Paying for Primary Care – Traditional vs. Direct Primary Care

Primary care costs

Primary care costs can be profoundly confusing, especially within the traditional healthcare system. If you were to ask anyone what they paid for an x-ray or an immunization they’d probably be unable to tell you. And these are very straightforward medical procedures! There are a lot of reasons for this lack of price clarity, many of them frustrating. 

Direct primary care has become popular, in part, because it offers refreshing transparency when it comes to costs. Under a direct primary care model, patients never have to think about the cost of a given procedure or visit. Instead, patients pay a monthly membership fee, making the DPC model both straightforward and easy to understand.

How Is Traditional Primary Care Paid For?

Traditional primary care plays an important role in the American healthcare system. But most people use health insurance to pay for it. As a result, counting costs can get murky fast. And that’s important, because there are two common ways that people pay for traditional primary care:

  • Health insurance: Most Americans have at least some health insurance coverage (though the precise percentage fluctuates from year to year). Under the majority of insurance plans, physician visits are usually rushed and short. There’s usually a high monthly fee associated with health insurance, though sometimes employers cover a portion of this fee. Which sounds great, at first glance. The problem is that there are also other expenses, many of which are hard to predict. Patients are expected to contend with copays, deductibles, out-of-network costs, premiums, and countless other uncertainties that can impact the final bill sent to the patient.
  • Out of pocket: Less commonly, some patients may pay out of pocket. This means that the patient does not have health insurance and, instead, pays for all services as they are used (aka “fee for service”). Usually, this is not a cost effective way of seeing your doctor. Some clinics will even refuse to take patients who do not have insurance. Others simply don’t have the capacity to bill individuals for services. As a result, most people who do not have insurance see their doctors far less often.

Because most Americans pay for healthcare through the health insurance system, the billing for services becomes incredibly confusing. The cost of an X-ray at a single clinic might be one price through Insurance Company A and five hundred dollars more through Insurance Company B. It all depends on the negotiated terms. 

In most cases, doctors and nurses won’t even know, when asked, how much a patient would be expected to pay for an X-ray, for example. The system is just that complicated. As a result, it’s nearly impossible to predict your healthcare costs in the traditional primary care system. 

Even when you have good health insurance, it’s nearly impossible to fully understand and anticipate what you’ll be paying for any given service. That’s due to those copays, deductibles, caps, and so on.

Calculating Direct Primary Care Costs

In contrast, paying for direct primary care is clear and easy. You pay a simple, monthly payment, which grants you membership into the clinic. Members are then provided access to all of the clinic’s care. Some clinics have different levels of membership, and premium members may see various perks. 

But when you’re a member of a direct primary care clinic, you know exactly what you’re going to be paying every step of the way. The pricing is incredibly clear and comprehensive. 

What’s better, paying for direct primary care is as easy to understand as paying for your monthly Netflix subscription. This one monthly payment covers virtually all of the costs you can expect to encounter, meaning you won’t pay out of pocket for visits, strep tests, diagnostics, and most other care. Patients also receive nearly immediate access to comprehensive care (compared to the appointment three weeks out that lasts a scant seven minutes you might receive under a traditional primary care system). In our practice we also dispense prescription medications at a discount to our members. Discounts are usually lower than the co-pay at many pharmacies. Our patients like the convenience of skipping the trip to the pharmacy and the lower costs. 

The Benefits of Carrying Both Insurance and DPC Membership

For most DPC members, health insurance may still be necessary. But a DPC and insurance combination can actually end up saving you money in the long run. Contrasting the options:

  • Without DPC Membership: Your health insurance will have to cover all of your medical related expenses. As a result, most people will select the most robust coverage they can afford. And anybody who has ever shopped for insurance on the open exchange or selected a plan through their employer will know: insurance gets expensive in a hurry. A high quality health insurance plan is often nearly-a-second-mortgage-level expensive. 
  • With a DPC Membership: When you’re a DPC member, you’re able to be much more selective about your health insurance. You can choose an insurance plan that only covers emergency care or specialist visits. And that means your health insurance plan might not need to be platinum level. For many people, a smaller insurance plan combined with a direct primary care membership is actually less expensive than a comprehensive health insurance plan (especially when you factor in additional fees that health insurance can require, such as co-pays and deductibles). What’s more, with a DPC membership you can continue your primary care even if you switch employers or change careers. 

Because the two terms are often confused, it’s worth pointing out that Direct Primary Care with supplemental insurance is not the same thing as concierge medicine. A concierge practice will charge a monthly fee, yes, but they will also submit a bill to your insurance company for all procedures and visits, meaning there’s still no price transparency.

A direct primary care clinic, on the other hand, will never charge your insurance company or any third party for your visits. That way, you’ll always know exactly what you’re paying for primary care costs. In addition, Direct Primary Care offices offer lab tests at significantly lower rates as insurance is not involved. Some practices even have eliminated the middle man for prescriptions and can provide medications at cost from the office rather than using a pharmacy. (Each state’s laws are different for this.) 

Opening Access to Primary Care

Comparing the costs of primary care in traditional and direct structures is important because primary care can be medically essential. Quality primary care can help you stay healthier over the long run–keeping your minor medical concerns minor. When patients can’t afford or predict primary care costs, they’ll often avoid seeking out that care. 

And that’s why direct primary care is so valuable to members of a DPC clinic. Members get the healthcare attention they need without the stressful overhead and uncertainty generated by health insurance. When it comes to paying for primary care, the direct primary care model has a lot to offer patients.  

If you have questions about direct primary care, contact our offices to schedule a meeting with a member of our staff!