Direct Primary Care

[Tuirc]

Has any had any experience with the Direct Primary Care model? If so, what has your experience been?

For those who don't know, this is a model where you pay a monthly fee for access. In the place three blocks down the street from me, the model looks like this: (taken from their FAQ page)

Quick rundown:​

You pay a membership fee that covers unlimited same or next day appointments, calls, texts. You get a direct phone number for your doctor that you can call or text and just have a "telemedicine visit" on the spot. You pay extra for office procedures and additional labs and imaging BUT these are usually much cheaper than if you went through your insurance company.

What is DPC?​

Direct primary care (DPC) is an innovative healthcare model that fosters a more personalized and accessible approach to patient care. By bypassing traditional insurance complexities, DPC allows patients to establish a direct relationship with their primary care providers. This enables doctors to focus more on patient needs and spend more time with them, as opposed to focusing on the needs and demands of the insurance companies.

With transparent pricing and minimal administrative barriers, patients feel empowered to seek medical advice without the fear of unexpected costs. DPC promotes preventative care and wellness, fostering a proactive approach to health management. Ultimately, this model not only enhances patient satisfaction but also contributes to healthier communities through better access to care and stronger relationships between patients and their healthcare providers.

 

[Lorenzo]

I have heard of this, and it all sounds great ... for routine primary care. But you would still need traditional insurance for any sort of major procedure unless you want to spend thousands or tens of thousands out of pocket, wouldn't you?

 

[Tuirc]

I have heard of this, and it all sounds great ... for routine primary care. But you would still need traditional insurance for any sort of major procedure unless you want to spend thousands or tens of thousands out of pocket, wouldn't you?

That's my understanding, you'd need either something like a catastrophic plan or decide to self insure. In this particular one, there is no drug coverage either. There are a few of these in our area and at least one does have an in-house pharmacy that is discounting drug costs as well.

The calculus for us is: we have to a little over 2.5 years (me) and 3.5 years (DW) to Medicare. We need to do Roth conversions in the same time period. We are healthy, not overweight, don't smoke, or take any kind of prescription drugs so do we get something like this and take the chance that the world doesn't fall in on us in the meantime? Or, do we pair this with a catastrophic plan (early reviews of this approach show that paradoxically, catastrophic plans look expensive too).

Some people have suggested that you do this, if something bad happens, you can always get an ACA plan (probably ok for disease, not good for accidents). Or, thinking another way about it, an ACA plan would cost between $75-$100 in that time period (not including continued skyrocketing prices), anything paid out of pocket less than that would still be a "deal." While lots of stuff costs more than that, lots also cost less than that.

 

[Sarah S]

If you had a disease that needed urgent specialists ( say cancer or heart disease that needed intervention to prevent permanent damage) you would need to get an insurance that would cover and probably a pcp in plan who can refer you to the specialists. I don’t believe you can pick up aca midyear without a qualifying event which you would not have and there is often a wait to see a pcp even if you could find one. Where I live it is hard to find new pcps. Sounds like a huge gamble.

 

[athena53]

This sounds very similar to concierge care to me. I agree with previous posts- it is not a substitute for traditional insurance. It's more of a "priority" system that gets you more attention faster. The only way I'd consider it would be if I had a lot of ongoing health issues that needed monitoring. Right now I'm just fine with my primary care doc, my cardiologist, Urgent Care when needed and the usual preventative screenings.

 

[YB88]

I have something like that through a group called MDVIP. I'm not a super fan of the overall group, but my personal doctor and his office are fine. Fast to get an appointment, two physicals per year, one a more complete one than Medicare pays for. In my previous situation there wasn't anything really like a primary care doctor, I just saw whoever was available and waited weeks to do it, typically before then being referred to a specialist and then waited weeks or months for that.
Now that first step is quick, and I always see the same primary care doctor. I still can end up waiting a fair bit for specialists, but it's definitely better.

Worth the cost? That's got to vary by the individual, both in terms of how much they're willing to spend, and what their health situation is like. I figure that if this ever catches something significant earlier on, it will have been worth quite a bit of money.

No way to know for sure, but at least this way I get the convenience, and adds less stress to my life --- for example, the same friendly receptionist answers the phone immediately rather than me navigating an automated phone system seemingly designed to drive me away. I have an after-hours cell number to call if there's something dire, though this hasn't come up.

 

[marko]

I've had this for about 8 years now. Yes, you still need regular health insurance for hospital and specialists, but as I'm on Medicare, don't need any referrals. He was able to refer me before Medicare and had admitting privileges at my hospital.

The main difference is that my doctor can (and does) spend an hour with me if necessary. I can speak with him directly and get an appointment within a few hours.

Short story: he's just 1000 times more accessible if I need him.

 

[Tuirc]

If you had a disease that needed urgent specialists ( say cancer or heart disease that needed intervention to prevent permanent damage) you would need to get an insurance that would cover and probably a pcp in plan who can refer you to the specialists. I don’t believe you can pick up aca midyear without a qualifying event which you would not have and there is often a wait to see a pcp even if you could find one. Where I live it is hard to find new pcps. Sounds like a huge gamble.

Fair. We have a med school here in the city so docs are not a problem. When my wife got breast cancer, the whole cost was $40k. We only paid a fraction of that because of insurance, but against $75k-$100k of insurance for the ~3 year period, with ugly looking deductibles <shrug>. Not sure it's a "huge gamble" but it is a risk for sure. Certainly not something that makes sense for most people.

 

[Tuirc]

I've had this for about 8 years now. Yes, you still need regular health insurance for hospital and specialists, but as I'm on Medicare, don't need any referrals. He was able to refer me before Medicare and had admitting privileges at my hospital.

The main difference is that my doctor can (and does) spend an hour with me if necessary. I can speak with him directly and get an appointment within a few hours.

Short story: he's just 1000 times more accessible if I need him.

Thanks, this is info I was looking for. If I can find a reasonably priced catastrophic plan, I'd much prefer having that in my back pocket on the off chance I might need it over the next 3 years. How much that piece of mind is worth, not sure yet. I have a few months to noodle it through.

 

[Sarah S]

I am glad you live somewhere with easy pcp access. Having med schools doesn’t guarantee that. We have three med schools in Boston but available pcps are a rare breed here

 

[MichaelB]

This sounds like a concierge practice. Yes, you get access, and that can have value. You might also get someone who can help choose a specialist, and help guide when dealing with health issues that require specialist care.

I’ve long thought that the most important physician (and best value) is a good PCP. They are a disappearing species because their reimbursement is so low.

 

[Tuirc]

This sounds like a concierge practice. Yes, you get access, and that can have value. You might also get someone who can help choose a specialist, and help guide when dealing with health issues that require specialist care.

I’ve long thought that the most important physician (and best value) is a good PCP. They are a disappearing species because their reimbursement is so low.

Since this has come up a couple of times: distinguishing between a DCP and Concierge, I'll post this from their FAQ:

How is DPC different to concierge medicine?​

Concierge medicine clinics charge a membership fee, in addition to billing insurance companies. This is makes them significantly more expensive than DPC, as they have to allocate significant resources to billing services and interfacing with insurance companies. In addition to the higher membership fees, patients still have to pay insurance copay with every visit. Some, but not all concierge clinics may offer expensive but non-evidence-based treatments or tests to their patients, in order to increase their cash flow.

FYI: the monthly access for people over 27 years old is $129/mo. in this instance.

 

[RetiredAt55.5]

Two of my brothers got serious cancer diagnosis's years ago (May and November for brain and pancreatic cancer).

Both smoked, but were otherwise healthy and had no health issues.

Neither could've waited for the next years open enrollment to begin treatment. Fortunately both had good insurance.

It's a gamble to go without insurance altogether.

 

[TripleLindy]

If I can find a reasonably priced catastrophic plan, I'd much prefer having that in my back pocket on the off chance I might need it over the next 3 years.

I hope you have better luck than I did. Catastrophic plans were no less expensive that Bronze ACA plans in my area. Indemnity plans are just awful, with pre-existing condition exclusions and coverage caps. They dress up coverage and it looks like it might work, but then you do the math with a couple of things, like knee surgery, and you quickly realize that you’re only covered for a couple thousand dollars for a $30k procedure.

 

[engineernerd]

That's my understanding, you'd need either something like a catastrophic plan or decide to self insure. In this particular one, there is no drug coverage either. There are a few of these in our area and at least one does have an in-house pharmacy that is discounting drug costs as well.

The calculus for us is: we have to a little over 2.5 years (me) and 3.5 years (DW) to Medicare. We need to do Roth conversions in the same time period. We are healthy, not overweight, don't smoke, or take any kind of prescription drugs so do we get something like this and take the chance that the world doesn't fall in on us in the meantime? Or, do we pair this with a catastrophic plan (early reviews of this approach show that paradoxically, catastrophic plans look expensive too).

Some people have suggested that you do this, if something bad happens, you can always get an ACA plan (probably ok for disease, not good for accidents). Or, thinking another way about it, an ACA plan would cost between $75-$100 in that time period (not including continued skyrocketing prices), anything paid out of pocket less than that would still be a "deal." While lots of stuff costs more than that, lots also cost less than that.

Do NOT think of this as in any way a substitute for health insurance! I repeat, do NOT drop your insurance on any account! At least, not if you have significant attachable assets (e.g. taxable investment accounts).

In 2023 when spouse got appendicitis the hospital sent a bill to our insurance for, drumroll, $93,000 - to cover ONLY two nights in the hospital and less than an hour's use of the operating room. The surgeon's fee, lab tests, miscellaneous other charges were on top (but paled by comparison, just a few thousand total).

I don't know what insurance paid in the end, but boy were we glad it wasn't our job to negotiate with that hospital! We have a lot in taxable accounts so they could have taken a hard line with us and I don't know what we could have done to fight it.

 

[marko]

DCP is not in lieu of insurance! It is in addition to insurance.

You're paying for better, more attentive PCP care. That's all.

That the doctor doesn't take insurance doesn't mean that you still don't need it.

 

[walkinwood]

The calculus for us is: we have to a little over 2.5 years (me) and 3.5 years (DW) to Medicare. We need to do Roth conversions in the same time period. We are healthy, not overweight, don't smoke, or take any kind of prescription drugs so do we get something like this and take the chance that the world doesn't fall in on us in the meantime? Or, do we pair this with a catastrophic plan (early reviews of this approach show that paradoxically, catastrophic plans look expensive too).

I wouldn't risk a huge uninsured medical expense if I were in your shoes. You've worked hard to save, why take a chance just to save an additional few thousand $s? This amount of expense is peanuts compared to what you'll spend in your retired lifetime.

You're healthy & after Medicare starts, you still have ~10 years to do Roth Conversions.

If your ACA MAGI for the next 3.5 years gets you a subsidy, is it more cost effective to get a Bronze plan?

Why do you need a DPC if you're pretty healthy? Use Urgent Care if you can't get a quick enough appointment with your PCP or their team. (I assume your insurance has Urgent Care clinics in their network)

 

[Lorenzo]

As far as I can determine, if you have to buy insurance anyway, you're paying for overlapping services, because insurance that costs less because it only covers what the DPC does NOT cover seems impossible to find. When I was a kid, I recall my parents paying out of pocket each time we saw the doctor and for prescription medications, and the occasional major procedure or hospitalization was all they had ("catastrophic"?) insurance for. This model does not seem to exist anymore. Nowadays, "insurance" is no longer just insurance but also covers routine primary care. There seems to be increasing interest in insurance that covers everything BUT routine primary care, but I haven't found it offered.

 

[TripleLindy]

Why do you need a DPC if you're pretty healthy?

Exactly. I would think a DCP would help managing multiple, chronic conditions, but if healthy, why pay a subscription just to have access to primary care?

 

[Tuirc]

I wouldn't risk a huge uninsured medical expense if I were in your shoes. You've worked hard to save, why take a chance just to save an additional few thousand $s? This amount of expense is peanuts compared to what you'll spend in your retired lifetime.

You're healthy & after Medicare starts, you still have ~10 years to do Roth Conversions.

If your ACA MAGI for the next 3.5 years gets you a subsidy, is it more cost effective to get a Bronze plan?

Why do you need a DPC if you're pretty healthy? Use Urgent Care if you can't get a quick enough appointment with your PCP or their team. (I assume your insurance has Urgent Care clinics in their network)

There is no scenario where I get subsidies. I still have a 9 years of mortgage payments on a house in the city (as in it isn't cheap). Then throw another $12k on top of other expenses before we get to optional stuff like food. So, I'm at $57k before food and utilities. Don't get me wrong, I can afford it. I just don't like blowing $10s of thousands for nothing. No probable benefit. I'm positive I won't even sleep any better than the 6 hours I get now. Bronze plan with no subsidies for both of us is the $75k for 3 years number.

 

[TripleLindy]

you can always get an ACA plan (probably ok for disease, not good for accidents). Or, thinking another way about it, an ACA plan would cost between $75-$100 in that time period (not including continued skyrocketing prices), anything paid out of pocket less than that would still be a "deal." While lots of stuff costs more than that, lots also cost less than that.

Not true. You can only enroll during open enrollment, not any time you want. I’m not sure what you are referencing with the $75-$100 cost, but if that’s your monthly premium, it would be foolish to forgo health insurance to save ~$1k. And ACA plans cover accidents, so you’re getting some bad information.

 

[Tuirc]

As far as I can determine, if you have to buy insurance anyway, you're paying for overlapping services, because insurance that costs less because it only covers what the DPC does NOT cover seems impossible to find. When I was a kid, I recall my parents paying out of pocket each time we saw the doctor and for prescription medications, and the occasional major procedure or hospitalization was all they had ("catastrophic"?) insurance for. This model does not seem to exist anymore. Nowadays, "insurance" is no longer just insurance but also covers routine primary care. There seems to be increasing interest in insurance that covers everything BUT routine primary care, but I haven't found it offered.

Some states don't have an authorized catastrophic plan anymore. That was my state up until last year. They are now authorized. No plan would cover DPC, that's the whole point -- they don't take insurance. Therefore they don't need to include all the expenses associated with that and insurance companies don't control how they practice medicine. All part of the model. Catastrophic plans don't cover routine visits, that's part of their model. High deductible if you need it, so there is a consumer behavior part to it.

 

[Tuirc]

Not true. You can only enroll during open enrollment, not any time you want. I’m not sure what you are referencing with the $75-$100 cost, but if that’s your monthly premium, it would be foolish to forgo health insurance to save ~$1k. And ACA plans cover accidents, so you’re getting some bad information.

$75K - $100K low number bronze plan, high number silver plan for 3 years coverage that we'll need. The accident comment is if I was not covered by the ACA and I had an accident, it's not like I could just call them up and get covered. There's no world where that would work. That's what I meant.

 

[TripleLindy]

Bronze plan with no subsidies for both of us is the $75k for 3 years number.

Ok, now I get it. We’re faced with a similar situation, although quite a bit higher at $34k/year. But one serious event could cost many times that. Check out some of the ACA threads. Someone referred to health insurance as “wealth” insurance, which is the best description. We are also in very good health, but I’m not taking the risk of going nekkid on healthcare.

 

[Tuirc]

Ok, now I get it. We’re faced with a similar situation, although quite a bit higher at $34k/year. But one serious event could cost many times that. Check out some of the ACA threads. Someone referred to health insurance as “wealth” insurance, which is the best description. We are also in very good health, but I’m not taking the risk of going nekkid on healthcare.

At a burn rate of $100,000 every three years, you won't have to worry about being wealthy very long. Usually, I like to get something out of it if I'm going to spend that much on it.