Do direct primary care patients need insurance?

The direct primary care (DPC) model operates primarily on patient membership fees. Independent physicians in a DPC practice set their monthly fees based on several factors, including their income needs and, often, their patients’ ages and basic primary care needs. For example, a DPC practice might charge a different monthly fee for babies as it would for older adults.

Even though the independent physician in a DPC practice generally does not accept insurance for the basic services provided on a normal basis, DPC patients are sometimes encouraged to secure high deductible, catastrophic insurance for those services not covered under the monthly membership fee.

DPCs can be a positive solution for the uninsured to receive basic medical services; however, those catastrophic illnesses require additional treatment and the costs can be devastating for patients who do not have the appropriate insurance coverage.

The basic membership fee charged by a DPC practice covers almost all primary care services including clinical, laboratory, consultative services, care coordination, and comprehensive care management. In addition to direct care, many patients elect to acquire that high-deductible wraparound policy to cover the emergency care that is not covered under direct care.

A recent article in Business Insider describes the potential need for such insurance for DPC patients, using the example of car insurance: “You don’t use your car insurance for small transactions like oil changes, but it’s there for you if you get in a car accident. Likewise, health-insurance plans — especially those with high deductibles — can be there if you require healthcare beyond primary care.”

In addition, many DPC practices use hybrid models to combine elements of direct care and fee-for-service, and bill insurance in addition to contracting directly with patients. Hybrid practices are popular for physicians who want to continue to see insurance patients while also transforming their practice towards direct care. Providers interested in a hybrid model should consult legal counsel to make sure they are compliant with insurance regulations.