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The Financial Sense of Choosing Head2Toe Pediatrics over an Insurance-based Provider

Can you think of a parent who doesn't want what is best for their child? I've come across many parents during my years as a pediatrician and I sure can't. As a mother to be myself, I also want what is best for my growing baby girl.

The caveat?

Children don't come with instruction manuals!


The good news?

Pediatricians go through extensive educational programs and rigorous training to specialize in the care of children. Choosing a pediatrician you can trust and communicate with is the closest thing to having an instruction manual for your child.


For me, providing the best in medical care translates into:

  1. Providing accessible care that gives parents the ability to easily schedule for preventative wellness visits, sick visits and answers to questions without delays. In an environment that is welcoming, safe and stress free.

  2. Providing compassionate care that is not restricted to 15-20 minute slots with the provider, because every child is unique and so are their healthcare needs.

  3. Providing quality care by highly skilled certified providers that are constantly growing and expanding their knowledge to better serve our families.

If you're a parent looking to provide the best for your child, I would argue that one way you can do so is by joining Head2Toe Pediatrics!


But first, let's discuses the financials...


Let's talk money!

A common question I get from prospective families is if my pediatric practice accepts health insurance. The answer is no, but let's dig deeper into the why and other things you may want to consider before crossing Head2Toe Pediatrics off your list.


What is direct primary care?


Direct primary care (DPC), commonly viewed as "having a doctor in the family", provides an alternative to the fee-for-service model and brings back the old-fashioned doctor-patient relationship. DPC providers charge families directly, removing third parties and insurance barriers, allowing for personalized care that has YOUR health goals and well being as the top priority. Many families tell us they feel like celebrities having their own personal doctor they can text and communicate with directly. Our view is that celebrities and the super-rich shouldn't be the only ones with personalized access to healthcare. DPC makes personalized healthcare affordable for everyone!


Head2Toe Pediatrics DPC model involves a monthly membership fee based on the child's age, which covers unlimited pediatric primary care needs without copays, deductibles or surprise bills. The membership plan offers families 24/7 access to a board-certified pediatrician and includes house calls!



How do families save money?


Let's highlight a few of our membership perks that save families money, even families with great health insurance coverage.


UPFRONT PRICING

Our flat monthly fee covers all health care provided by Head2Toe Pediatrics, offering families price transparency. This includes unlimited wellness visits, unlimited sick visits, unlimited telemedicine, emails, texts, calls, 24/7 access, house calls as well as certain acute care procedures. There are no copays or extra charges per utilization of services. In the scenario where there may be additional charges for a service, families are informed of this cost prior to consenting for treatment.


What is it like with an insurance-based provider?

First, it's important to understand your insurance plan and the agreement you have. All health insurance providers require the insured to pay some of the healthcare costs, this is known as cost sharing and you can learn more about it HERE. Different plans vary in how they structure their cost sharing.


One of the biggest downsides to health insurances is that you don't know the price of medical care upfront. When you call the insurance company for pricing, a common answer will be that they are unable to tell you what your coverage amount will be until the billing codes and services are submitted by your healthcare provider. This means that you don't know how much a service will be until after that service has been received. Even when preventative care may be an included benefit, it's not uncommon to later receive a bill in the mail.


Consider this: You take your child for their routine 6 month wellness visit. During this visit you have some concerns that your child may be constipated and ask about this. A few weeks later you receive a bill in the mail informing you that a payment is due. You went in for your routine wellness visit which is a covered benefit, so you are obviously confused. What happened? Because you had a concern related to an acute issue, this visit was now billed as both a sick and wellness visit when the provider submitted diagnosis codes not related to wellness care to the health insurance company, in your case, constipation concerns. But this also now means that if sick visits are not a fully covered benefit in your health plan, you will receive a bill in the mail for this portion of the visit.


How does upfront pricing save families money?

Families save money when they sign up for one of our membership plans because they can budget for the known expense and not worry about limiting their child's access to healthcare in order to avoid unforeseen medical expenses. New parents with lots of questions about their new baby, families with more acute care needs, families on high deductible insurance plans or families with insurance plans where the cost sharing falls mostly on the family will benefit the most from our membership plans.


CONTINUITY OF CARE

When you join Head2Toe Pediatrics your child will always be cared for by the same healthcare provider for every visit and every concern/question that you have. Families have the doctor's personal number to call or text with questions directly, 24/7. This means that you get to develop a personalized patient-doctor relationship. If your provider is away, chances are they will still remain accessible via text, phone, video and email to answer any concerns you may have about your child. If your provider is unavailable for visits, tele-health or message due to illness or vacation, arrangements are made to ensure your child is still cared for by a qualified clinician until your provider is available.


What is it like with an insurance-based provider?

The majority of insurance-based providers work for large organization or as part of a group practice. It's likely that you could see the same provider for wellness visits, but it's unlikely that you will be seeing your regular provider for sick or urgent care concerns. When you call in with questions a staff member, nursing line or other intermediary person will be answering the call and your concerns may not even get directed to your medical provider.


How does continuity of care save families money?

Having a healthcare provider that knows your child and family at every encounter leads to better management of chronic conditions, personalized care coordination, lower utilization of emergency services (ER, urgent care) as well as less unnecessary treatments and procedures. All these not only lead to decreased health care expenses from avoiding unnecessary ER visits, specialist referrals, prescriptions, etc. but also to a better patient care experience and improved health outcomes.


SMALL PATIENT PANEL

Head2Toe Pediatrics maintains a small panel size with each provider carrying 80-90% LESS patients than traditional insurance based providers. This means that we are able to offer families longer appointment times, more flexibility with scheduling and 24/7 access to our board-certified pediatricians. Families don't sit around in waiting rooms waiting long periods of times to see the doctor, they are less likely to be directed to an urgent care or the ER for acute concerns that arise when the clinic is closed and our providers encourage shared decision making since they have time to educate and provide informed consent.


What is it like with an insurance-based provider?

Insurance based pediatric offices have patient panels up to 2,000-3,000 patients per provider. Insurances reward quantity over quality as payouts are based on a fee-for-service model and not on the quality of medical care that is provided. This means that your provider is restricted to 15-20 minute appointment slots which may not cover all of your questions and concerns. Your provider is likely to be booked when an acute care concern arises, which means that you are either scheduled with a different provider or squeezed into your providers already booked schedule. During office closures you are more likely to navigate through nursing lines, end up with clinic appointments that could have easily been handled through a tele-medicine consultation or end up with an unnecessary urgent care or ER visit. You may feel your doctor dismisses concerns, visits feel rushed even after you've waited hours to see the doctor, or the doctor doesn't encourage shared decision making given the little time provided per visit.


How does a small patient panel save families money?

Time is money! With highly accessible healthcare, families save time. No sitting in waiting rooms, no cancelled appointments or multiple reschedules which means getting care when the family needs it, at their convenience. When families have a provider that is flexible this means less time spent on Google searches, decreased need for follow up clinic visits to address concerns that weren't fully addressed the first time around, as well as decreased utilization of urgent cares/ER/specialist referrals and unnecessary procedures. All of this translates to more family time, less missed school days and less missed work days for the parents.


There are many more ways in which a direct primary care model can save you money (read more HERE), but before this post gets too long, let's address a very important question-


Do I still need health insurance if I'm a member of Head2Toe Pediatrics?

Yes, we highly encourage families to carry a health insurance plan.



Let's talk health insurance!

While Head2Toe Pediatrics membership fee covers your child's primary care needs, it is not a replacement for health insurance nor does it cover catastrophic health issues. Health insurance will cover services outside of those provided by Head2Toe Pediatrics, while also covering costs for vaccines, labs, and imaging.


99% of our members carry health insurance and we find that our model pairs well with PPO health plans or healthcare cost-sharing community plans which may provide reimbursements to the families for our services. Although we do not do any of the insurance billing, families are welcomed to submit claims themselves for insurance reimbursements.


Other options for families looking to minimize spending include pairing our membership plan with a high deductible health plan or health saving accounts such as an HSA or FSA.


Why does Head2Toe Pediatrics not accept insurance?


After completing my pediatric training I went the traditional route and worked as a fee-for-service insurance-based provider. This means that services provided by me to the families would be billed through an insurance plan. This worked well until it didn't. The system was set to reward quantity over quality and many insurance regulations limited not only the care that I could provide but also access to services for the families. The busier I got, the more barriers I faced and the more frustrated I became with the regulations. Medicine had become more about the administrative tasks than about the reason I went into medicine in the first place - to take good care of my patients. So I decided to leave the fee-for-service world and open Head2Toe Pediatrics, a direct primary care pediatric practice in Tampa Bay offering the very best in healthcare for your little ones!


We hope that you were able to learn more about ways in which we can save you money and look forward to telling you more about our membership plans and model of care.


Thank you for reading!

-Dr. Lastra


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