ACA Compliance

Direct Primary Care: Another Option, Another Decision

Given the ever-changing, and at times volatile, health care climate, it’s not surprising more autonomous and curated options arise—like the Direct Primary Care model. With DPC, patients have a contract—based on their age, the practice they visit and family members—with their medical providers allowing them to directly pay a monthly, quarterly or annual fee for a range of services. Like any other insurance option, this specialized payment method comes with pros and cons.

By
Derek Owens
,
on
January 22, 2020

Given the ever-changing, and at times volatile, health care climate, it’s not surprising more autonomous and curated options arise—like the Direct Primary Care model. With DPC, patients have a contract—based on their age, the practice they visit and family members—with their medical providers allowing them to directly pay a monthly, quarterly or annual fee for a range of services. Like any other insurance option, this specialized payment method comes with pros and cons.

The Upside

DPC typically cuts out the traditional fee-for-service billing to third party insurance plan providers, which can be a major bonus. “For family physicians, this revenue model can stabilize practice finances, allowing the physician and office staff to focus on the needs of the patient and improving their health outcomes rather than coding and billing,” according to the AAFP site

This contract fee payment structure is most ideal for those with high deductibles who would be paying astronomical amounts out of pocket for any services not considered preventative.

Not being bound to insurance reimbursement restrictions is probably the most gleaming attribute of DPC, allowing physicians to concentrate more on one-on-one time with their patients—either in person or over the phone. The method galvanizes the patient/provider relationship, depending on what is actually covered in a DPC plan.

The Downside

As attractive as cutting out a middle man might seem when it comes to dealing with your healthcare, sometimes enacting a plan through an insurance provider offers the advantage of broader coverage.

“The variance between DPC practices is often found in the breadth of primary care services covered by their retainer contract fee structure. Some DPC practices have retainer fees that cover the entirety of primary care services, including care management and care coordination, as well as services involving external organizations such as off-site diagnostic facilities. Other DPC practices cover a far more limited scope of services and collect service fees from patients at the time of care to cover costs occurred in the visits,” as reported by Medical Group Management Association.

Because of the potential restrictive nature of the DPC when it comes to the exact services covered with the fee payment method, typically people with this kind of plan still have to purchase insurance—pairing their contract with something like HDHP, HSA or prescription coverage.

“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), comprehensive care (visits for strep throat or the flu), and consultations,” according to Good Rx. However what if something happens that doesn’t fall into any of the latter categories? That’s where you could be financially vulnerable with only a DPC set up.

Like any other insurance endeavor, exploring setting up a DPC takes deliberation based on your personal needs and circumstance. With this payment method, you have more of a direct relationship with your healthcare provider—free of contracts and third-party billing. However, eliminating that tie to payers may also cut into your coverage.