There are many changes in health care, and physicians are making choices regarding their practice. Some key issues physicians face are managing a practice day to day operations in the ever-changing health care environment. They are also managing contracts and payments with insurance companies. Many physician groups are choosing alternative options like concierge medicine and Direct Primary Care (DPC).
Understanding the options will help you make smart decisions should you choose to participate in one of these plans. While it is true that DPC and concierge medicine may be viewed as the same, there are some unique differences to consider.
Direct Primary Care
Direct Primary Care (DPC) is when a practice does not accept insurance and charges a monthly fee for care. In most cases, it is a monthly basis, and members can choose to drop out at any time, although some groups may require a yearly contract.
An example of charges could be:
- Individuals 0-50, $60 a month
- Individuals 51 + years old, $85 a month
- Families $175 a month
There could be additional charges for house calls or business rates, confirm with your physician clinic.
An example of services offered:
- Unlimited visits with a physician
- Longer visits with a physician
- House calls
- Extended hours, weekends and holidays
- Telehealth options
- Annual physician and follow up care
- Discounted labs and prescriptions
Benefits:
- Lower patient population allowing more focus on you.
- Average primary care practice may have 4000-5500 patients. Direct primary care may have 400-500 patients.
- Easy scheduling and usually appointments within one to two days
- A personalized approach with more time and access to your primary care physician.
Be aware:
- Covers basic visits, some additional items may be out of pocket.
- A DPC is considered out of network; therefore, no insurance contracts. Should you need to be referred to a specialist, your DPC can recommend, but costs for a specialist would be out of pocket.
- In this case, carrying a lower premium High Deductible Health Plan (HDHP) may be an option to cover any unexpected costs and visits to specialists.
- Or investing in a Health Care Savings Account (HSA) to cover those unexpected costs
Scenario: You are a healthy individual, but in a routine visit with your DPC, a skin check and a suspect mole requires a visit to a dermatologist. After a consultation and biopsy, it is determined you need MOHS surgery to remove the mole.
- Your monthly fee to your DPC is $85
- Your consultation with a dermatologist self-pay is $100
- Mohs surgery is $2600
- Year-end you have paid $85 X 12 = $1,020 (yearly dues for DPC) + $2700 (MOHs and consultation) = $3720. Bear in mind if other one-off issues or chronic conditions or daily medications are required, the expenses above and beyond the monthly fees add up.
- Resource: to get estimated costs refer to Fair Health Consumer.org. A website that helps you evaluate your health care expenses.
My goal is to provide relevant data so you can make the best decision. An article by Direct Primary Care has Limited Benefits for Doctors and Patients.
Concierge Medicine
Concierge medicine has been around longer and has similarities to DPC. If you choose a concierge physician, there is usually an annual fee with a yearly contract.
An example of charges could be:
- Individuals 18-39, $1800 yearly
- Individuals 40-49 $2500 yearly
- Individuals 50+ $3500 yearly
- Couples over 50, $6000 yearly
Example of Services Offered:
- Comprehensive annual exam
- Lab testing and consultation review
- Easy access to physician including use of telehealth
- Coordination of care with specialists
Benefits:
- Easy access to care usually 24/7
- Easy scheduling and usually appointments within one to two days
- A personalized approach with more time and access to your primary care physician.
Be aware:
- Covers basic visits, some additional items may be out of pocket
- A concierge practice may also take health insurance should you decide to keep an HDHP plan for any services that fall outside the concierge services.
Scenario: You are a healthy individual, but in a routine visit with your concierge physician, there was a suspicious lump with additional tests and the need to see an oncologist.
- Your yearly fee for concierge medicine includes the care coordination with a specialist but not the cost of care.
- Your consultation with an oncologist self-pay is $175
- Tests and biopsies may run $3000
- If chemotherapy is needed, average cost monthly without insurance $40,000 and with insurance $11,000
- Year-end you have paid a yearly rate assuming 50+ = $3500 (yearly dues for concierge) + $11,000 (assuming you have an HDPH plan) = $14,500. Bear in mind if other one-off issues or chronic conditions or daily medications are required, the expenses above and beyond fees add up.
Benefits of concierge Medicine, Access: A Critical Benefit of Concierge Medicine
DPC and Concierge Medicine Comparison
| Factor | Direct Primary Care | Concierge Medicine |
| Membership Fee | Monthly, ability to drop out anytime | Annual fee with contract |
| Cost | Usually lower, sliding scale based on age | Usually higher, a sliding scale based on age may be offered |
| Insurance | Does not accept insurance | May still accept insurance for items not covered under yearly fee. |
| In-Network referrals (Specialists) | Out of Network | May refer to a specialist within your insurance’s network |
| Deductibles | Out of Network – annual fees cannot be applied to deductible | Annual fees cannot be applied. If provider is in network services such as copays or services paid out of pocket may be applied |
| Services | Comprehensive annual examLab testing and consultation reviewEasy access to physician including use of telehealth | Comprehensive annual examLab testing and consultation reviewEasy access to physician including use of telehealth |
| Patient Demographics | Does not accept Medicare and, typically younger patients | Usually 50+ retires |
| Viability | Newer model, still evolving | Around for 15 years, making changes consistently to address market needs. |
**Comparisons are typical and may vary based on your providers services provided under DPC or concierge.
Why choose DPC or Concierge Medicine?
- Ability to schedule an appointment within one to two days.
- Quality time with your physician for a comprehensive and total health plan.
- House calls
- Treat total health not just the symptoms