How Direct Primary Care Works With Health Insurance

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March 20, 2019

How Direct Primary Care Works With Health Insurance

direct primary care insurance | how direct primary care works with insurance | dpc | paladina health

About the Author

Rick Kjerstad | Vice President Business Development | headshot

As Vice President of Business Development, Rick Kjerstad leads Paladina Health's sales team. He is passionate about communicating the value of Paladina Health's cost-saving solutions to clients and prospective clients. 

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By Rick Kjerstad

Before employers add Paladina Health to their benefits package, they’re often curious about how our direct primary care (DPC) program works with their existing health insurance plan(s). The short answer is that Paladina Health does not act as a replacement to health insurance but as a supplement to it, with the potential to greatly reduce overall healthcare costs for businesses and their employees over time.

How does this happen? 

Our direct primary care services are funded by employers on a flat per-member-per-month basis independent of health insurance. This is very different from the traditional primary care model (often called “fee-for-service”) in which doctors bill insurance based on every exam and procedure performed during a given visit in addition to collecting a co-pay from the patient.

80 to 90 percent of our members’ healthcare needs can be met by a Paladina Health provider, usually without billing a member’s health insurance at all, and always without co-pays or a laundry list of billing codes and financial red tape. This is what puts the “direct” in direct primary care, as we sidestep health insurance to provide high-value healthcare at a flat rate directly to the consumer through an employer-sponsored flat rate. To boot, this care model frees our providers up to spend substantially more time with patients and address multiple health concerns in a single visit.

Related reading: 5 Ways Direct Primary Care Saves Costs

In the long run, organizations offering Paladina Health as a benefit to their employees enjoy a two-fold effect: reduced healthcare insurance premiums and improved employee population health. This in turn leads to happier employees and further reductions in healthcare spending.

How does direct primary care make insurance more efficient? 

When patients have easy access to primary care services at little to no out-of-pocket cost, they are more likely to use it. Open lines of communication between providers and patients foster a preventive approach to healthcare rather than a reactive one.

Our providers are able to address risk factors that lead to costly and complex chronic illnesses rather than waiting to treat a full-blown chronic condition. Moreover, we employ sophisticated population health analytics to identify patients who may be suffering from chronic illness or at high-risk for developing one, and proactively reach out to them to ensure their healthcare needs are addressed.

When circumstances inevitably arise that require our members to utilize the care of a specialist, surgeon, or other provider that must bill insurance, our doctors are able to refer them to high-quality, high-value providers. In this way, health insurance for many members begins to look and operate more like insurance – something used for unforeseen events and emergencies – rather than a pass-through for every single healthcare transaction.

How do I know if direct primary care is right for my organization? 

Organizations utilizing our direct primary care program range from small businesses to midsize municipalities to Fortune 500 companies with thousands of employees under their care. My team can work with you to learn the details and nuances of your company and discover how Paladina Health might positively impact your employed population and healthcare spending.

To get the ball rolling, contact us online or call us at 1-866-808-6005 and select option 4. You can also reach out to me directly via email at

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Further reading: case studies and white papers

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