Health Plans and Direct Primary Care: What You Need to Know

Direct Primary Care
Health plans

Understanding Direct Primary Care

Direct Primary Care (DPC) is a healthcare model that eliminates third-party insurance companies from the patient-physician relationship. Instead of billing an insurance company, DPC practices charge patients a monthly or annual fee. This fee typically covers unlimited primary care services, from preventive care to in-office procedures.

Traditional health care often involves copays, deductibles, and complex billing. In DPC, this complexity is stripped away, offering a more direct, streamlined approach to primary care.

Benefits of Direct Primary Care:

  • Direct Patient-Doctor Relationship: DPC promotes a personalized relationship between the patient and their primary care physician. Most DPCs offer both in person and virtual care.
  • Transparent Pricing: Patients understand exactly what they're paying for with no hidden fees.
  • Reduced Administrative Burden: Without insurance payer billing, DPC practices face less administrative overhead, leading to more patient-focused care and reduced doctor burnout.


  • Coverage Limitations: DPC fees cover primary health care, but patients might still need insurance reimbursement for specialist visits, hospitalizations, or medication. Medicare and Medicaid won't cover your membership fee for a direct primary care arrangement.
  • Upfront Costs: The monthly or annual fee might be a hurdle for some patients.
  • Paying Twice: Historically small employers who wanted to offer both DPC and traditional health plans to employees were "paying twice", since part of the cost for most traditional health plans covers traditional primary care. Decent builds small group health plans around DPC, helping the DPC act as the quarterback for the member's care in and out of the primary care setting.

The Role of Direct Care Providers

Direct care providers, be it a family physician or primary care provider, form the backbone of the DPC model. These physicians offer a range of medical services, often without additional costs beyond the membership fee.

Relationship with Patients: The patient-provider relationship in DPC is enhanced. With fewer patients overall, physicians can spend more time with each individual, leading to more comprehensive, personalized care.

Switching to DPC: Transitioning to a DPC practice might mean longer appointment times, more direct access to your primary care doctor, and a more preventive approach to healthcare.

Direct Care Medical Practices

Operation: DPC practices operate by charging a retainer or membership fee, usually monthly. This fee covers primary care services. Unlike concierge medicine, which often serves the luxury market with additional fees on top of the retainer, DPC offers transparent, all-inclusive pricing.

Available Services: Examples of medical services under DPC include annual check-ups, care coordination, urgent care visits, and some in-office procedures.

Choosing a DPC Practice: When looking for a DPC practice, consider factors like the range of services offered, fee structure, and patient testimonials. Ensure they can meet your medical care needs and offer the direct, personalized attention that defines DPC.

What to Consider Before Adopting Direct Primary Care

Before diving into DPC, evaluate your health needs. If you see a primary care doctor often and desire a direct relationship without insurance company interference, DPC might be for you. However, you'd still need insurance for broader healthcare coverage.

Questions to Ask:

  • What services are included in the membership fee?
  • How does the practice handle referrals to specialists or hospitals?
  • Is my DPC integrated in a health plan or health share?

(Note: Most patients can't currently use HSA funds for DPC fees, but always check current HSA guidelines.)

Financial Implications: Though DPC fees are upfront, they can lead to long-term savings, especially when considering the reduced need for co-pays, deductibles, and surprise medical bills. Employers who want to pair a DPC membership with a high-deductible health plan (HDHP) and a Health Savings Account (HSA) should check the status of IRS regulations related to the Affordable Care Act that govern the potential use of DPC with an HDHP.

Addressing Frequent Questions:

  • DPC vs. Concierge Medicine: While both models offer direct patient-doctor relationships, concierge medicine often has additional costs beyond the retainer, targeting a more luxury market. DPC's focus is on affordability and transparency.
  • Types of Primary Care: The three main types are Family Medicine (general care for all ages), Internal Medicine (focused on adults), and Pediatrics (focused on children).
  • Is DPC Worth It?: This depends on individual needs. If you value personalized care, transparent pricing, and dislike dealing with insurers, DPC is likely worth it. However, it's essential to consider the full spectrum of your healthcare needs, as well as your health plan type (especially given regulations around an HDHP).
  • Number of DPC Practices in the US: While the exact number evolves, thousands of DPC practices operate across the US, with many more expected as the model continues to gain popularity.

Direct Primary Care in Small Group Health Plans

Historically DPC has only been available in large group plans or paired with a health share (not insurance). DPC can now integrate into small group health plans via Decent, offering employers an alternative to traditional insurance.

Case Studies: Several large businesses have documented savings, improved patient satisfaction, and decreased hospital visits when adopting plans that include DPC.

Cost and Benefits: In general, plans that include DPC can offer cost savings over traditional plans, especially when considering reduced administrative costs and insurance fees.

The DPC model offers a unique approach, transforming the patient-doctor relationship and simplifying healthcare billing. If you're considering a health plan with integrated DPC, research practices in your area and weigh the benefits against your specific health needs. As always, for more in-depth questions, contact a healthcare professional or primary care provider in the DPC field.

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