Somewhere along the line, we began thinking that all of our healthcare had to be “covered” by insurance – quick visits with your doctor, preventative care, routine medications, and the like. Overnight, health insurance became thought of as a necessary means to access healthcare.
If you’re wondering why “covered” is in quotation marks, it’s because “covered” doesn’t necessarily mean “paid for”. Most people don’t meet their deductible each year, so they usually pay quite a bit (sometimes all) of their medical bills, especially for primary care. Common examples are visits and testing for acute and chronic illness like respiratory infections and medication checks. Although these are technically “covered” by insurance, according to insurance-speak, most people pay the full amount in two payments (copay and balance bill) because they haven’t yet met their deductible.
Instead of assuming having insurance is less expensive, take a pause and consider your options for high quality primary care that not only increases access to your doctor, but also can provide substantial cost savings for you, the patient, even if your employer pays your insurance premium.
Direct Primary Care (DPC), which allows you to have a direct financial relationship with your doctor, is an option. For the equivalent of (or even less than) your monthly cell phone bill, you can receive comprehensive direct primary health care services and testing, from your annual exam to stitching up your child’s finger, and everything in between, all done less expensively because the middlemen aren’t there. It’s a more traditional approach to the patient-doctor relationship – think old fashioned general practitioner who knows you well, isn’t too busy, and isn’t expensive – a model that embraces the simplicity of an affordable, transparent direct payment, before all the complexity came along.
With DPC, due to the transparent and simplified cost structure, we can tell you the costs for all primary care health services up front. Physician services are included in membership. When testing, there are no surprises, but rather a set cost for labs, procedures, etc. For example, routine labs (blood sugar, CBC, metabolic profile, cholesterol, thyroid labs) are only $5-10 per test, that alone is a huge cost savings when you look at the hundreds of dollars in deductibles paid through insurance for routine labs.
It can be difficult to understand the cost breakdown of healthcare through insurance. Even if your employer pays your whole premium, you still have co-pays, deductibles, and co-insurance that are coming out of your pocket. Most people assume it’s less expensive to have insurance for primary care, but that’s not necessarily true. Even if you see your doctor only a few times a year, you’re probably paying more out of pocket with insurance than you would be with a DPC membership.
A helpful exercise to gauge the potential cost savings and to see if DPC is right for you and/or your family is to consider how it measures up to a conventional high deductible insurance plan.
You can do this dollar for dollar to look at your total out of pocket expenses for a typical primary care visit.
Click below to view a side-by-side service and cost comparison for a “Dawn” a 55 year old patient with a Conventional High Deductible Plan compared to a Table Health Primary Membership (DPC) services.
In network PCP $2,000 deductible per individual $4000 per family
Only preventative visits (annual physicals and well child checks) are covered by this plan. All other medical visits patient will pay out of pocket until deductible is met and then the services will be covered at 80%. In this example the 55 year old patient pays $25 a month for the high deductible plan.
COMPARISON: WHAT’S INCLUDED
- No deductible to meet
- No copay
- ALL MEDICAL VISITS INCLUDED in your monthly fee
- Select medications and discounted labs.
- The monthly fee for a 55 year old is $67 per month (less for a younger person)
In network PCP $2,000 deductible per individual, $4000 per family
Only the annual exam and certain tests (physicals and well child checks) are paid for by this plan. Other diagnoses and tests (which may come up during the annual visit) are not paid for. All other medical visits and tests the patient will pay out of pocket until the deductible is met.
In this example the 55 year old patient pays $25 a month for the high deductible plan through payroll deduction.
Dr. Visit 1
Complicated Respiratory Infection: Consult and Prescription
- 30 min visit $0
- Z Pack Antibiotic $0 (get it in-office, no need to go to the pharmacy)
- All included in the monthly membership fee.
- Cash pay for 15 min office visit *$138
- Z Pack Antibiotic $8 (Good Rx)
- Total: $146
Dr. Visit 2
Type 2 Diabetes Checkup, Testing & Prescription
- 45 min office visit which includes diabetic diet and lifestyle education $0
- A1C $5.46
- Lipids $6.54
- Basic Metabolic Panel $3.35
- Medication – Metformin $0 per month
- All included or heavily discounted in the monthly membership fee.
- 30 min office visit repeated every 6 months $0
- Medication monthly $0
- Labs every 6 months $0
- Year Total: $50.70*
*includes $10 lab draw fee
- 15 min office visit $208
- A1C $81
- Lipids $24
- Basic Metabolic Panel $118
- Medication – Metformin $15
- Office visit repeated every 6 months = $276 (follow up visits are less expensive)
- Medication monthly $195
- Labs every 6 months $446.
- Total: $917
Dr. Visit 3
Cut your finger cooking dinner.
- Your DPC doctor is on call for you 24/7. They meet you at the clinic within 30 minutes.
- Evaluation and repair of laceration $0
- Total Cost for laceration: $0
- The on call provider for your PCP office sends you to urgent care.
- Average urgent care visit is $150
- Average cost of stitches for minor
- laceration $150
- Total Cost for laceration $300
Total out of pocket payment for Primary Care related services
In one year you paid:
- $300 for your high deductible plan
- $964 for your Direct Primary Care membership, including your sign up fee.
DPC option SAVED you $399 in one year on medical expenses, plus you received wellness services and coaching from your doctor
In one year you paid $300 for your high deductible insurance plan and paid an ADDITIONAL $1,363 in services not covered by your high deductible plan.
Total Year Expenses: $1,663
*Average cost for Office or other outpatient visit for the evaluation and management of an established patient, cpt code 99213 is $138 2018.
Ask yourself the following questions:
- How much do I have to pay in my deductible before primary care is paid for by my plan*?
- What are my copays?
- What is the out of pocket cost if I need to go to urgent care?
*The word ‘covered’ doesn’t mean ‘paid for’. It means the provider and the insurance company have contracted a certain price for this service. “Covered” does not mean the insurance will pay for the service.
Many times, DPC patients are saving money and time without even realizing it. For example, DPC patients benefit from same day appointments as well as routine options to access their doctor (even after hours) via phone, telehealth, or portal.. This added convenience also allows for less time off of work so you’re not wasting PTO, seeking childcare, etc.
All of this is shared to give you more information to consider when deciding if DPC is the right choice for you and your family. A common misconception is that DPC doesn’t work with insurance. That’s not the case at all. In fact, DPC can work extremely well with or without insurance. Although Table Health does not accept insurance, we do recommend it, but more as a necessity for an emergency or catastrophic care, not for primary care.