Making the middleman in medical insurance go away

Medical insurance is usually not a small-talk subject: Few find it interesting; even fewer know what they’re talking about.

But direct primary care, the new kid on the insurance block, may change that.  DPCs are gathering both professional and public interest, locally as well as nationally, as they provide an option to traditional insurance that both doctors and their patients find interesting. 

Similar to health-savings accounts, for which members pay a third-party a monthly amount to cover future medical expenses, and to retainers for professionals whose services one knows are going to be needed, DPCs establish a direct provider-user reimbursement route. In short, individuals pay a doctor a set subscription fee and as a result are entitled to a range of medical services without additional charge.

SPONSORED CONTENT

Business Cares: April 2024

In Colorado, 1 in 3 women, 1 in 3 men and 1 in 2 transgender individuals will experience an attempted or completed sexual assault in their lifetime. During April, we recognize Sexual Assault Awareness Month with the hopes of increasing conversations about this very important issue.

DPCs and providers

DPCs offer providers several advantages over traditional fee-for-service reimbursements: They receive, in advance, payment for their services; they can establish a direct relationship with the people they’re treating without having to deal with third-parties; and they don’t have to deal with having their clinical decisions questioned by non-medical personnel.  Also among the pluses is being able to see the patients they wish to, rather than being limited to people covered only by the particular insurance plans with which they have contracts.

The main DPC disadvantage for providers is unfamiliarity, among their peers as well as the public, with the concept.  A Medical Group Management Association survey in May of this year found that nearly 75 percent of the approximately 1,500 health providers who responded to the survey were unaware of the direct primary care model. 

Dr. Jan Hester of Fort Collins Caring For The Family noted that much of her time spent with patients involved educating them about the concept.  Hester, who opened her practice in 2004 and switched to the DPC model in 2016, said that she did so because traditional insurance is “challenging for both physicians and patients,” and because she feels that patients and employers “pay too much for health insurance instead of paying for health care.” Her practice is currently approximately 70 percent traditional insurance and 30 percent DPC, and the balance she feels will become weighted toward the latter as more people become aware of the DPC model. “The DPC continues to increase daily.”

Using this model, she emphasizes, allows her to provide wholesale prices for both prescriptions and laboratory work.  And a big additional plus is that her patients can reach her by e-mail, cellphone, or text, whenever they wish to without having to wait until regular office hours.

DPCs and consumers

DPC consumers find that they immediately know how much their medical care will cost instead of waiting, often months, for their insurers to determine what that cost will be.  They also can enjoy discounted prices on procedures and medications because doctors, not insurance companies, determine those costs.  Few doctors now know how much patients pay for their prescriptions.

However, the downsides of Direct Primary Care for consumers are few, but they’re not trivial.  First, direct primary care is exactly what its name says: It’s primary, and does not cover surgery nor hospitalization.  Second, the number of providers who offer this payment structure is limited.

Also, in Colorado, “DPCs are not regulated by the Division of Insurance,” said Peg Brown, chief deputy commissioner of that agency.  Should there be dissatisfaction, patients would have to turn to the Consumer Protection Agency since they would not have protection through the Division of Insurance.

Many types of health insurance

Knowledge of DPCs is still relatively limited, so it is often confused with concierge medicine.  Unlike that type of medicine, though, DPCs do not limit the number of “members” that can belong to their practices and, perhaps more importantly, they are an acceptable option under the Affordable Care Act for not having traditional medical insurance.

DPCs also differ from short-term medical insurance, the insurance “flavor” that provides temporary coverage during unexpected gaps.  Short-term policies usually don’t meet the minimum essential coverage required by the Affordable Care Act; therefore, being covered by a short-term plan may result in a tax penalty.  Additionally, short-term insurers can discriminate against applicants due to pre-existing conditions and/or health history; DPCs don’t.

Advocates of direct primary care believe the plans are a step for doctors and patients toward achieving the insured’s best health interest. 

“Health insurance”, said a health provider’s representative who asked to remain unnamed as she was not authorized to speak for her facility “is structured to be in the financial best interest of the insurer, not the insured”.

____________________________________________________________

Members of the Direct Primary Care Coalition

Nextera Healthcare
www.nexterahealthcare.com

North Vista Medical Center
4790 Table Mesa Drive., Suite 100
Boulder 80305

4943 State Highway 52, Suite 240
Dacono 80514

1006 Robertson St.
Fort Collins 80524

275 South Main St., Suite 201
Longmont 80501

Colorado Integrative Medical Center offering Nextera Healthcare
www.cointmedctr.com
2575 Park Lane #101b,
Lafayette 80026

Whole Family Healthcare of Longmont offering Nextera Healthcare
www.doctorvank.com
600 S. Airport Road, Building A, Suite 203
Longmont 80503​​

Hinman Family Practice offering Nextera Healthcare
Longmontfamilypractice.com
1350 Tulip St.
Longmont 80501​

Paladina Health
www.paladinahealth.com/find-clinic

Boulder Goose Creek Clinic
2880 Folsom St., Suite 104
Boulder 80304

Denver State Capital Clinic
230 East 13th Ave.
Denver 80203​​

Broomfield Interlocken Clinic
12202 Airport Way, Suite 170
Broomfield 80021​​

Denver 15th Street Clinic
1783 15th St.
Denver 80202​

Fort Collins Caring for the Family
1120 E Elizabeth St., G#1
Fort Collins 80524

Cloud Medical Center
www.cloudmedical.io

Lofts at the Peloton
38th & Arapahoe
Boulder 80301

Highland City Club
9th & Arapahoe
Boulder 80302

Prospect New Town
2017 One Hundred Year Party Court
Longmont 80504

Foothills Family Care, LLC
1032 Luke St., Suite 1
Fort Collins 80524

Balance Health
1709 61st Ave.
Greeley 80634

Source: Colorado Hospital Association