Breaking Barriers: Health Insurance and Direct Primary Care 2019

Cost is the number one barrier to engaging your doctor. Direct Primary Care is an emerging practice model that breaks down that barrier.

Just in time for your Halloween candy hangover, today is November 1st. This day has been gaining infamy in recent years as the day that opens for business for the purchasing of health insurance plans for the following year. I make it a habit of trolling local media for stories related to the Exchange, and I have to say that I’m struck this year by the relative paucity of news coverage. Could this lack of coverage may be due to the fact that Election Day is just five days from now? This year, we were supposed to be able to get a preview of plans being offered on the Exchange by visiting So in hoping to prepare for this blog post last week, I did just that. But I found that when I tried to look up details of the plans, I was greeted by the message “Internal Server Error.” The plan details are finally live just this morning. How interesting. I smell a conspiracy. But I digress.

This health insurance season (so I’ll call it), will be CovenantMD’s third. And the business owner side of me loves this time of year. November, December, and January are all busy months for us in terms of adding new patients, and in engaging many people with the question of how our practice model, Direct Primary Care (DPC), interacts with health insurance. As in past years, to help meet the demand for more information about CovenantMD, we’ll be holding periodic group info sessions. Stay tuned to our website and Facebook page for announcements of upcoming group info sessions. (By the way, our first will be held Tuesday, Nov 13 at 6:30pm at our office in Lancaster. Call or email if you would like to come, as space will be limited.)

DPC works on the premise that while health insurance is needful to protect against the unexpected, costly things that can sometimes befall us, it nevertheless ceases to be insurance (in the true sense of the word) when it also pays for the less expensive, more common things that we are virtually guaranteed to need, like primary care services. (Think about your car insurance. Does it pay for your gas? Does it pay for your oil changes?) In DPC, we essentially “carve out” the common stuff (primary care, urgent care, labs, medications), allowing you the patient to pay for these yourself at low, transparent rates, and thereby saving your insurance for the less common, more costly things. In the old model, you might think twice about paying $150 for an office visit if you’re suffering from a cough with a fever. Why not consult WebMD instead? But in the new model, in DPC, that cost barrier is torn down.

At CovenantMD, patients pay a monthly fee, from $20 for kids up to $85 for seniors, in exchange for several amenities, like same and next-day visits, extended time with the provider, and substantial discounts on medications and labwork. DPC gets patients (and doctors and nurses!) off of the impersonal treadmill of insurance-taking, fee-for-service practices (the kind we’re all used to), and instead finds an alternative model that puts the priority back on the patient/doctor relationship. Since we opened our doors in January, 2016, we’ve been blessed with substantial growth. We recently added a third provider in nurse practitioner Jane Snyder, and in January we’ll be opening a second location in York. This concept of Direct Primary Care has certainly touched a nerve in our local market! For more about DPC, check out my blog post series “What is Direct Primary Care” here, here, and here.

But how does DPC interact with health insurance? I’ll again address this question by comparing what a hypothetical family of five, who purchases their insurance on the Exchange, might be expected to spend out-of-pocket over the course of a year if the family chooses one of three scenarios: 1) a Gold plan, 2) a Bronze plan, and 3) a Bronze plan paired with CovenantMD. The goal will be to make the argument that Option 3 can save a family substantially on total out-of-pocket costs, and offer a higher quality experience at the primary care office to boot.

Just a couple more thoughts related to this year’s Exchange before I move onto the hypothetical scenario. Whereas last year there were just ten plans being offered on the Exchange for most people, this year there are 18. And just like last year, all plans will have NO COPAYS for primary and urgent care office visits before the deductible is met. In other words, we will pay the full cost of non-preventive office visits, medications, labwork, etc prior to reaching our deductible.

So let’s begin the scenario: Let’s take a hypothetical family of five (two adults, 3 kids). Let’s assume they have a busy healthcare year for 2019, but certainly not catastrophic. One person needs an x-ray, one person needs labwork, there are 8 office visits between them, etc. Some important thing to keep in mind as you look at these numbers:

  • I did not pick an income level for this hypothetical family. Depending on income, this family’s cost of premiums can be affected substantially. For instance, if the family makes the median household income for Lancaster County ($57,000/year), they will have a $983 monthly discount on their premiums, and they would only need to purchase insurance for the two adults in the household, as the three children would be covered on CHIP.

  • The Gold plan numbers assume that ONE of the family members is being prescribed both medications and underwent fasting labs, which is why the pricing in these columns is a lot less than in the Bronze columns.

  • In all scenarios, the family did not come close to reaching its maximum out-of-pocket as stipulated by the plans.

Here are the numbers:

So what is our takeaway from this analysis? Bronze planners can save substantially on premiums, but they risk more out-of-pocket costs by virtue of the high deductible. Gold planners are in essence agreeing to pre-pay a substantial amount for their healthcare. But DPC, with its zero copays, after-hours availability, free procedures, low-cost meds and labs, etc, helps to hedge against “digging into” a high deductible, and therefore fits very well with lower-premium, higher deductible health insurance. For a low monthly fee, about the price of cable for a family of five, it means a free 60-minute visit compared to a 15-minute visit costing $150. It means paying $17 for a cholesterol panel, thyroid function, blood sugar screen, and kidney and liver function, as opposed to $305 for typical insurance-negotiated prices.

It means breaking down the number one barrier to healthcare: cost.

Patrick Rohal, MD, FAAFP is a family doctor and the founder of CovenantMD. Last week, he dusted off his copy of the movie The Matrix, circa 1999. As many things in life find a ready metaphor in The Matrix, he sees insurance-based fee-for-service as the Blue Pill, and DPC as the Red Pill. The rabbit hole does indeed go deep.