Direct Primary Care really is that easy. It's a "Progressive" way to get your primary care.
We’ll see how long until Progressive gets mad at us for using this. Until then, feel free to share. Send it to family. Whatever. We hope you get a chuckle out of it as well.
Courtesy of DPCNews.com.
The short and sweet of it is that HMOs are very restrictive and want you to remain in their “network” - which means you need a Primary Care Physician who participates in the network with them. Such a physician has signed paperwork saying they will follow the insurance companies rules, only refer you where the insurance company says, and receive payment when they bill your insurance of a set rate.
On the other hand, PPOs are flexible. They allow you to go “out-of-network” - including not only any specialist you’d like to see but also any primary care doc! That’s why we encourage patients to check their insurance plan before joining our practice. If your plan is an HMO, it lets us (as out-of-network doctors) to care for you as you and we see fit. The gist is that we can see you, you can see who you want, and we are only paid by your monthly membership fee to be part of the practice.
If you’re a patient who has lots of specialists and needs help with coordination, likes the idea of a doctor who is not “on the hook” with the insurance companies, or just plain likes the idea that you can choose who you’d like to see - a PPO plan alongside a DPC doctor - like us at Balanced Physician Care! - might be the perfect match for you. And no it's not paying twice for healthcare, we think it’s making a smart choice for your health! For more on how we practice primary care differently in Jacksonville, FL, check us out at BalancedPhysicianCare.com
TRICARE is an incredible benefit for members of the armed services and retirees, and a couple of its versions work exceptionally well with a Balanced Physician Care membership. The ability to get lab and imaging tests as well as some specialty care directly from the base means you can get the best of both worlds.
TRICARE Select (formerly TRICARE Standard) is a version that has small enrollment fee (like a premium) of $12.50 per month ($250 annually) individual and $25 per month ($300 annually) for a family
enrollment fee is waived if you’re:
A 20% cost-sharing (also known as co-insurance) for charges incurred outside of the “direct” system. Direct means you’re getting care, tests, or prescriptions directly from the military clinic. Pairing your Select plan with a direct primary care membership means you get fantastic, easy-to-access primary care for an affordable cost. No worries about getting in to be seen the day you call, and you’ll see your doctor when you do. Labs, imaging tests, and prescriptions can still be done at the base at no cost. If you need care that neither the membership nor the military clinic can provide, we work to make sure you know what something is going to cost before you go.
TRICARE for Life is essentially second-payer coverage for Medicare for people 65+ or otherwise eligible for Medicare. It also works great with a Balanced Physician Care membership for the same reasons is works for TRICARE Select — affordable access to your doctor when you need it AND the ability to get tests and prescriptions from the base. We appreciate your service.
Unfortunately, Prime doesn’t work quite so well with a Balanced Physician Care membership. Prime functions like a “health maintenance organization” (whatever that is), which limits Balanced Physician Care’s ability to do referrals. It’s still an option, but you’d basically just have to operate outside the system.
The bottom line is that TRICARE Select and TRICARE for Life work great with a Balanced Physician Care membership — the relationship, access, and value we provide in our clinic combined with the ability to still get tests, medications, and specialty care at the base at no additional cost!
To learn more about the membership options at Balanced Physician Care. Visit our membership page
Direct Primary Care makes complete sense as a concept. In the real world, of course, it’s a bit more messy and complicated, especially within the confines of an employer’s health plan, and finding the right pathway to achieve the desired results is sometimes tricky. Replacing the traditional entry point to a health care journey with a higher-performing primary care partner sounds ideal, up until the point when personal preferences and emotional bonds prove larger barriers than originally expected.
The main arguments against the traditional primary care pathway include:
The main value-propositions heralded by the DPC provider often include:
So, yes, it’s easy to see how the employer or consumer starts to recognize the advantages of this strategy. If the employer shifts their money from paying for services and instead moves that investment into a direct primary care relationship, their employees should get better care through a relationship with a provider who is compensated to focus more time on their employees and have fewer upstream referrals for testing and specialist interventions.
There are several factors that determine whether the membership fees that a direct primary care practice receives are paid on an invoice basis to the employer, or whether their health plan administrator or TPA will make that payment.
Fully insured scenarios
The first and easiest distinction is the fully insured health insurance plan and its relationship to DPC practices. This one is simple: There isn’t a relationship. The DPC practice has rejected the traditional fully insured plan and built a practice where that relationship is predominately viewed as toxic and unhealthy for the patient and the provider. If an employer wants to establish a DPC relationship for their employees and the employees’ family members, this is a “bolt-on” option. The employer will either pay a monthly invoice for the membership fees, or the employees will pay directly and get a reimbursement from their employer.
Now, if you’re wondering, “Why would an employer pay extra for a DPC membership on top of their high-cost health care?” you are not alone.
I asked Dr. James Pinckney of Diamond Physicians in Dallas about this during my very early investigation into DPC in my local community. His response was simple: It’s about access and providing a huge benefit. His clients who were doing this were looking to provide an unparalleled benefit, and this was a simple way to do so while showing interest in the wellness aspect of their employees’ lives through the DPC memberships.
Most brokers I’ve spoken with who have this arrangement often use a high-deductible plan as the insurance vehicle for these arrangements, either because they need to save some money on the insurance to finance the DPC investment, or because the client already had an HDHP and needed to find a solution to address the perceived barrier to care that the health plan’s deductible was creating in the minds of their employees.
Self-insured or level-funded scenarios
The self-insured health plan is a much easier vehicle to customize with a built-in DPC option. When working with a plan’s administrator, you can typically arrange a per member per month fee to be invoiced to the employer and then submitted to the DPC practice, or you can define how the membership will be paid from the plan’s claims funds each month.
Of course, the real world is more complex than that made it sound.
Not all self-funded or level-funded plan administrators are adaptable. Some will simply have a set number of plan designs and pre-set protocols that they can’t and shouldn’t deviate from due to their operations. Others will give great lip-service to the concept and promise to accommodate, then utterly fail when it comes to execution or implementation.
To be fair, this is still a new process and hasn’t yet been adopted by the masses. Thus, most are learning with us as we go. And a plan administrator that can’t coordinate the monthly membership fees shouldn’t be a deal-breaker. Most DPC practices actually prefer to receive their payments directly from the employer group. Running a DPC arrangement as a bolt-on solution is not a horrible outcome, even with a self-funded plan.
I talked to Josh Butler of Butler Benefits about his experience with the bolt-on approach as the purest relationship for the employer and the DPC practice. “I’ve seen two mindsets from our employers. They either want to work directly with the DPC providers and form a deeper partnership with them, or they want to see the health plan take care of the tactical aspects of the provider relationship.” When I asked him which he saw driving better results, he said, “What kind of question is that? You know the employer that gets their hands dirty finds the gold.”
But, there is still great upside potential in the self- and level-funded arenas for the DPC arrangement to take hold and multiply.
For one thing, upfront cost reductions are possible here. Some stop-loss vendors will give discounts for a plan that uses a DPC solution. I’ve seen quotes that reduced insurance costs in the $25 to $40 per member per month range, and I’ve heard from peers about even higher per employee savings.
Coupling this fixed cost savings with the plan’s year-round performance through reduced upstream costs each time a member avoids unnecessary or overpriced care should be sweet music to the employer’s ears.
Prescription costs are another area of concern for the self-funded health plan, and monitoring the prescription usage before and after implementing a DPC strategy can help shed light on the greater potential of this relationship. Prescription usage will obviously be a slower impact item, but having that higher engagement and the anecdotal data that most DPCs gather after blunt conversations about the cost of care and the cost of prescriptions will inevitably begin to assist the plan’s performance in this area.
Inevitably, the actual implementation will be some variation or expansion on the simple DPC arrangement. There will be an adjustment to the concept based on discussions that arise with the employer and their leadership team. There will also likely be adjustments once all parties review prices from various DPC vendors and after employees provide their feedback.
More than one DPC vendor
You will need to be prepared to address the impact of geographical regions, which could include discussing a 20-minute drive across one city, a two-hour commute between different counties in the same state, or even coverage across multiple states.
Some DPC practices have grown their own geographical footprints to meet the needs of the customers they currently serve through hiring; some of those practices will also extend their billing and administrative services to other independent DPC practices to create a seamless experience for the employer group, while not having to own and staff a new region.
And there are software services that can leverage existing relationships to create custom networks of DPC practices. These services have really started refining their deployment, and while these services typically add expense to the setup and administration, the flexibility for a multi-location employer to deploy a DPC solution without spending the time to create individual relationships or band-aid geographic holes can be a huge value for the right clients.
Sharing DPC costs with the employee
This is where we come back to the built-in or bolt-on conversation. This is really a moot point in the built-in scenario when the plan or TPA administers the membership fees, and the employer has bundled everything into the traditional payroll deduction scenario. But, in the “bolt-on” or separate enrollment and billing scenario, things get more interesting.
Tom DiLiegro of Benefits Advisors of South Charleston has seen the full spectrum. “When the employer understands the impact and the savings at stake, they immediately want to pay for the membership fees in full. Once they start to consider employees who don’t go for routine care today, they start down the slippery slope of not wanting to pay for medical care on behalf of employees who don’t receive care today. Inevitably, they end up with a 75%/25% cost-sharing or 100% cost-sharing for a limited time, but then reduce or remove the employer portion of the DPC for those employees who don’t have their first visit within a set number of months into the new DPC arrangement.”
DPC and VDPC options and combinations
All DPCs have virtual care covered in their memberships; that is one of their main value propositions. Some even give price breaks for a virtual-only membership. But the emergence of 100% virtual primary care practices and the expansion of services offered by telemedicine solutions is going to be central to any DPC conversation.
My personal experience has been predominantly with the DPC/VDPC combination using two different vendors. The structure is to use a DPC for those in a reasonable geographical location, and a virtual-only vendor for employees who live in a region without a feasible DPC relationship, or a region without enough employees to establish a company-paid membership with a DPC provider. This isn’t always the solution that the DPC partner prefers, but the price point on these arrangements is often more palatable for the employer groups and the VDPC vendors are often easier for the employer to deploy.
Sherpaa founder and CEO Jay Parkinson’s prediction that care will be “primarily online and strategically in person” is increasingly likely and occurring a little quicker than even he expected when he offered this as a central theme to a talk he delivered in February 2020.
So many hurdles, shifting scenarios, and uncertainties beg the question: Are the results worth the time, effort and money?
This is about a journey in pursuit of a different result. When an employer, advisor or individual wants a reset on their health care expenditure, they need to try a new path. Whether the first step is a DPC arrangement, a virtual DPC, or even contracting directly with a traditional practice willing to perform in a more attentive and high-value manner similar to the ACO model, a new pathway that starts with primary care is a sensible place to start.
Savings might occur immediately, in year three, or might never be realized, but anything strategically done to lower costs and improve the health of a workforce has to be considered worthwhile.
Want to learn more about Direct Primary Care for your business? Visit our dedicated employer page - www.HealthcareforJax.com
At Balanced Physician Care we often have patients who are confused about whether we can be their child’s doctor too. As Family Physicians, trained in Family Medicine, we are able to take care of kids too! Sharyl Truty MD trained at Loyola Stritch School of Medicine and had lots of Pediatric patients at ParkWest Family Physicians and Seton Family Health Center in Chicago, IL.
Family Doctors, in general, tend to be more focused on "outpatient medicine". This means that for adults and children, our training is much more focused on things that happen to you outside of the hospital, and a bit less focused on hospital-related issues (as compared to Internal Medicine adult doctors and Pediatric doctors who spend more time training inside the hospital on “inpatient medicine” during their residency). Therefore, we are well equipped to see your children in our office for well child checkups, vaccinations, sick visits, chronic illness care, and everything in between!
We work with Pediatric Specialists - i.e. trained in Allergy Medicine, Cardiology, or Endocrinology, to name a few - when needed for pediatric patients who have issues that are beyond our scope of training. That allows us to work alongside experts in specific medical diagnoses to help ensure our patients have the best care possible.
Just like all of our adult patients, our pediatric patients (who range in age from newborn to teenager), get the same treatment that all Balanced Physician Care patients are accustomed to. This includes same day acute office visits for illnesses and unlimited access by phone/Zoom/email directly to your doctor. Kids will never have to wait in a crowded waiting room full of sick kids at Balanced Physician Care.
The most valuable service we offer to parents of pediatric patients is the peace of mind of knowing that we are always no more than a phone call or text message away. So, if your child wakes up in the middle of the night with a high fever or your daycare sends them home with the request for a doctor’s visit, you will be able to reach your child’s doctor immediately. To find out more about our family plans at Balanced Physician Care - that includes our pediatric care - check out our membership page
With health care costs on the rise, a growing number of Americans are throwing out the old way of seeing a doctor and turning to a membership model. A monthly or annual fee gets you direct access to a doctor, no insurance needed.
Balanced Physician Care is a membership-based primary care practice located in Ponte Vedra Beach, Florida. Please give us a call at 904-930-4774 for more information.
Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. Patients have extraordinary access to a physician of their choice, often for as little as $69 per month, and physicians are accountable first and foremost their patients. DPC is embraced by health policymakers on the left and right and creates happy patients and happy doctors all over the country!
Better Health Outcomes
Patients achieve superior health outcomes with Direct Primary Care's innovative service delivery. DPCs provide better access to physicians, empower an authentic therapeutic relationship, and comprehensive patient care.
Affordable, transparent costs based on a periodic overall flat rate (i.e. membership or subscription). Patients pay for their care directly to the physician. No third parties or Fee for Service billing ("FFS") to inflate costs. Most DPC memberships/subscriptions cost less than the average cell phone bill.
Enhanced Patient Experience
Patients receive unrestrictive access to their healthcare provider, report little to no wait time, and longer appointments (in person, virtually, or phone). In turn, creating a real therapeutic relationship between patient and provider.
Your average physician’s office cannot accommodate the needs of the 2000+ patients that they have per doctor in the normal day. If the doctor is full or not in the office that day, they will often either recommend that you come in and see a non-physician practitioner or go to the local urgent care where you can walk-in anytime you need it.
At Direct Primary Care practices, like Balanced Physician Care, we do our best to be available to our members when you need it. 24/7, 365 days a year we can be sure to get back to you when you have an urgent need. Our members email or call our after-hours phone number when they have an urgent concern and they hear back from their doctor directly within hours (and usually within minutes!). When scheduling allows and the need requires an in-person assessment or treatment, their doctor directly schedules them to come in for what they need.
We keep our panel of patients to under 600 patients with 2 providers, unlike the national average in a regular Fee-For-Service practice of 1000s per provider. This lets us be sure we can offer what we’re recommending to patients without long wait times on hold with a receptionist. We call, email, or message our members back directly and we arrange their urgent visit when needed. We can also handle many urgent requests remotely (i.e. that annoying UTI is back and you need the antibiotic again - you don’t have to have a visit!).
To find out more about how direct our care works and how Balanced Physician Care practices it, give us a call at 904-930-4774
The DPC Coalition and American Academy of Family Physicians spent two years in collaboration with Milliman and the Society of Actuaries on a comprehensive evaluation of Direct Primary Care (DPC) as a growing health care delivery and financing model. The full report was published last week by the Society of Actuaries as a part of their ongoing research on health care cost trends. The Society of Actuaries report shows how the new and growing DPC financing and delivery model provides an alternative to traditional fee-for-service-based primary care, improving the patient-doctor relationship, reducing the fragmentation of patient care, as well as personal and professional satisfaction for PCPs.
This important research shines new actuarially sound light on how DPC generates system wide reductions in unnecessary health care utilization such as hospitalization, emergency department usage, radiology and certain diagnostics, and specialist care, leading to broad-based health care cost savings. “Primary care physicians (PCPs) are the front line of health care,” the report concludes. “How often a patient accesses primary care, and the quality of that care, can have significant impacts on downstream costs and patient health outcomes.” However, the study concludes, “while PCPs are almost universally acknowledged as essential to achieving the health care Triple Aim of providing high-quality care, at lower cost,” the current state of primary care as being in crisis characterized by physician burnout, large patient panels, and low pay for PCPs relative to other physician specialties with increased administrative burden and longer work hours. Key data points:
Virtual Care and Telehealth are at the core of DPC service offerings:
99% of all DPC practices surveyed were doing virtual consults via text/phone as a part of the membership fee (two years prior to COVID-19).
88% said they provided “telemedicine” benefits (meaning expanded video or additional digital communications assets).
Enrollment in DPC is associated with a reduction in overall member demand for health care services outside primary care:
DPC members had 19.90% lower claim costs for employers on an unadjusted basis and 12.64% lower claim costs on a risk-adjusted basis during the two-year period.
DPC members experienced approximately 40% fewer ER visits that those in traditional plans.
DPC members experienced a 53.6% reduction in ER claims cost.
DPC members experienced 25.54% lower hospital admissions on an unadjusted basis. While this figure may have statistically variance, it validates previous research trends showing a reduction in the use of hospitalization and more complex specialty care by DPC members.
DPC is Affordable Primary Care:
The average adult monthly DPC Fee is $73.92. (DPC fees are paid on a monthly subscription basis).
Concierge patients enrolled in an MDVIP membership pay an annual membership fee ranging from $1,650 to $2,200; MDVIP also bills third-party payers for all services provided to members.
The median age for DPC patient was 31.8 years old, v. 36.1 for traditional insured (PPO). The survey finds the member mix did not vary materially between the DPC option and traditional option.
*article is courtesy of DPC Coalition
