Direct Care and Insurance: How to Choose What Makes Sense for You

A Kidney MD patient guide

Many patients at Kidney MD ask:

“If I have health insurance, why would I pay directly to see a nephrologist?”

The answer depends on one key factor:

Do you expect to meet your insurance deductible this year?

Understanding this can help you choose the most cost-effective and patient-centered way to receive kidney care.

What Is Direct Care?

Direct care is a healthcare model where patients pay their physician directly, rather than billing insurance for every visit.

At Kidney MD:

• Insurance can still be used for labs, imaging, hospitalizations, and procedures

• Direct care focuses on access, continuity, and proactive management

• Pricing is transparent, without surprise bills or facility fees

This model allows us to practice medicine the way it was meant to be practiced—unhurried, thoughtful, and relationship-based.

Why Insurance Alone Doesn’t Always Mean Lower Costs

Insurance is essential for protecting against high-cost medical events.

However, for routine and ongoing physician care—especially before your deductible is met—insurance does not always lower your out-of-pocket cost.

In fact, the negotiated insurance rate is often higher than the self-pay rate.

Why Is the Insured Price Often Higher?

Traditional insurance-based practices must account for:

• Billing and coding staff

• Insurance claims submission and follow-up

• Denials and collections

• Compliance requirements

• Delayed or partial insurer payments

These administrative costs are built into the price of care and ultimately passed on to patients.

A Real-World Example

Patient With Insurance (High-Deductible Plan, Deductible Not Met)

• Negotiated rate for specialist visit: $300

• Facility fee (common in hospital-owned practices): $200

• Total out-of-pocket cost: $500

Even though the patient is insured, they pay the full amount until the deductible is met.

Patient Paying Directly (Self-Pay / Direct Care)

• Transparent self-pay price: $225

• No facility fee

• No insurance-related administrative overhead

• Total cost: $225

Same physician expertise. Very different cost.

The Key Decision: Will You Meet Your Deductible?

This is the most important question patients should ask.

If You Expect High Medical Costs This Year

Traditional insurance-based care usually makes more financial sense if you expect:

• Hospitalizations or procedures

• Expensive imaging or treatments

• Frequent high-cost services

Once your deductible is met:

• Insurance covers a larger portion of costs

• Visits become less expensive

In this situation, using insurance strategically helps maximize your benefits.

If You Do NOT Expect to Meet Your Deductible

Many patients:

• Have high-deductible plans

• Are relatively stable

• Need ongoing kidney care and monitoring

• But never reach their deductible

In this case, patients often pay full price all year, despite having insurance.

For these patients, direct care can allow you to save your own money, avoid inflated negotiated rates, and still receive high-quality, continuous nephrology care.

Why This Matters for Kidney Health

Chronic kidney disease (CKD), hypertension, and related conditions benefit from:

• Regular follow-up

• Early medication adjustments

• Timely lab review

• Easy communication with your nephrologist

Direct care supports proactive management, rather than waiting for problems to escalate.

The Kidney MD Approach

At Kidney MD, we help patients:

• Understand their insurance options

• Decide when direct care makes sense

• Use insurance when it truly adds value

• Avoid unnecessary costs and delays

There is no single right answer—only the right choice for your health and your situation.

Frequently Asked Questions

Is direct care the same as concierge medicine?

No. Direct care focuses on access and transparency, not luxury services. It is designed to improve care, not exclusivity.

Can I have insurance and still use direct care?

Yes. Many patients use insurance for labs, imaging, and hospital care while paying directly for physician visits.

Is direct care cheaper than insurance?

It depends. If you do not expect to meet your deductible, direct care may cost less for physician services.

Does Kidney MD accept insurance?

Kidney MD works with patients to determine when insurance or direct care is the best option for their care.

Is direct care good for chronic kidney disease?

Yes. CKD benefits from continuity, close monitoring, and timely adjustments—all strengths of direct care.

The Bottom Line

• Insurance is essential for high-cost medical events

• If you expect to meet your deductible, traditional insurance-based care is often best

• If you do not expect to meet your deductible, direct care can be a cost-effective and patient-centered option

The goal is not to replace insurance—but to use it wisely, while ensuring you receive the care you need.