Modern American medicine is a dizzying morass of policies, procedures, vague terminology, marketing ploys, surprise traps and a resulting general dissatisfaction in medical care among patients. This despite the fact that we spend about double, per capita, than our other first-world allies. We are going to recap insurance-based care before exploring the world of Direct Care.
Not All Scenarios are Equal
- When it comes to navigating healthcare, Traditional Medicare is the least confusing. They write their rules out every fall, publish them in December, and they don’t change again until the following fall. Traditional Medicare covers 80% of expenses. The deductible is only $225 for outpatient care. Patients who have a Supplemental insurance policy will have the remaining 20% of services covered.
- Navigating the VA would be the next easiest. They definitely do things Their Way in that system, but once you understand their parameters, you can make it work fairly well. The extent to which care is covered does depend on a complex process of how much and which type of military service you provided.
- Commercial insurances? Forget it. They’re changing the rules day-to-day. It used to be that PPOs were the cadillac plans with the most flexibility and the HMOs made you jump through more hoops. Now they ALL require a huge amount of hoops, and they all have high deductibles. It used to be that commercial plans paid clinics well. Nowadays it’s commonplace for commercial plans to pay a fraction of the medicare rates.
- Medicare Advantage plans–which I like to call the Disadvantage Plans–are owned by the parent companies (i.e., United, Blue Cross, Humana, etc.). They are beholden to those companies’ Networks, deductibles fee schedules and restrictions. Much like their commercial counterparts, the rules can change several times throughout a year.
But What Else is There?
This is where the Direct Care movement comes in.
These are practices that have “jumped off the hamster wheel” of insurance. They do not bill insurance directly themselves, and so they are not beholden to its rules.
Because of this, they are able to simplify their practice: no need for outside billing companies, no full-time staff just to fight for prior authorizations or appeal denials. Just a transparent subscription and time with the doctor.
In Direct Care, practices are much smaller. Instead of seeing 30+ patients/day and managing a census of 2,000 patients, these practices may only see 5-10 patients in a day and have a census of 300-400.
Access and Quality of Care
Most of the time, a new patient might have to wait 3-9 months to get an appointment with an endocrinologist. Because we are Direct, patients are able to get in within a couple days or a couple weeks.
Patients are not double-booked, so when they arrive, they don’t spend an hour waiting to see the doctor.
Once they do see the doctor, they get all the time they need. For a new diabetes patient, we spend an hour together. Diabetes is a complex condition and there are a lot of moving parts. Some patients need more hands-on care than others. This way they are able to have ongoing contact as is needed, without limitations.
Need a telemedicine visit? No problem, because we’re not worrying whether United thinks that’s OK or not. Need to be seen every week to have your questions answered? That’s OK, because we aren’t worried that Blue Cross is going to cut you off because you weren’t “authorized” for that many visits.
Nothing comes between the patient and the doctor.
And you know what? Patients THRIVE.
So Who Pays?
Because a Direct Care practices does not bill insurance directly, the patient does make their payment either up-front at the clinic, or on a subscription basis.
The clinic then provides the patient with a “Superbill”–the document that is needed to submit to insurance for reimbursment.
There are even apps like Reimbursify to help the patient navigate the reimbursement process.
And when it comes to paying for labs, imaging tests, medications or medical equipment, all your usual insurance rules apply.
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