The traditional healthcare landscape is complicated and largely dictated by insurance companies; patients are often restricted to a limited panel of specialists and preferred lists of covered medications and tests, based on algorithms that determine appropriate courses of treatment. Specialists’ medical judgment becomes secondary since they’re beholden to the payer and not the patient. For patients, between premiums, copays, co-insurance and deductibles, the cost of patient care has become both confusing and astronomical. and appointments often must be booked several weeks, or even months, in advance. This all severely limits access to vital care. 

According to the American Medical Association over 1,000 physicians found that more than 90% of respondents said prior authorization “had a significant or somewhat negative clinical impact, with 34% reporting that prior authorization had led to a serious adverse event such as a death, hospitalization, disability or permanent bodily damage, or other life-threatening event for a patient in their care.” This data, based on AMA’s 2021 Prior Authorization (PA) Physician Survey, is a clear red flag for change. 

Direct Specialty Care Overview

Direct Specialty Care (DSC), similar to Direct Primary Care, flips the model of traditional, insurance-led healthcare, and puts the patient-physician relationship at the center of care. It operates as a subscription service with an affordable membership fee instead of fee-for-service and insurance billing. Patients are able to access the care they need quickly without third-party payor interference, resulting in receiving the care they need. Providing patients with access to specialty care without the need for referrals, pre-authorization, and insurance gatekeepers, DSC results in improved access and transparent pricing for patients. 

Physician-Led Care with Transparent Pricing 

By removing insurance from the equation, patient care is led by physicians, enabling them to practice their medical specialty in the way that they envision best for their patients. Physicians have more time to review a patient’s health holistically, so they can treat the person, not the individualized symptoms. This leads to higher patient compliance of treatment plans since the doctor-patient relationship is stronger and the patient is better informed and supported in their plan of care.

Direct Specialty Care practices do not charge copayments or send surprise bills. Because they don’t contract with insurance, practices eliminate overhead costs for billing and coding, filing insurance claims, following up on reimbursements, and other administrative tasks. This directly translates to lower costs to the patient.

In direct specialty care, practices do often contract with lab and imaging centers, providing patients with discounted and transparent pricing up front. Insurance can still be used to cover costs of imaging, test, and medications, however, which gives patients the option to pay a discounted cash price or submit as an insurance-covered service, based on their out of pocket costs. Insurance companies do not disclose how much they pay for patient appointments and tests, and patients often end up limiting their care based on covered services. DSC solves this issue; physicians bundle comprehensive courses of care, so that pricing isn’t exorbitant, and patients know what they’re costs will be - affordable pricing at fair market value. 

Improved Access and Patient Satisfaction

A major concern in specialty care is patient access; insurance companies limit patients to a finite list of facilities and practices, often resulting in weeks or months long wait times for a fifteen minute appointment. This is often in addition to preauthorization requirements. Direct Specialty Care expedites diagnoses and interventions - essential for time-sensitive health concerns. Adding to the patient experience, DSC creates continuity of care between physicians and specialists, gives patients direct communication with their providers, and, again, increases patient adherence to treatment plans. 

A Win for Patients, Providers, and Employers

Direct Specialty Care not only benefits patients and healthcare providers, but also employers who offer healthcare plans to their employees. Contracting directly with specialist providers, employers can offer their employees streamlined access to high-quality care they need, eliminating unnecessary insurance-related costs and worker’s time away from work. 

Ultimately, the Direct Specialty Care model represents a shift toward a more patient-centered, efficient, and transparent healthcare system. Eliminated are the limited access, and long wait times to see a specialist as well as the surprise bills, and jumping through hoops to achieve a path to wellness. By prioritizing the patient-physician relationship, removing unnecessary administrative burdens, and providing affordable, accessible care, DSC offers a promising solution to the shortcomings of traditional healthcare. 

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Ready to get your practice started on the Direct Specialty Care model? Hint provides powerful membership management, billing, and payment software for primary care, urgent care, and specialty practices that offer memberships, subscriptions, or cash pay services. Learn more: https://www.hint.com/software 

For a comprehensive guide to starting, managing and growing a Direct Primary Care practice, download Chapter One of our DPC Playbook, a step-by-step guide for DPC clinicians, or become a Hint Customer to access the full playbook.