Frequently asked questions

How does Direct Primary Care (DPC) save me money?

1. Appropriate medical care, at the right time, is the best value care there is - taking the time to get to know you and obtain a thorough history helps avoid overtesting, overmedicating, inappropriate treatment and over treatment, which are significantly more expensive than a physician's time. There is significant inefficiency and improper medical care in typical insurance clinics, as insurance views physicians like production line workers and patients as widgets. There are 4 types of medical care - 1. Appropriate, 2. Excessive, 3. Harmful and 4. Insufficient care. DPC is able to focus on #1 and minimize 2-4. Primary care physicians are not paid by insurers to do everything that is necessary and a likely end result is increased downstream costs: pennywise is pound foolish. For example, many blood tests, imaging tests and specialist referrals are unnecessary if the primary care physician can spend as much time as needed with the patient. Excessive and inappropriate testing occur due to too little time with the patient with resulting expensive testing to compensate. The blood tests, imaging and medications we order cost much more than we do, so we are spending more money and time to get less appropriate care. This type of testing also further disrupts your schedule to obtain the testing and then to follow up to find out nothing was shown that was clinically relevant to you. For example, back xrays or MRI for back pain have specific clinical indications - most back pain does not require imaging. Regarding lack of care, we can ensure you get appropriate preventive medicine and not just preventive medicine because it works for some - we avoid one size fits all approaches used to simplify insurance based healthcare. 2. You also save money on many medications, the savings of which for some patients is more than the cost of membership. For cash pay patients, you won’t get clobbered with the exorbitant “usual and customary” fees insurance providers charge, and are really designed to be used in the game of insurance billing. 3. With timely care, may be able avoid some ER and urgent care visits, which will cost a minimum of several hundred dollars. 4. For those with high deductible plans that don’t cover primary care until the deductible is met, you will spend less as you can get cash prices - cash prices are less expensive as the provider does not have to deal with the insurance company. If you have a Health Savings Account, the money spent on qualified medical expenses is not taxed.

What type of insurance works best?

High deductible plans with a Health Savings Account (HSA) will work for many, although the monthly membership fee can’t be paid from the HSA. Anything else per IRS regulations like hospitalizations, labs, medication, procedures and many health related expenses can be paid. The goal of DPC is to provide the bulk of your health care needs, minimizing relying on insurance - it doesn’t make sense to pay your insurance company’s middleman fees for what we can provide directly. Plus using insurance makes the medical services provided more expensive, which you have to pay for inevitably through increased premiums. Indemnity insurance is quite efficient and I accept the amounts in full, but require 3 visits minimum as establishing care generally takes an hour. Health Share programs save even more money than high deductible plans, like Sedera and Zion Health. For maximum savings, then pay for a la carte medical services, but the benefits are limited to one visit at a time. OHP members are restricted to physicians contracted with OHP.

Define Direct Primary Care (DPC).

DPC restores the patient-physician relationship and gets the insurance middleman out of the way by forming a direct, transparent and ethical relationship. Care is focused on you, is more efficient, minimizes schedule disruption and is more timely. Physicians are now free to provide the care you need and that we are capable of. Patients unfortunately underestimate our capabilities as the current system restricts our capabilities: we don't have time to listen, educate and are rewarded for treating superficially. For the health care system to work, we must prioritize transparency, honesty and ethics: the truth is hard medicine to take. The current system encourages gaming the system, nickle and diming with the consequence of financial ruin if you don’t have insurance. Patients and physicians are pitted against each other by insurers. But we have the choice to continue or not. DPC is often misconstrued as insurance. Billing is in "arrears" meaning, you aren't billed until the end of the month, not the beginning.

What is a differential diagnosis and why is it important?

The differential diagnosis is to medicine what a neuron is to the brain. A differential diagnosis is the list of prioritized conditions generated when a patient has an undiagnosed condition. This is the crux of what a physician evaluates when seeing patients and takes time to evaluate correctly as there are often dozens of different possibilities. There are simply no shortcuts to a thorough differential diagnosis evaluation, and expensive overtesting is often employed to compensate for lack of time, which leads to increased harm and costs. Being overburdened with excessive documentation also takes away from the differential evaluation and obscures the thought processes so that subsequent readers of the chart can't tell what has been considered.

How do Health Savings Accounts (HSA) work?

The accounts need to be paired with a "qualified high deductible health plan". They have a high deductible, but the savings on premiums can be deposited and will eventually cover the deductible. The money contributed into the accounts is tax free, earnings are tax free, and if spent on qualified health care expenditures are tax free as well. The account money can be invested and after you retire, can be used as regular income without paying penalties. The money can't be used to pay DPC membership fees, unfortunately.

What are Medical Cost Sharing plans?

These cost roughly $150-$600, a fraction of typical insurance plans. They do this by not covering expenses that can be paid out of pocket and only cover major expenses associated with a health event such as a trauma like a broken bone, heart attack, cancer diagnosis etc. They don't pay for routine physician visits, chronic medications, or routine labs. There are two such plans associated with my clinic, Sedera and Zion Health. These plans "share" in the qualified medical costs you may incur, but have restrictions. For example, they won't cover expenses associated with illegal activities. They work well for the relatively young, healthy, but briefly, they are not insurance and thus use different terminology. They are efficient and administrative costs are less than 10%, compared to insurance companies who can go over 30%. These plans can be sponsored by employers. If you are healthy and responsible for your health and cost consicous, these plans will work well.

I want you to take my insurance.

That’s what the insurance companies have trained you to think, by getting you to focus on copays and deductibles and losing sight of the big picture of premiums, prior authorizations and other expenses. One needs to consider the overall cost of care and the quality. Insurance absolutely drives the overall costs up and quality down - don’t be fooled by a low copay. DPC puts you in charge and frees your doctor to work to their fullest potential. Besides, over 50% of doctors have symptoms of depression, which lead to increase errors in medical judgement. Many people think that since they have paid high premiums, they want to get something out of their insurance company. But that’s not how insurance works - the expectation with insurance in general is that you pay the premiums and don’t use it. As a model, insurance doesn’t pay out more than everyone who puts into it - that’s a Ponzi scheme.

How do I pay?

Payment plans are set up through Hint Health. Checks and Electronic Fund Transfers are accepted.

Why join if I don't see a physician very often?

Because you have always been restricted by your insurance by having to have face to face appointments for everything. DPC removes the traditional barriers and we can stay on top of conditions much more easily before they get out of hand. If you contact me before the appointment so I know what is going on can prescribe a medication (no controlled substances) to prevent things from getting worse before you see me. Or labs or x-rays can be ordered prior to the appointment making the appointment more efficient. Depending on the medications you take or chronic conditions, we can minimize the cost of the medications significantly and minimize overtesting - saving you money, time and interruptions to your schedule.

DPC vs. Concierge.

DPC is one low, transparent price. Concierge patients pay a much higher retainer fee in addition to insurance premiums and other plan obligations like copay, out of pocket expenditure. The practice continues to bill insurance, but is still beholden to the insurance carrier. They still have to spend more time documenting than they do on your care, interefering with and limiting the care they can give you.

I have insurance. Do you refer to specialists, labs and medications that are in network?

I can if you find out what specialists are in your plan. Your insurance company should have resources on their webpage to call or direct you to who and what are in network.

What services are not covered?

The main idea of DPC is to provide as much as reasonably possible within the office. Those things that are outside the office are generally not covered - medications, dental, vision, hearing, specialist referrals, hospitalizations, surgery, imaging, labs, pathology services and radiologist interpretations. I can't provide gynecologic exams as I have no staff.

Who can join?

People 14 and older. Note, there is nothing about pre-existing conditions, race, ethnicity, gender, sexual orientation, religion, etc. that precludes you from being a patient. My goal is to enable you to be the healthiest you can be both mentally and physically, whatever your demographics and medical conditions.

How can you spend so much time?

Without signing insurance contracts, I can dramatically lower costs and the monthly membership payments make revenue consistent. I keep my office simple as the primary service is cognitive. We don’t need fancy office space to impress. This means fewer patients are needed. Fewer patients means more time and resulting efficiency and quality for each patient. In a typical insurance clinic, many shortcuts are taken to keep revenue up, but if you don’t have the time to do something well the first time, how much more time is it going to take when things go wrong? Really, there is no substitute for adequate time, so it’s not a matter of how, but how can we not? Studies currently show that insurance doctors spend more time documenting your care than providing it - this is backwards from how care should be. The EMR Elation is designed for DPC and captures a much more meaningful picture of who you are, like a jigsaw puzzle being put together. EMR’s that insurance companies prefer separates your history into discrete units of data, losing the connections. Also, they require overdocumentation which dilutes and obscures the relevant parts of your history, analgous to breaking apart a jigsaw puzzle and mixing them up with other sets. This is great for the insurance company, but not for you - why would you want to benefit the insurance company at your expense? Since insurance companies demand face to face appointments for everything we do, taking care of issues via email, phone and texts takes much less time.

What is the cancellation and refund policy?

The minimum initial membership is 3 months. Afterwards, cancellation can occur at any time. However, reinstatement then requires a intiation fee and another 3 month minimum.

How do you study?

UptoDate is a paid subscription service with research showing physicians who use this provide more effective care. I frequently access this resource as each subject is written by experts in the field who have reviewed all of the latest research and applied it clinically. This is the most effective means to keep current with the incremental changes in medicine. I don’t go to conferences as they are infrequent, expensive and time consuming. I keep up with the specific issues encountered contemporaneously, which is the most effective method of learning. I know where to look or whom to refer to.

Services offered

Unlimited access to your primary care physician: take care of problems when they occur. Same day urgent care: reduce the need of using expensive ER or Urgent Care services. 24/7 email and cell phone access: information when you need it. Same day return phone calls: your questions answered. Longer visits 30-60 minutes: thorough evaluation leads to improved diagnostic accuracy and appropriate treatment. Comprehensive preventive care: reduce risk based on best evidence. Diagnosis and management of chronic conditions: diabetes, heart disease, arthritis, asthma plus many others Simple skin procedures: skin tag and wart removal, precancerous skin lesion removal.

What about pre-existing conditions?

DPC is made for people with pre-existing conditions. In typical insurance clinics, the sicker you are, the more overwhelmed they are and thus relatively complex patients are given short shrift. The sickest 5% of patients consume 50% of healthcare costs, and in large part occur due to the current system's many failures. Let's prevent you from getting there. Besides, I didn't go to medical school to care for perfectly healthy people.

As an employer, why would I pay extra for your services that I can get elsewhere?

You can't get the level of service I offer from a physician that is a "preferred provider" as they work for you insurer, not you. Do you want to lower your overall costs, get a good return on investment, increase employee loyalty by offering a unique health benefit and, most importantly, keep your employees healthy and working? Some report savings of 20-40%, but this is anecdotal evidence. The software I use can give some information about utilization to give an indication of costs. What motivates your insurer is very different than what motivates you - I have signed insurance contracts and am very well aware of the perverse incentives physicians are placed under in order to get paid. We have to produce a high volume of patient visits, do as little as possible each visit and encourage excessive return visits to maintain income. The schedule has to be overbooked to account for lost revenue from no show appointments, which means you wait longer for a visit that is too short. Documentation is overburdensome and is in the best interest of the insurer, while distracting from thinking about what the patient needs and wants. Additionally, most physicians are now employees and physician productivity is tracked, not quality.

What is and how does indemnity insurance work?

This is a relatively new type of insurance and guarantees a set reimbursement amount for medical services. This type of insurance saves money as it doesn't have the administrative costs associated with constructing different insurance plans and then contracting with numerous providers. It is the contracting and verification of services being covered that is labor intensive for the insurer and health care provider, which is around 30% fo reach. By accepting indemnity insurance, both of us save money and yet have more time.