How much value do you truly receive with insurance-based healthcare? It’s a question that is on the mind of patients and providers alike these days. Many patients are clearly paying more for less, with insurance premiums, deductibles, and out-of-pocket costs rising steadily over the last two decades. Despite increasing costs, health outcomes have declined, especially among incidences of preventative and non-communicable health conditions. Value-based care models and other targets to achieve value in healthcare have been implemented in many states as a way to focus on quality of care and prevention. Direct Primary Care is an example of a model that aims to increase value in healthcare by reducing overall costs for patients, improving the quality of care, and lowering the administrative burden on providers. But with typically higher out-of-pocket costs, many shy away from committing their care to an often-privatized system without a full understanding of the value it can bring to their short- and long-term health.
According to the Centers for Medicare & Medicaid Services, U.S. healthcare spending reached $4.5 trillion in 2022, averaging over $13,000 per person, yet life expectancy and chronic disease management outcomes now lags those of other developed nations. A 2023 survey by the Kaiser Family Foundation found that the average annual premium for a family plan was over $23,000, with employees contributing nearly $6,000 of that cost. This is largely due to the insurance-based model still being primarily structured around a fee-for-service payment system, where providers are paid based on the number of services they deliver rather than the quality of care they provide. Ironically, increasing the number of tests, treatments, and procedures has not consistently led to better health outcomes or greater satisfaction for patients and their families.
Value-based healthcare, on the other hand, is designed to align incentives for providers and patients (and payers in conventional settings). This means providers are financially “rewarded” for improving patient health and patients can expect more value for their cost of care in terms of satisfaction and outcomes. Some examples of value-based healthcare models are Accountable Care Organizations, Bundled Payments, Pay-for-Performance plans, and Patient-Centered Medical Homes. The benefits of value-based healthcare include improved patient outcomes, cost efficiency, increased patient satisfaction, a focus on preventive care, and enhanced provider accountability. Challenges within a value-based healthcare model are difficulty in measuring value and outcomes, a shift in financial risk to the provider, and for some, higher short-term costs.
The Value of Direct Primary Care
Outside of conventional settings, Direct Primary Care (DPC) is an example of a value-based model, as it emphasizes delivering high-quality care that aims to improve patient health and reduce financial waste. DPC is typically a membership-based healthcare model where patients pay a monthly or annual fee directly to their physician for a more personalized and accessible approach to their care. A patient in a DPC practice can expect longer appointment times, shorter wait times, immediate access to their provider, and more of an emphasis on prevention. While insurance is typically not accepted in most DPC models, patients often pay less over time compared to their rising insurance premiums and copays, and possible costly health complications in the future due to a lack of preventative care. DPC practices cannot take the place of emergency healthcare services, in most cases, but for many, they can serve as a valuable replacement for conventional primary care and help increase access to specialty care.
Direct Primary Care & Functional Medicine
While it is not required that a DPC practice adopt a non-conventional philosophy of care, this model can allow more flexibility for providers to practice medicine how they choose, one avenue being functional medicine. Functional medicine aims to address the root causes of health conditions instead of only relying on treating symptoms through prescription medications or surgeries. Providers use a comprehensive, whole-body approach to care with the goal of alleviating health issues and often optimizing health and longevity even further. This type of care emphasizes personalization by considering genetic, environmental, mental health, and lifestyle factors that contribute to an individual’s health. A functional medicine-based care plan typically starts with an in-depth health assessment, labs, and a discussion of symptoms, then is followed by expert interpretation of lab results and a fully personalized health optimization plan.
A Direct Primary Care model that uses a functional medicine approach can deepen both access to a physician and the personalization of care. DPC practices typically have a limited patient panel, allowing providers more time with their patients to develop strong patient-provider relationships. Infusing functional medicine within this type of care model means a more in-depth and comprehensive experience for patients. Under conventional plans, different types of care are often separated into specialist appointments, and therefore separate billing structures. Coverage for mental health, nutrition counseling, and advanced protocols is often limited or excluded altogether. Chronic disease management programs, wellness initiatives, and lifestyle interventions are typically underemphasized in conventional primary care settings, and patients are left to pay out of pocket for these services or forego them entirely, leading to poorer long-term health outcomes. Due to the comprehensive nature of functional medicine, a patient can receive more than one aspect of evidence-based care within one appointment – and one bill. Without the conventional constraints or limitations on a provider’s practice philosophy, direct primary care delivered through a lens of functional medicine can be a highly valuable investment to make for patients and providers alike.
In theory, buying into the health insurance system should provide patients with financial protection and access to high-quality healthcare. However, many patients feel they do not get the value they expect from their insurance-based healthcare plans. True value in healthcare does not come from high volumes of services or brief appointments once a year, but from a system designed to deliver personalized, comprehensive care focused on better outcomes.
If you’re ready for a different type of experience as a provider or a patient, connect with our team to learn more about Essential Primary Care and our other programs rooted in functional medicine.