Direct Primary Care (DPC): A Consumer’s Guide to This Payment Model

As health insurance gets more confusing and costly, new models of care have emerged. Some people are turning to direct primary care (DPC) as an option to access and afford basic medical services. Here’s what you need to know about DPC, so you can decide if this practice and payment model is right for you.

What is direct primary care, and how does it work?

DPC, or direct primary care, is a financial arrangement made directly between you and your healthcare professional. It cuts insurance providers out of the process — eliminating the need to file health insurance claims.

With DPC, you don’t pay monthly health insurance premiums or copays. Instead, you pay your healthcare professional a monthly fee. And because DPC practices don’t bill insurance companies, they don’t accept any form of insurance. That said, most people who use DPC are also enrolled in a high-deductible health plan.

Most DPC professionals come from the primary care medical specialties:

• Internal medicine, which produces internal medicine physicians or internists, who treat adults

• Family medicine, which produces family medicine physicians, who treat people across the lifespan from infants to seniors

• Pediatrics, which begets pediatricians, who treat babies, children, and adolescents

Depending on where you live, DPC practices may include the following healthcare providers as part of the care team or with full or partial practice authority to diagnose people, order tests, and prescribe medications:

• Physician associates (PAs), who are also known as physician assistants and may be using that title in your jurisdiction

• Advanced practice registered nurses, such as nurse practitioners

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Some people distinguish between DPC and concierge medicine, which offers premium services to consumers who tend to have higher incomes. Both offer consumers extended visits with their physicians. Concierge medicine practices typically charge higher monthly fees and accept insurance.

The benefits of direct primary care

There are many advantages to using DPC. Here are a few benefits of entering into a financial agreement with a healthcare professional.

More time with your healthcare professional

DPC practitioners do not have to prepare and file insurance paperwork. This allows them to have more in-depth visits and spend more time with you. DPC offices typically treat fewer people than practices that accept insurance. Healthcare professionals can take time to get to know your health history in detail, which creates an atmosphere conducive to more personalized care.

Upfront pricing

With a traditional health insurance plan, you have little knowledge of exactly what — and how much — your insurance will be billed and your out-of-pocket responsibility. Deductibles, copays, and coinsurance are applied. Discounts are negotiated between the healthcare professional or practice and your insurance company. Then you get an explanation of what you’re expected to pay for the visit.

DPC eliminates that confusion. You’ll know the exact monthly cost of membership for basic care and specific additional fees for enhanced services.

Accessibility and convenience

With DPC, you’ll usually have access to many perks. These may include:

• Same-day and next-day visits

• Appointments lasting 30 to 60 minutes

• Telehealth options with your healthcare professional, such as phone calls, emails, texts, and video visits

• Around-the-clock access to your healthcare professional 

The disadvantages of direct primary care

DPC has a few challenges. You’ll have to consider these drawbacks before making a DPC arrangement with your healthcare professional.

You still need an insurance plan

The monthly fee for DPC covers consultations, office visits, and basic care. But, depending on your contract, you may have additional costs for lab work, imaging, or procedures. That’s why you’ll probably need to pair your DPC membership with some sort of insurance plan. Many people using DPC also have a high-deductible health plan.

If you have health insurance, you can use DPC. But if you have government health insurance, such as Medicare or Medicaid, you have to sign an agreement stating that any and all services provided will not be billed to those health plans.

Membership doesn’t count toward a deductible

You can deduct your monthly membership fee as a medical expense on your taxes, according to the IRS. But your cost for DPC cannot be counted toward your deductible if you also have a high-deductible health plan or other insurance.

What are the direct primary care costs and payments?

The monthly fee for most DPC services is typically around $100 and could be less. That fee gives you unlimited and direct access to your primary care provider (PCP), also known as a primary care professional. Some DPC practices charge an additional visit fee at the time of service. 

In general, fees are based on your age, the type of practice, and the number of family members on your plan. The monthly fee may cover all or some of these typical primary care services:

• Preventive care (such as routine screenings)

• Laboratory tests (such as blood tests or urinalysis)

• Management of chronic conditions (medication checkups)

• Acute-care visits (for strep throat or the flu, for example)

• Consultations

The monthly fee doesn’t include visits to specialists, urgent care, or hospital services. And medications — prescription or over the counter — are also not part of a DPC financial agreement.

Why do you sometimes need insurance with DPC?

Although DPC’s monthly fee may be less than a health insurance premium, having DPC alone may leave you at risk of medical debt. That’s because you will lack coverage for other health-related expenses, such as emergency and hospital care, as well as prescription medication. To prevent incurring medical bills you can’t pay, DPC is typically paired with one or more of the following options:

• A high-deductible health plan (HDHP): This covers services such as surgeries or catastrophic health issues. It also covers emergency room treatment or hospitalization. An HDHP is one way to prevent financial devastation if you need emergency or extensive care.

• A health savings account (HSA): Anyone enrolled in an HDHP is eligible to contribute money to an HSA. You make contributions before income tax is deducted from your earnings. This lowers the amount of your taxable income. You can only use funds in an HSA for health-related eligible expenses, such as prescriptions, copays, deductibles, vision care, and dental care.

• Prescription coverage and/or coupons: Whether you have health insurance or have enrolled in DPC, you can use GoodRx to save on medication. Using Goodrx.com or the GoodRx app, type your medication into the search bar, adjust your dose and quantity, set your location, and find the lowest price near you. You can print the free coupon, send it to your phone or email, or save the coupon on your app to use at participating pharmacies to save on prescription medications and over-the-counter medications with a prescription. You may even pay less by skipping your prescription plan and using GoodRx.

Is direct primary care worth it?

People using DPC can typically contact their provider at any time, which may be appealing to: 

• Families with small children

• People who travel frequently

• Older adults with limited mobility

Because DPC arrangements are often paired with high-deductible health plans, they might not be the best choice for everyone. A DPC may not be ideal for people who need specialized care or people who have complex medical issues. A DPC may work best for people who are generally healthy or for people who want improved access to a primary care provider for routine visits or short-term health issues.

So, if you’re considering a high-deductible health plan — or already have one — adding a DPC membership may be a good option for you.

How can you find a direct primary care professional?

If you have a primary care professional, ask if they’re willing to enter into a DPC agreement. If that doesn’t work, look for a DPC practice near you. 

The Direct Primary Care Coalition and DPC Frontier Mapper are two resources to help you locate a DPC practice in your area.