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Membership healthcare – Fad or viable ACA alternative?

July 31, 2017

The failure of the Congress to deal with Obamacare has more people now in the exchanges searching for an alternative form of healthcare.

The immediate reaction to the failed Senate vote was a hearty chorus, of  “Screw ’em! I can’t afford Obamacare now, and I won’t pay another red cent for it, and I’m not paying the X$!@#” fine either!”

Which is a great way to vent, but what will they do about getting actual care? Believe it or not, there are alternatives.

Many are landing on so-called membership models, also known as Direct Primary Care practices or DPC’s.  (While some people call any such practice model concierge medicine, there are some differences.)

So what are DPC’s and how do you find them?

DPC’s are typically family practice-based, and as the name implies, they usually only offer routine primary care.  In most cases, a web search using the term direct primary care medical practices will turn up providers, although this map shows where some are located along with some descriptive practice type information.

In most cases their patients usually pay a small monthly fee of $50-$60 (each patient) plus a nominal fee for each child, whether they use services or not. Typical membership monthly outlays for a family of four are often in the $120 to $150 range or about $1800 annually, although charges do vary according to locality.  For most, this is the answer to truly afordable health care, at least at the family practice level.

DPC’s do not accept insurance for payment and usually will not offer a bill for you to bill Medicare or Medicaid.  In short, this is an all-cash deal.

This is because government and insurance is still paid as fee-for-service.

The membership fee is not considered a “premium” but also is not directly tied to the care you receive, making it impossible to code it properly for reimbursement. That creates problems for both patients and providers, meaning that DPC’s usually “opt-out” of being listed as Medicare orMedicaid providers.

In return patients often see the doctors without getting a per visit bill. Often these practices offer some prescriptions at cost plus 10%, and lab tests are either covered by the monthly fee, or are billed at wholesale or slightly above.

Most recommend that patients carry a low-cost catastrophic health insurance plan, and some will offer guidance on how to find such plans .

DPC’s have been around since about 2000, but Obamacare accelerated their development.

Doctors originally initiated the model out of frustration with the delays and red tape involved with insurance companies and government agencies. Many cite the savings just in administrative time alone as a significant reason they can offer care at vastly reduced prices, while others contend that being able to spend more time with the patients results in better, more accurate care, thereby reducing overall treatment cost.

With Obamacare premiums expected to skyrocket again in 2018, it’s a pretty sure bet that DPC’s will experience a growth spurt.

Users report that doctors take more time and seem to be more personally involved with the patient than is seen in many “normal” practices, and also say that they feel they have more of a voice in their care.

They are not for everyone, since using them will not necessarily prevent the patient from having to carry some form of insurance for catastrophic or specialty care.  That means you should definitely compare the fees and associated costs against your combined normal annual healthcare and health insurance costs.

There are also tax deductibility questions, some of which are covered in this DPC industry paper.

Also, the fees are usually not allowable expenses under HSA’s or MSA’s, meaning you can’t use the fees to cover the withdrawal requirements for those plans.

Of course, many people are now just creating a separate passbook style, after-tax savings account for medical costs, and those are not affected.

This is not just push-button medicine.  You have to be willing to participate in your own health care decisions.

Like any other medical decision you make, it is wise to check out the quality of the care, using one of the online physician rating services, or through word of mouth. Like any other industry, quality varies. Also, be sure they offer the services you need.  Some do not offer vaccinations, for instance.

DPC’s are definitely not for everyone, particularly those with the better individual health plans, or good employer coverage, but the practice model is not a fad.

It is unknown how many of those so-called young healthy people that do not buy Obamacare may be receiving care under the DPC model, but you can bet that if DPCs are perceived as a threat to the insurance companies, someone will target them for annihilation in the future.

Indeed, CMS has already created some barriers related to Medicare, as explained here.

For many people now or soon to be priced completely out of the Obamacare model, but not eligible for Medicaid or Medicare, the DPC care model at least offers a viable alternative to the emergency room for obtaining routine primary care.

From → op-ed

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