Frequently Asked Questions (FAQs)
What is “Direct Primary Care?
Direct Primary Care (DPC) is a model of practice that is growing in popularity with patients and doctors across the country. It is direct because the patient pays the doctor directly, and the doctor works for the patient directly, without the interference of insurance companies or government bureaucrats. In a DPC practice, the patient (or the patient’s employer) pays a monthly or annual subscription fee to the doctor’s office. In exchange, the doctor provides all services normally offered by a primary care physician at no extra charge (or with minor exceptions that are clearly spelled out). This benefits the patient because their health care costs are predictable, and they do not have to worry about feeling “nickelled and dimed” every time they go in for a visit. Their health care is already paid for. All they might pay is for medications, vaccines, all of which are provided at the doctor’s wholesale cost, with no additional mark-up. It provides unprecedented access to the doctor and staff. Unlike most other doctor’s offices, we are happy to answer simple questions by phone or e-mail, at no additional charge.
How is Direct Primary Care different from Concierge Medicine?
While there are a lot of similarities between DPC and concierge medicine, there are several key differences that make Direct Primary Care better for the patient. Annual DPC membership usually cost far less than concierge membership (usually $600 for DPC vs. $1500 or more for concierge). With a concierge practice, patients still must deal with co-payments, and all the other rules that insurance companies enforce to take as much of your money as they can, while at the same time paying as little as possible for the health care you deserve. Because DPC practices do not contract with insurance companies, the doctor cares about your needs, not insurance company rules. The term “concierge” has taken on a negative connotation as being very expensive and elitist. We are convinced that DPC provides a better level of service which is also more affordable. Some have started to call Direct Primary Care “Blue Collar Concierge Medicine.”
If I have insurance, why should I consider membership in a DPC practice?
Whether you have insurance through your employer, individually, or through the Obamacare exchange, membership in a DPC practice probably still makes good sense. Even when most people had insurance deductibles of $2000 or less per year, over 90% of patients never reached those deductibles, so they ended up paying almost all of their health care costs out of their own pocket. Now that deductibles are going up, often as high as $6000 per year for an individual, almost no one will reach their deductible, unless they have a major illness or accident. A family physician can take care of approximately 80-90% of most people’s medical problems. For an annual cost of $600/year, which may be only 10% of your deductible, we can handle up to 90% of your medical care. For every emergency room visit we prevent, we save our patients the equivalent of 2-5 years of subscription payments.
Is DPC qualify as insurance under the “Affordable Care Act” (aka Obamacare)?
A DPC membership is not insurance. It should be considered more like a personal service contract with your doctor. Only having a membership with our practice will not protect you from the Obamacare individual mandate tax/fine/penalty. We strongly recommend that our patients partner their DPC membership with a high deductible health insurance policy or a faith based health ministry sharing membership. (We can provide you with more information on this option.). The combination one of these arrangements and DPC membership should shield you from penalties. We also recommend the use of health saving accounts (HSAs) to bridge the gap to pay for services we cannot provide in our office, up to the point the high deductible is reached.
Can I pay for DPC membership with my health savings account?
That is a good question. While it makes perfect sense that HSA funds should be able to be used to pay your DPC doctor, there is nothing we can point to in the tax code saying that it is permissible. There are bills in front of the U.S. Congress to fix this oversight. Until they are passed, we recommend consulting your accountant or tax preparer.
Why don’t you take insurance anymore?
We are in the medical field to take care of people. Insurance regulations and Medicare laws were interfering with our ability to do this. Filling out paperwork and trying to keep up with all the bureaucratic rules were taking too much time from our time with our patients. We would rather work directly for our patients than any insurance company or bureaucrat.
How is this good for patients?
By taking the insurance companies and the government out of the doctor/patient relationship, the doctor works for you. You can rest assured that the choices we make for you about your care are not influenced by your insurance company or any other organization that could gain from you not getting what you need. We will be able to respond to your needs, not the demands of the insurance companies. We work for the benefit of the patient, not the stock holders of an insurance conglomerate. Your care can never be rationed if you are paying for it yourself.
For which patients will this work best?
This type of medical practice will benefit many different types of patients. Patients who have no insurance or patients who have high deductibles will probably spend much less money for medical care in this office. Patients who have PPOs (Preferred Provider Organization) who do not need referrals for care may or may not spend slightly more for care with us, we are confident that the level of service will more than make up for the financial cost. Patients with government insurance (Medicare/Tricare) will pay more. Again, we are sure that the service we offer will be worth it for most people. For patients who have HMOs with strict network restrictions, this may be a more difficult proposition if they require you to be seen by a doctor in the insurance company’s network to get referrals. The same is true for MaineCare patients because they require a doctor to accept MaineCare in order for them to refer patients to specialists.
Can I get reimbursed by the insurance company?
It is unlikely that any insurance company would reimburse you for our subscription fees.
Can I get reimbursed from Medicare?
The government has very strict rules about this. If a doctor has “opted out” of Medicare, he/she cannot submit bills to them for at least 2 years. Medicare patients must sign an acknowledgement of this, with the understanding that they are forbidden from asking for reimbursement for our office visits. This contract must be renewed every 2 years, unless the doctor agrees to start taking Medicare again. These rules apply only to services performed in our office.
I have Medicare; can you refer me to specialists? What about labs, X-rays, medicines and other supplies?
We can still refer you to specialists who take Medicare. We can also order medical services and supplies from vendors who accept Medicare (for oxygen, visiting nurses, physical therapy, medical equipment, etc.) We can order X-Rays, CT scans, MRIs, and other procedures, which are done outside our office. These should be covered under your insurance just like it always had been. The facility doing the test will bill your insurance company. Labs that we draw in our office that we send to an outside lab (cholesterol panels, liver and kidney functions, thyroid tests, blood counts, etc.) will also be covered by your insurance as before. Services that we provide in the office, such as EKGs, breathing tests, urine tests and finger prick blood tests will not be billed to your insurance and will be part of our bill to you. Prescriptions will be covered under your current insurance as before.
I have commercial insurance; can you refer me to specialists?
For patients who have PPO insurance, there is not usually a referral required. For people who have HMOs with very strict network requirements, we may not be able to do referrals for you because of their rules. We strongly recommend that you check with your insurance company to find out if this will present a problem or not.
Why don’t more doctors practice this way?
ALL of the doctors with whom we have talked before making our decision to change our practice are concerned about the future of medicine. Most are afraid of trying something new. The direct pay model has been working well in other parts of the country. We are proud to be the first practice in Maine to provide this service. Other doctors in Maine are following our lead.
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