Direct primary care and health insurance seem to be at odds with each other, but is that really the case?
In 2023, I was diagnosed with a chronic medical condition that changed the course of my life. The early days of my illness were filled with visits to medical specialists, lab draws and imaging studies. Even as a physician myself, I struggled to navigate through the medical system to get the care that I needed. Thankfully, I have a direct primary care physician who has helped me to gain access to care. In addition, she has helped with medication prescriptions, lab draws and sorting through mountains of paperwork to get me an appointment with a specialist. I am also thankful that my family and I also have a traditional health insurance plan that covers my very expensive specialty medication.
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 fill in the gaps in my care when it was difficult to get a hold of the specialist. As my primary care provider, she also has lots of experience in managing everything from minor colds and flu to chronic illness. When I catch the latest virus that is going around my child's classroom at school, my primary care doctor treats me.
In addition to being cared for by a DPC family physician, I was also a DPC doctor for seven years. I took care of a small panel of pediatric patients in my local area. Direct primary care not only changed my life as a patient, but as a physician too. The care that I was able to provide through the DPC model made me love being a doctor again.
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
Direct Primary Care (DPC) is an alternative healthcare model that has emerged as a solution for both patients and physicians seeking a more direct relationship. Instead of billing insurance companies, DPC doctors charge patients a flat, recurring monthly membership fee. This fee grants you access to a wide range of primary care services. It’s a return to a simpler model where patients pay their doctor directly for care, bypassing the complexities and bureaucracy of the insurance system for routine services.
Think of DPC like a gym membership or a streaming subscription: you pay a fee for consistent, reliable access. For doctors, this means they don't have to get permission from insurance companies to be paid for the care they provide. This allows DPC practices to offer more personalized care and direct access to a smaller number of patients. In most DPC practices, the monthly fee covers the ability to contact your doctor directly via text or phone for questions and to easily schedule appointments.
Time with Your Doctor
Time is precious, and you don't get it back. Many people complain about the traditional health care system. Often, you wait a long time for a rushed and short visit with your physician.
In contrast, direct primary care is different. With fewer patients to care for and less red tape getting in the way, DPC doctors can offer longer appointments with minimal wait times. Office appointments often last anywhere from 30 minutes to a full hour, ensuring your concerns are fully addressed. Plus, you’re far more likely to get in and out on time, allowing you to spend less time away from work and life to manage your health.
Transparent Pricing
A cornerstone of DPC is financial transparency, which is a welcome contrast to the surprise bills and hidden fees of the traditional system.
DPC doctors like to keep things simple by offering clear pricing that is often available right on their website. The low-overhead DPC model allows doctors to offer an alternative to the traditional insurance based practice.
Direct Access and Convenience
Imagine being able to text your doctor a quick question and get a timely and helpful response. That's a standard feature for DPC members and this kind of direct access to your doctor is a huge privilege.
Frequently asked questions.
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.
Does my membership fee count against my deductible?
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, but the convenience still stands.
Even though this is my case most years, I don't want to give up the relationship that I have with my PCP and the ability to access her directly. Our family is privileged in that we can afford both a DPC doctor and traditional health insurance. I realize that this is not the case for everyone, but there are many other options of plans that can pair well with DPC to keep costs down for your family.
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.
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.
