What I realized (about what insurance really covers)
Insurance doesn’t pay as much as I thought. I recently looked at my personal insurance rider, and I am responsible for all medical costs up to $2000 except for routine medical care! That means, in scenario #1, I would be responsible for $1325!
Here’s an example of how hidden insurance costs can add up—
The Old Way: Let’s look at what happens when you see your primary care doctor in the traditional, fee-for-service system.
You wake up with a cough, and call to get an appointment in a few days. You have the appointment, and it costs a co-pay of $25. Your doctor does an x-ray that day and sends it out to radiology. Your doctor bills insurance $125 for the whole visit.
Some time later, you get an EOB (explanation of benefits), which shows that you owe an extra $20 for that visit. The new $20 charge is for the “co-insurance”. In this case, that’s 20% of $100.
Then, you get a bill from the radiologist for $40. They charged $200 for the x-ray and the interpretation, and you had to pay 20% of that bill.
You aren’t better. You call your doctor back. You get an appointment in seven days. While waiting for that appointment you get much worse. You go to Urgent Care and pay the $75 co-pay.
They send you to the emergency room, where you have a CT, receive IV antibiotics, and are sent home after eight hours. The emergency room co-pay is $200, and then you have 20% of the $1000 bill from the ER. You return to work after two weeks.
The New Way: Let’s look at the same scenario from a Direct Primary Care standpoint.
You pay your monthly direct primary care membership fee (you can use your flexible spending dollars to pay that fee).
You wake up that morning with a cough, and you call me. I see you that afternoon, virtually. You pay NOTHING. I order an x-ray and radiology reads it. You use insurance, and it still costs you $40 (20% of $200).
You aren’t better. You call me. I need to assess you further, and offer an in-person visit the same day. I call in an antibiotic and tell you to use over the counter cough medication. You use your insurance to pay for the medications, which are generic, for $10.
I check in with you by phone the next day, and you feel like you are getting better, but the cough is keeping you up. I call in a different cough suppressant, and you get some sleep (the biggest factor in getting better). It costs another $10.
We do another phone check-in and you tell me you are getting better. I tell you to call me for more shortness of breath, a new fever, or feeling weaker.
You have the peace of mind knowing that if any of those things happen, you will be able to get the medical care you need. You return to work in a week.
Now granted, there were a lot of assumptions in the scenario above. Needing to go to the ER is a worst case scenario, and doesn’t happen often. And, even if you are able to access care early, sometimes an ER visit is unavoidable. But, in general, earlier access to care and treatment translates to an earlier recovery.
The beauty of direct primary care is that it allows me to keep my panel small and manageable because of the monthly fee. That fee essentially preserves your access, and it means that you can get the care you need when you need it. The peace of mind that comes from knowing I have your back can make all the difference.
Insurance Charges:
Co-Pay: office visit $25
Co-Insurance office visit: $20
Co-Pay Urgent Care: $75
Co-Pay Emergency Room: $200
Co-insurance ER: $200
Medication: $20
Total (if deductible is met): $540
Total (if deductible is not met): $1325
Direct Primary Care Charges:
Monthly fee: $100
X-ray fee: $40
Medication: $20
Total: $160
