Because direct primary care is a relatively new take on healthcare, understanding the differences between DPC and the traditional primary care we’ve grown accustomed to is important, not only to see all the benefits of direct primary care, but also determine which option works best for you as a whole. This article will help better acquaint you with direct primary care and help you differentiate between direct and traditional healthcare.

What is Direct Primary Care?

Direct primary care (DPC) gives family physicians a meaningful alternative to fee-for-service insurance billing, typically by charging members a monthly, quarterly, or annual fee. This fee covers all or most of your primary care services including clinical and laboratory services, consultative services, care coordination, and comprehensive care management.

Because some services are not covered by a retainer, DPC practices often suggest that members acquire a high-deductible wraparound policy to cover emergencies, or another insurance alternative option that will protect members in the case of necessary surgeries, hospitalization or a large medical claim. Basically, the DPC concept is intended to take the practice of medicine back to its roots, where physicians were able to get to know their patients because they weren’t forced to practice within such tight time constraints now imposed by insurers. Direct primary care practices do not accept insurance of any kind, eliminating the associated red tape and allowing physicians to build rapport with each member.

What is Traditional Health Care?

Traditional health care (where health insurance pays for nearly all types of medical services and products) has been the standard in the US for almost a century. With traditional care, you see a physician, typically called your primary care doctor or general practitioner. They see you about everyday concerns, checkups and health issues. You may get assigned one without ever meeting them and most lower-income insurance plans don’t allow you to or make it very difficult to change doctors. 

Is Direct Primary Care Expensive?

On average, Direct Primary Care’s costs are lower than your traditional healthcare plans. This helps members feel more at ease when they visit their care provider and encourages members to seek out regular care rather than avoid seeing their doctor until something is wrong. 

Benefits of Direct Primary Care

Members get to Know Their Doctors

Americans value having a relationship with their doctors and want someone who knows their background and medical history. Younger generations also want more personalized healthcare, with 54 percent of millennials reporting they are or would like to follow their health care professional on social media. Direct primary care offers a kind of one on one service you just don’t get with traditional health care.

Clear Pricing and Billing

Because DPC doesn’t go through insurance, members pay a monthly fee that covers their costs, with no added fees. You won’t get shocked by a large bill with hidden fees like traditional healthcare has become notorious for. Monthly payments for DPC may change marginally over time, but members receive advanced notice before anything goes into effect. 

Better Member/Provider Relationship than Traditional Healthcare

The DPC model thrives off of the fact that members get more with their physicians. Getting more one-on-one time allows for better service, proactive care, and understanding and diagnosis of issues that may have otherwise gone unnoticed, leading to a deeper understanding of one’s health. As a result this empowers members to open up about their health concerns, improve communication in regards to those health concerns, and get better results as a result. 

Limitations of Direct Primary Care

Only Available for Primary Care

Direct Primary Care only covers your primary care needs — it is not comprehensive healthcare. If you need to see a specialist or require any type of surgery, for example, it will not be covered by DPC, and you will need to see specialists outside of the DPC system.

You Still Need Health Insurance

Though DPC doesn’t require health insurance for billing, it doesn’t completely negate the need for health insurance or a health insurance alternative, as stated above, it is only for primary care and may not cover more serious health care issues, events, or specialized procedures. 

Personalized Healthcare with You in Mind 

At Assurance Health & Counseling Center, we believe that you and your health are what matters most. Our membership plan grants our members unlimited access to our medical providers for one low flat monthly fee, which means no copays, no deductibles, no dealing with insurance requirements or regulations.

We also offer counseling to all members, as we believe in taking care of the whole person, body and mind. 

Contact us today and learn how a membership with us can help you live a happier, healthier life.

You can now drop / change or add a Medicare Advantage plan

For those who are wishing to keep their Direct Primary Care membership (like Assurance Healthcare & Counseling Center) with their medicare plans, our general recommendation (as of 2020) is to save your money and do not purchase a medicare advantage or supplement plan. Read our general medicare advice for more information on how supplemental plans don’t offer great value. Now is the time you can move away from your Medicare Advantage plan!

In general, a Medicare Advantage plan is going to be too limiting (especially in a place like Yakima, WA) to really care for you in a way that provides great access. The cost may be attractive, but it’s likely that the costs are low because they are limiting access to care in many ways. Most importantly, Assurance Healthcare & Counseling Center will not be able to make referrals for any members who are part of a Medicare Advantage plan, as we are not an ‘in-network’ primary care provider.

You can add or drop Part D now

If you would like to sign up for Part D (prescription coverage) because you haven’t yet, now is the time you may sign up.

Why sign up for Part D when Assurance offers such deep discounts on medications? Great question… while you may never need to use Part D, there may be some point in the future where Medicare will cover a prescription that we aren’t able to get inexpensively. Perhaps the most extreme scenario is with chemotherapy – an expensive treatment that Part D may cover, but Assurance cannot find at a discount. There are very affordable options for Part D – our best resource is Senior Solutions here in Yakima.

Adding or removing Part A or B

Open enrollment for Parts A & B are either of the following:

• Three months before your 65th birthday, the month of your 65th birthday, or the three months following your 65th birthday.
• Between January 1st and March 31st each year, in order to be active on July 1st of the same year.

If you delay enrolling into Medicare until after your 65th birthday, you may have to pay an increased premium.

For more information, read Medicare’s official website here.

For many school employees that choose to add family members to their health plan, this is likely a favorable change – at least financially. To those that choose a plan for only themselves, the benefits are likely less.

At Assurance Healthcare & Counseling Center, our goal in the future is to be able to be formally inserted into a state-wide plan like the SEBB plan, where individuals and families can choose to include a membership-based primary care doctor (direct primary care) as part of their overall plan. Direct Primary Care (DPC) plans have lowered overall health costs, helped improve health outcomes, and offer much better accessibility to health professionals.

But, for now, here is how we would help navigate these plans if you are a school employee in Yakima County…

What to Avoid: Kaiser Plans

All Kaiser plans are considered “Managed-care plans.” While the price is attractive, and some of the benefits may sound good, here are the facts:

• You HAVE to choose a primary care provider in their network. In large cities, this may not be a problem, but in Yakima County, the number of physicians accepting new patients from these plans is on the decline.
• These care plans are also very restrictive when it comes to specialty care, where they may not pay for any out-of-network specialist provider.

In short, steer clear of Kaiser plans – especially if you want to pair your plan with Assurance Healthcare & Counseling Center (or another DPC clinic).

Option 1: UMP High Deductible Health Plan

This is the one plan that offers a Health Savings Account (HSA) alongside the health insurance plan. Compared to our Option #2, this is only an extra $3 per month as an individual ($9 for a family), but the State will contribute $375 per year ($750 for couples / families) into an HSA account. This money can be applied towards your deductible or any other medical costs, and is yours for life.

Here’s the caveat…

There are exemptions to qualifying for this plan (at least for having the HSA account attached to it). One of them is:

“You are enrolled in another health plan that is not an IRS-qualified high-deductible health plan (HDHP)”

Directly from the SEBB Enrollment Guide

Nearly every other entity or law written recently about healthcare (the Department of Health, the Affordable Care Act, and more) has claimed that DPC is NOT a health plan (we’re not health insurance, nor are we trying to be). The IRS is the one entity that does not yet have a clear definition for DPC, and therefore is by default considering us a health plan. THIS COULD MEAN POSSIBLE DISQUALIFICATION FROM A HEALTH SAVINGS ACCOUNT.

There’s a possible change to this… but it is ‘possible’ – not definite. It came from the “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First” released on June 24th, 2019. In this executive order, President Trump writes,

“Within 180 days of the date of this order, the Secretary of the Treasury, to the extent consistent with law, shall propose regulations to treat expenses related to certain types of arrangements, potentially including direct primary care arrangements and healthcare sharing ministries, as eligible medical expenses under section 213(d) of title 26, United States Code.”

Sec. 6 (b), Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First, June 24, 2019

The key word is “potentially” – meaning that the Executive Order has recommended, but not demanded, that the Secretary of the Treasury include Direct Primary Care as an eligible medical expense under the IRS code written for Health Savings Accounts.

So, it’s possible that you could legally have a DPC membership AND and HSA account beginning on January 1st, 2020. Or, it might not be possible. But here’s the reality…

Who is going to know if you have both a DPC membership and an HSA account?

DPC clinics don’t report membership to any entity. You don’t have to disclose your DPC membership to your health plan. So it’s likely that you can have both, you just won’t be able to pay for your DPC membership with HSA monies. Not a huge deal in our opinion.

Option 2: Premera Standard PPO

At $22/month for an individual, this is a plan that makes financial sense, and will work well if you choose to pair with a DPC membership.

We won’t have any issues referring you out to specialists if we need to (we don’t refer out very much, because we do as much as we can in-house), and you’ll have something just in case something major happens.

Again – our job is to keep you away from expensive and unnecessary medicine. The job of health insurance should be to take care of you in case something major happens.

Have any questions? Contact us and we’d love to help!