Using Direct Primary Care Doctors

benenglish · Feb 23, 2020

From another thread:

TX OMFS said:
If you're self insured a direct primary care doctor (DPC) is the best thing going.

I once had a primary that I liked and she changed her business model to something conceptually similar. The difference was that she charged a $2000 (or was it $3000?) initiation fee at the first visit. Yes, it would be a 3 to 4 hour visit where she personally took an extensive history but it was still multiple thousands of dollars to get started then it was something like $200/month after that. She would have nothing to do with insurance. The care was top-flight but I just couldn't stay with her when her prices went that high.

Now you're pointing out practices that do something similar at reasonable prices. Since I'm without a primary at this time, I'm intrigued.

Do those business models merge well with folks who have insurance? For example, I have good insurance so labs (Well, anything that Quest can do.) are free to me and specialists may be seen without referral at affordable costs. However, using insurance for my primary care is a pain. They're always rushed and they never get a chance to get to know me since they're always trying to get through as many patients per hour as the insurance companies say they should. I've spent years in massive frustration over the fact that I can assemble a team of excellent specialists but I just can't find a primary in whom I have confidence to quarterback the whole shebang.

I could see combining the two approaches but I'm wondering if there's some sort of gotcha that might prevent that from being workable.

rotor · Feb 23, 2020

These concierge medical practices may sound good as long as you don't need to go into a hospital or have any lab or x-ray that is not in their group. For example, on exam they find a hernia. You need surgery. Not covered and you will pay the most expensive price as a cash paying patient. When you have insurance there is a contracted rate (Blue Cross is always the lowest rate- medicare is lower but 65+) and that's the maximum you will pay. No insurance and you likely will pay 5 times as much. Let's say you are on medicare but your concierge doctor is not on medicare, any lab or x-ray he/she orders will not be covered at all by medicare. Let's say you have a heart attack. More than likely your concierge doctor doesn't have hospital privileges and will NOT be seeing you or caring for you in the hospital.

I personally like the idea of concierge ( I am on medicare ) but if I use a concierge doctor not signed on medicare everything he/she orders I will have to pay for out of pocket including all meds, labs, radiology, surgery and whatever else. For my pets it is fee for service, one stop at the vets office, out of pocket and all is fixed. But it is unlikely that your concierge doctor is able to fix your hernia. Therefore you will be paying lots for that fix. If you are a rich person none of this matters and you can just hire a doctor for 24/7 care and not worry about it. I am sure Mike Bloomberg is not using medicare.

TX OMFS · Feb 23, 2020

I have insurance too and my DPC doc will send the lab orders anywhere, including Quest, but for the $3 or $5 she charges I just go through her.

I get plenty of time w/ Dr. Navejar & unlimited access & visits for the $60 or so I pay a month. I paid for a year &, IFRC, got a small discount for doing so.

The model your doctor switched to, Ben, is call concierge & is different. Mainly it's more expensive and may include house calls. Otherwise, I have never seen the advantage of concierge over DPC.

Last year I had an endoscopy & paid cash instead of going through my insurance. I would have spent about $3k out of pocket with insurance. Using cash I spent about half that.

ZX9RCAM · Feb 23, 2020

Help me understand paying extra cash for your PCP, rather than your insurance paying for it.

rotor · Feb 23, 2020

TX OMFS said:
I have insurance too and my DPC doc will send the lab orders anywhere, including Quest, but for the $3 or $5 she charges I just go through her.

I get plenty of time w/ Dr. Navejar & unlimited access & visits for the $60 or so I pay a month. I paid for a year &, IFRC, got a small discount for doing so.

The model your doctor switched to, Ben, is call concierge & is different. Mainly it's more expensive and may include house calls. Otherwise, I have never seen the advantage of concierge over DPC.

Last year I had an endoscopy & paid cash instead of going through my insurance. I would have spent about $3k out of pocket with insurance. Using cash I spent about half that.

This is why we need price transparency for procedures. If there are 10 insurance companies there are 11 prices for any procedure, the highest is cash and the lowest is Medicaid. The lowest insurance contract is usually Blue Cross. So, depending on which insurance you have your out of pocket may be high, low or nothing also dependent on your plan and deductibles. When you go outside of your insurance though you do not eat your deductibles.
If you somehow can find the CPT code for the procedure you are going to have and google the medicare allowable for that procedure in your area (different in different areas), you will get an idea of what you can work with when it comes to bargaining.
The average person can not figure out the complexity of the system. I could see a business model that would act like an ombudsman (for a fee) between patient and hospital before an elective procedure. Emergency though and you are screwed.

TX OMFS · Feb 23, 2020

rotor said:
I personally like the idea of concierge ( I am on medicare ) but if I use a concierge doctor not signed on medicare everything he/she orders I will have to pay for out of pocket including all meds, labs, radiology, surgery and whatever else.

That's not true. Doctors can enroll as "ordering & certifying providers" which allows them to order things under Medicare while still billing how they please for professional services.

deemus · Feb 23, 2020

I don't have insurance since Obamacare. It went up to $1700 a month, and I couldn't afford it. (so much for the AFFORDABLE healthcare act)

I signed up for Christian Healthcare Ministry last year. Just in time, as I had my first medical issue in a decade.

I ended up having surgery, and other tests done that in total cost me around $17K. I have received most of that back from CHM. However, the key to getting reimbursed is getting the "self-pay" price from providers. I was shocked at the difference.

Hospitals wrote it down 90%.
Doctors wrote it down 50%.
Labs/testing/radiology wrote it down 60-79%.

You have to tell them its self-pay, and ask for the discount. They are happy to do so, as it frees up their staff for other things and they get payment on the spot.

Edit - sorry didn't address the primary care question. I have a primary care doc, and they take insurance. But they also have self-pay rates for guy like me. Its part of the Baylor system. I have been very happy with the service. Seeing the doc is often short, but thorough. But she has an assistant that you can call and get questions answered. Call, leave a message, then get a call back or voice mail regarding question.

TX OMFS · Feb 23, 2020

rotor said:
This is why we need price transparency for procedures. If there are 10 insurance companies there are 11 prices for any procedure, the highest is cash and the lowest is Medicaid. The lowest insurance contract is usually Blue Cross. So, depending on which insurance you have your out of pocket may be high, low or nothing also dependent on your plan and deductibles.

I just provided an example of cash being less than insurance.

My practice is busy because my cash prices are often less than insurance. If you have insurance & get reimbursed from insurance then my prices are usually significantly less than using an in-network doc.

The Surgery Center of Oklahoma & the Texas Free Market Surgery Center are both class-based and frequently cheaper than insurance. Their prices are listed on their website. SCO was the first to fo this & where I got the idea to do it on my website.

https://surgerycenterok.com/
https://texasfreemarketsurgery.com/austin/surgery-prices-in-austin-tx/

TX OMFS · Feb 23, 2020

ZX9RCAM said:
Help me understand paying extra cash for your PCP, rather than your insurance paying for it.

I pay more but I like it. I'm not quite ready to get rid of my health insurance all together. I would get rid of my current plan if I could get a true catastrophic plan instead.

With DPC I get as much times as I like with the doctor, no crowded waiting room, unlimited access, & a personal relationship.

The DPC model really shines if you use a healthcare sharing ministry instead of regular insurance. In that scenario you can save a lot of money.

Ted Cruz, Chip Roy, & others are working to make Health Savings Accounts more flexible & to increase their limits. I believe they have already changed HSAs so that they can be used for DPC doctors.

The best scenario would be to get rid of Obamacare regs so that we could actually have catastrophic coverage only health insurance again. You pay for a DPC for 90% of your needs & fall back on the catastrophic for car wrecks & cancer.

TX OMFS · Feb 23, 2020

rotor said:
Let's say you have a heart attack. More than likely your concierge doctor doesn't have hospital privileges and will NOT be seeing you or caring for you in the hospital.

I forgot to mention almost no one's primary care doc, Medicare, DPC, insurance, or concierge, will care for you in the hospital. Almost all PCPs have stopped coming to the hospital. Primary care docs called "hospitalists" do that now.

deemus · Feb 23, 2020

TX OMFS said:
I forgot to mention almost no one's primary care doc, Medicare, DPC, insurance, or concierge, will care for you in the hospital. Almost all PCPs have stopped coming to the hospital. Primary care docs called "hospitalists" do that now.

Yep. My surgery was done by my doctor (a specialist) but was performed at a surgery center, not at a hospital.

rotor · Feb 23, 2020

TX OMFS said:
That's not true. Doctors can enroll as "ordering & certifying providers" which allows them to order things under Medicare while still billing how they please for professional services.

Yes, if your doctor has opted out of medicare and is willing to be a ordering and certifying doctor. As long as you know that your doctor has signed up to do this and contracted with you then you are right. Again. transparency - the average person doesn't necessarily know this.

rotor · Feb 23, 2020

TX OMFS said:
I forgot to mention almost no one's primary care doc, Medicare, DPC, insurance, or concierge, will care for you in the hospital. Almost all PCPs have stopped coming to the hospital. Primary care docs called "hospitalists" do that now.

I realize that but when you pay $3,000 a year to that PCP just realize that you will not see him in the hospital. That hospitalist will also make rounds on 20-30 patients that are probably sick and will not know the history in detail like your PCP. This is a real gripe that I have with hospitalists. You have a rash, derm consult. Vaginal discharge, gyn consult. Classic hospitalist exam.

rotor · Feb 23, 2020

deemus said:
Yep. My surgery was done by my doctor (a specialist) but was performed at a surgery center, not at a hospital.

My ex had to have a hysterectomy, quoted $10k at hospital, $4k at surgicenter and got 20%discount paying up front. That included all lab and anesthesia but not path. Yes you can get a good deal if you know how, but all for elective stuff. We are not in disagreement, I didn't know that an opted out of medicare physician might be able to order lab and meds. Thank you for informing me.

benenglish · Feb 23, 2020

It's beginning to sound to me like finding a primary care physician, something that should be rather straightforward, is enormously more complicated than it should be.

ZX9RCAM · Feb 23, 2020

My PCP closed his Woodlands office.
His nearest office now is ~40 miles away.

I need to get one as well.

deemus · Feb 23, 2020

benenglish said:
It's beginning to sound to me like finding a primary care physician, something that should be rather straightforward, is enormously more complicated than it should be.

Referrals from friends is a good start. Its how we found our doctor.

TheMailMan · Feb 23, 2020

Government and insurance company lobbyists have made sure the system is so screwed up that almost no one can understand it.

oldag · Feb 23, 2020

rotor said:
These concierge medical practices may sound good as long as you don't need to go into a hospital or have any lab or x-ray that is not in their group. For example, on exam they find a hernia. You need surgery. Not covered and you will pay the most expensive price as a cash paying patient. When you have insurance there is a contracted rate (Blue Cross is always the lowest rate- medicare is lower but 65+) and that's the maximum you will pay. No insurance and you likely will pay 5 times as much. Let's say you are on medicare but your concierge doctor is not on medicare, any lab or x-ray he/she orders will not be covered at all by medicare. Let's say you have a heart attack. More than likely your concierge doctor doesn't have hospital privileges and will NOT be seeing you or caring for you in the hospital.

I personally like the idea of concierge ( I am on medicare ) but if I use a concierge doctor not signed on medicare everything he/she orders I will have to pay for out of pocket including all meds, labs, radiology, surgery and whatever else. For my pets it is fee for service, one stop at the vets office, out of pocket and all is fixed. But it is unlikely that your concierge doctor is able to fix your hernia. Therefore you will be paying lots for that fix. If you are a rich person none of this matters and you can just hire a doctor for 24/7 care and not worry about it. I am sure Mike Bloomberg is not using medicare.

In some situations, you can negotiate a significant discount by paying up front. Thus avoiding paying "sticker", which is ludicrous.

TX OMFS · Feb 23, 2020

If you have FB & are a little wonky Dr. Shiva, Republican senate candidate in Massachusetts, has a great video explaining how we got here & how to get out.

Dr. Marty Makary is a renowned Hopkins pancreatic surgeon who wrote a book on the subject. Great video here. It's longer & good for a listen while driving.

I am co-sponsoring a lecture by Dr. Makary in about 10 days in San Antonio. It's a free event open to the public. Non-medical people have an interest in this & are welcome too. We have several business leaders coming bc healthcare is part of their benefits packages. The Express News will be there & so will one of Chip Roy's reps. Register for free here:

https://www.eventbrite.com/e/san-an...st-quarterly-meeting-2020-tickets-89436973395

Most Americans don't think about healthcare & just accept the crap sandwich both parties want to give you. There are some geeks like me that think about it all the time & work to improve things. What we want is simple: a truly free market, not cronie capitalism.

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