of course, prices vary depending on location and cost of living in your area. Families who choose DPC often have a better healthcare experience than families who find care through traditional insurance.
Where do I look to find this kind of care?
Thankfully, this model is catching on and a simple google search will often lead you to a direct primary care doctor in your area. Additionally, there are resources such as the direct primary care mapper that lists DPC practices by city and state.
This article exists for informational purposes only and should not be construed as medical advice.
Dr. Andrea Wadley is the owner, pediatrician, and breastfeeding medicine specialist for 127 Pediatrics. She has an established house-calls-only concierge pediatric practice in Colleyville, TX. She is also the owner and operator of the 127 Pediatrics Online Breastfeeding Medicine and Education Center.