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What is DPC?

How does direct primary care work?

Since arriving on the healthcare scene in the mid 2000s, direct primary care has grown in popularity. As health insurance gets increasingly confusing, expensive, and frustrating, new models of care are rising. Patients without health insurance, or those fed up with paying skyrocketing monthly premiums, are turning to direct primary care as an option to afford basic medical care.


Direct primary care is a financial arrangement made directly between a patient and healthcare provider. It cuts the insurance providers out of the process, erasing the need for patients and providers alike to file health insurance claims. 


Patients who use direct primary care don’t pay monthly health insurance premiums or copays. Instead, they pay their healthcare provider a monthly fee. But because direct primary care providers don’t bill insurance companies, they don’t accept any form of insurance. That being said, most patients who use direct primary care are also enrolled in a high deductible health plan (HDHP).


Here’s everything you need to know about direct primary care, and if it’s right for you.



The pros and cons


Along with the financial risks and potential rewards, there are several aspects of direct primary care to consider before entering into a financial agreement with a healthcare provider.


Pro: More time with your healthcare provider

Direct primary care provider are able to avoid the time normally spent preparing and filing insurance paperwork. This allows for in-depth visits and consultations with their patients. Direct primary care practices also typically have fewer patients than those accepting insurance. Providers are able to get to know their patients’ health history and story in detail, creating opportunities for more personalized care.


Con: You’ll still need an insurance plan

The monthly fee covers the primary care consultations. But if you need any additional testing, procedures, or medication, you’ll likely be on the hook for the cost. That’s why you’ll probably need to pair your direct primary care membership with some sort of insurance plan. Many direct primary care patients also have a high deductible health plan. You can learn more about HDHPs here.


Patients on Medicare or Medicaid may use direct primary care providers. However, they will have to sign an agreement stating that any and all services provided will not be billed to Medicare or Medicaid.


Pro: Upfront pricing

With a traditional health insurance plan, a patient typically leaves the doctor’s office without knowledge of exactly what — and how much — their insurance will be billed. After deductibles or copays are applied and discounts are negotiated between the provider and insurance company, the patient receives an explanation of what they’re expected to pay for the visit.

Direct primary care eliminates that confusion. Patients know the exact monthly cost of membership as well as the flat fee (if any) for visits. This fee does not vary based on the services provided.


Con: Membership doesn’t count toward a deductible

The IRS currently categorizes direct primary care and its monthly membership fee as a “health plan.” So the monthly cost is not eligible to go toward a deductible if you also carry high deductible health insurance coverage.


Pro: Accessibility and convenience

Direct primary care patients usually have access to same-day and next-day visits, 30- to 60-minute appointments, and the option to call, email, text, or video chat with a provider 24/7. In traditional health insurance plans, many doctors don’t provide this much accessibility because it’s difficult to bill for phone or video visits.



Costs and payment


The monthly fee for most direct primary care services is typically around $75, or more. That fee gives patients unlimited* and direct access to their primary care provider. Some providers also charge an additional visit fee at the time of service. In general, fees are determined based on a patient’s age, the type of practice, and the number of individual family members on the plan.


The monthly fee covers all — or most — typical primary care services. This includes preventative care and laboratory tests like blood tests or urinalysis, care coordination (medication check-ups), and comprehensive care (visits for strep throat or the flu).


Visits to specialists, urgent care, or the hospital are not included in the monthly fee. Prescriptions are also not part of a direct primary care financial agreement with a doctor. Accepted forms of payment vary by provider. In most instances, options like card, cash, or reoccurring payments are accepted.


You’ll probably still need insurance coverage


Although direct primary care may cost less than traditional health insurance monthly premiums, the lack of coverage for other health-related expenses leaves you financially vulnerable. To prevent facing medical bills you’re unable to pay, direct primary care is typically paired with one or more of the following options:


  • A high deductible health plan (HDHP): Direct primary care providers do not offer services like surgeries, treat complex or catastrophic health issues like cancer, or handle emergencies like heart attack. Direct primary care also does not cover hospitalization charges from circumstances that may require stitches, a cast, or other treatment received in the emergency room or at an urgent care facility. An HDHP is one way to prevent financial devastation in the event you require emergency, serious, or extensive care. 


  • A health savings account (HSA): Anyone enrolled in a HDHP is eligible to contribute money to a health savings account. The contribution is made before income tax is deducted from your paycheck. This reduces your amount of taxable income. Funds in an HSA may only be used on health-related expenses like prescriptions, copays, deductibles, and some other expenses like medical equipment.


  • Prescription coverage or coupons: Regardless of your insurance or direct primary care membership, you can use GoodRx to save on prescription medications. GoodRx offers free coupons on a wide variety of medicine. Just go to goodrx.com, type your medication into the search bar, adjust your dose and quantity, and discover the savings. You can download and print the coupon, or send it to your phone or email. Take these coupons to participating pharmacies to reduce the amount paid for a prescription.



Is direct primary care worth it?


Because patients using direct primary care can typically text or call their provider at any time, this option may be appealing to a range of people. For example, families with small children, patients who travel frequently, or elderly patients who can’t travel to the doctor.


However, because direct primary care memberships are usually paired with HDHPs, they might not be the best choice for people who need specialized care or who have complex medical issues. Direct primary care may be best for patients who are generally healthy, and need to see a primary care provider for routine visits or short-term health issues.


So if you already have — or are considering — an HDHP, adding a direct primary care membership may be a good option to limit costs of physicals and other routine visits to the provider.




Direct primary care continues to grow

In 2015, there were 141 direct primary care practices operating at 273 locations in 39 states. Of these, 82% posted cost information online. The average monthly cost was $93.26 and almost a quarter of the practices also charged a per-visit fee ranging from $5 to $35.

Currently, there are over 1,000 practices participating in direct primary care in 48 states plus Washington D.C. And experts expect those numbers to continue to grow.



The takeaway

As with any health insurance plan, it’s best to weigh all the pros and cons based on your individual needs before entering into any agreement. Be sure to ask your primary care provider about any exclusions, restrictions or limitations, and requirements of their specific direct primary care plan before making any changes to your health care coverage.



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