Diagnosed in 2 Months After Searching Since 2022. Her Doctor Still Says Keep Insurance for the Big Stuff.

Dominique Spagnola had just had a baby. Then her body started acting wrong, and she couldn't get in to see her primary care doctor or the specialists she needed.

She'd been chasing answers since 2022. So she reached out to Dr. Meghan Montie, who runs Heirloom Family Medicine, a direct primary care practice in Albany. "She immediately got me right into these specialists that I needed to see," Spagnola told CBS6.

Within 2 months she had an official diagnosis, primary aldosteronism, a condition where one adrenal gland malfunctions, and a pathway to a cure.

Years of searching. Then 2 months.

That's what happens when a doctor has time. Heirloom patients pay a monthly membership of $250 to $600 and get 24/7 access by phone, text, or email, same- or next-day appointments, and longer visits. Montie even sees some patients at home if they're postpartum or have trouble getting around. "It really just allows me to go much deeper with my patients," she said.

Spagnola's verdict on the fee: "The monthly membership is something I don't even notice." She figures that if she'd started with Heirloom sooner, she'd have saved about $2,000.

Here's the line I want every direct care patient to hear, and it came from the direct care doctor herself:

"Health insurance is still very important for catastrophic events."

She's right. Spagnola kept her insurance through work alongside the membership, and Montie says that's common. Some of her patients pick a higher-deductible plan with lower premiums and pair it with direct care.

So direct primary care handles the everyday. It fixed a diagnosis that the old system dragged out for years. But it was never meant to pay for the night you end up in the hospital.

The catch is what those higher-deductible plans actually do when something big happens. You hit the deductible first. You find out what's in network and what isn't. Then you get the bill.

That gap is why we built Atlas Direct. It pairs with your direct care membership and pays cash benefits for hospital stays, ER visits, surgery, and childbirth. No deductibles to burn through first. No networks to check. The money goes to you, and you decide how to use it.

Your doctor handles your health. Atlas Direct handles the catastrophe. Neither has to pretend to be the other.

Montie says direct care fits people with nontraditional jobs who don't have insurance, and people who change jobs often and don't want a new doctor every time their coverage changes. That second group should think hardest about the big stuff, because coverage tied to a job leaves when the job does.

Spagnola got her answers in 2 months. The next step is making sure the bill for the worst day of your life doesn't take years to pay off.

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Source:

• CBS6 Albany, "As insurance costs rise, more doctors offer direct primary care as a cheaper option" (Oct 19, 2026): cbs6albany.com/news/wellness-watch/as-insurance-costs-rise-more-doctors-offer-direct-primary-care-as-a-cheaper-option

0.9% Instead of 6.2%: What Happened When Michigan Employers Paid for Direct Primary Care

Picture a warehouse supervisor with diabetes. It's Saturday. His meter reads 340 and his feet feel strange. Last year he would have spent 4 hours in an emergency room waiting to be told what to do. This year he texts his doctor. She adjusts his insulin over the phone, checks on him Sunday night, and sees him Monday at 8.

Nothing dramatic happened. That's the whole idea. Multiply that Saturday across a whole workforce and 5 years, and you get a number.

Last week SALTA Direct Primary Care, a membership practice with clinics in southeast Michigan, released 5 years of results with the benefits company Ameriflex. Their employer clients paid for workers' memberships through a health reimbursement arrangement, so the flat monthly fee went out in pretax dollars. The regular health plan stayed in place for specialists, hospitals, and surgery.

They reported annual health care cost growth of 0.9%, against an expected trend of 6.2%. Emergency department visits fell 31%. Inpatient admissions fell 71%. Patients came back to the ER at a rate of 23%, compared with 42% for traditional primary care groups. Employers saved $13.84 million over 5 years, a 2.2x return.

For scale, KFF says the average family premium for job-based coverage reached $26,993 in 2025, up 6% in one year. A cost line that grows 0.9% a year is a different kind of business.

Now the honest part, because you deserve it, and so do the employers deciding this month.

Medical Economics covered the release on Monday and listed what it leaves out. Who ran the analysis. How many employers and employees took part. Which years. Where the 6.2% came from. This is a press release, not a peer-reviewed study.

There's a known trap, too. A 2020 Milliman study for the Society of Actuaries found that employees who choose direct care tend to be healthier to begin with, and studies that don't adjust for that can hand DPC credit it didn't earn. After adjusting, Milliman still found DPC members used less emergency and facility care. But the employer's net cost came out an estimated 1.3% higher, within a wide range, partly because the employer paid the fees and also waived the deductible for everyone in the DPC option.

So I won't tell you 71% is a law of nature.

I will tell you the direction keeps showing up. When people can reach their doctor, fewer of them end up in the most expensive building in town. SALTA's own case study says clinic users had a 25% lower rate of hospital stays than members who didn't use the clinics, even though they carried 40% more chronic illness. An ER visit is often a primary care visit that couldn't find an open door.

At AtlasMD we see the same thing from our side of the exam table. Members text and call their doctor. Meds are at cost plus 10%, and the prices are posted. A worried Saturday becomes a phone call instead of a triage bracelet.

It's open enrollment season. Employers are deciding right now how to absorb another year of increases, and the usual answer is a higher deductible and a bigger paycheck deduction. That moves the bill around. It doesn't make it smaller.

Paying for the doctor first is a different bet. Keep insurance for the wreck. Put everyday care up front, at a flat price, where people will actually use it.

I'd love to see SALTA publish the denominator. Everyone in direct care should want better data more than bigger headlines. But if you're an employer staring at a 2027 renewal, ask your broker one question: what happens if my people can just call their doctor?

0.9% isn't a miracle. It's what an open front door looks like on a spreadsheet.

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Sources:

Medical Economics, "Paying for direct primary care through employer HRAs slowed cost growth over five years, data show" (Oct 19, 2026): www.medicaleconomics.com/view/paying-for-direct-primary-care-through-employer-hras-slowed-cost-growth-over-five-years-data-show

Ameriflex and SALTA Direct Primary Care release, Business Wire (Oct 14, 2026): www.businesswire.com/news/home/20261014604123/en/Ameriflex-and-SALTA-Direct-Primary-Care-Announce-Breakthrough-Results-from-HRA-Backed-Healthcare-Model

Accresa, SALTA case study: accresa.com/scaling-direct-primary-care/

KFF 2025 Employer Health Benefits Survey: www.kff.org/health-costs/annual-family-premiums-for-employer-coverage-rise-6-in-2025-nearing-27000-with-workers-paying-6850-toward-premiums-out-of-their-paychecks/

Society of Actuaries / Milliman, Direct Primary Care: Evaluating a New Model of Delivery and Financing (2020): www.soa.org/globalassets/assets/files/resources/research-report/2020/direct-primary-care-eval-model.pdf

A Tie Is Not a Discount

Hospitals have had to post their prices since 2021. They post two of them: the cash price, and what insurers negotiated. SumHealth, a price-data company, put both side by side for a brain MRI at 539 hospitals.

At about half, cash was cheaper than the median insurance rate. At the typical hospital, it was a tie.

I am not shocked. The network discount was always sold as the good price. A tie with walking in and paying isn't a discount. It's paperwork.

I am not anti-insurance. Keep a policy for the wreck. But for the scan, the labs, and the visit, a posted price you can see before you go beats a negotiated rate you find out about after.

Direct care has done this from the start. The number on the door is the number you pay.

READ MORE (sumhealth.org/blog/cash-beats-coverage)

43% Didn't Take Their Meds as Prescribed Over Cost. Epic's Price Tool Arrives Summer 2027.

43%.

That is the share of American adults who told KFF this year that they had not taken a medication as prescribed because of the cost. 31% took something over the counter instead. 27% never filled the prescription. 19% cut pills in half or skipped doses. When KFF asked 3 years ago, the total was about 31%.

Last Thursday, Epic announced its answer. It's called Prescription Marketplace. When it ships in summer 2027, doctors and patients at health systems using Epic will see what a drug costs at different pharmacies, with insurance and without, before the prescription is sent. Amazon Pharmacy, Costco, LillyDirect, and Mark Cuban Cost Plus Drugs are in on it.

Cuban put it plainly: "If someone's insurance says a prescription costs $500 but they can buy the exact same drug for $100 at CostPlusDrugs.com, they should know that before they leave the doctor's office."

He's right. And good for Epic. I mean that. Putting the cash price on the doctor's screen before the prescription leaves the room is the right instinct. It's a crack in the wall.

But read Epic's own sentence again: "Depending on the medication, the patient's insurance plan, and the pharmacy, paying cash can sometimes cost less."

Sometimes. We built a system where people pay a premium every month for drug coverage, and the coverage can be the more expensive way to buy the drug. Then it took 2 years of development, and some of the biggest names in retail, to tell them so.

I am not shocked. When a pill has to travel through a formulary, a benefit design, a copay tier, and a claim, nobody at the counter knows the real price. Not the patient. Often not the doctor either.

In direct care, we skipped that part. At AtlasMD, meds are cost plus 10%, and the price is posted. When I wrote about sildenafil, our wholesale invoice was $9.59 for 100 generic tablets. The patient doesn't wait for a marketplace. They ask. I answer. Many common medicines go home with them from the office.

Picture a man with new high blood pressure. In the old system he gets a prescription, a copay he can't predict, and a decision at a pharmacy counter he makes alone. Maybe he fills it. Maybe he's one of the 27%. In a direct care office he leaves with the pill, the price, and my cell number.

I am not anti-insurance. Keep a policy for the wreck. Keep it for the drugs that really do cost a fortune. But for the everyday blood pressure pill, the statin, the antibiotic, insurance often isn't a discount. It's a toll booth in the fog.

Epic's tool will help patients inside big health systems shop smarter. That's progress. Direct care asks a simpler question: why did the price ever need a marketplace to be found?

43% of people aren't failing their prescriptions. The prices are failing them. Summer 2027 is a long time to wait for a number your doctor could tell you today.

Want more like this? Get the free newsletter: directcare.org/newsletter

Sources:

Epic, Prescription Marketplace announcement (Oct 15, 2026): www.epic.com/epic/post/prescription-marketplace-will-let-patients-compare-pharmacy-cash-prices-before-leaving-the-doctors-office/

Healthcare IT News (Oct 16, 2026): www.healthcareitnews.com/news/epic-launches-new-prescription-marketplace-price-transparency-tool

Fierce Healthcare (Oct 15, 2026): www.fiercehealthcare.com/health-tech/epic-teams-amazon-pharmacy-mark-cuban-launch-prescription-drug-pricing-tool

KFF, Public Views on Prescription Drug Costs (Mar 13, 2026): www.kff.org/public-opinion/public-views-on-prescription-drug-costs-regulation-affordability-and-trumprx/

directcare.org, Eighty-Seven Dollars a Pill Versus Ten Cents: directcare.org/blog/view/44/eighty-seven-dollars-a-pill-versus-ten-cents

44% of Texas Nonprofit Hospitals Bill You Before Checking for Free Care

Nearly half.

Tradeoffs and KFF Health News read the charity-care policies of 166 nonprofit general and children's hospitals in Texas. 44% say they will send you a bill before they screen you for free or discounted care. Some wait until after multiple bills. Some wait until a collector is already dialing. Only one system, Memorial Hermann, has a written rule to wipe the slate before the first invoice goes out.

Here is the part that sticks. Only 10 of those 166 hospitals guarantee a full refund if you paid first and later qualified for help. Aimee Carlock, a house cleaner, had to put up $5,500 before Texas Health Resources would schedule her surgery. She later got free care. The leftover $16,000 vanished. The $5,500 did not come back.

I am not shocked. Charity care is a policy on a website, not a price on the door. You apply. You wait. You borrow. You hope somebody reads the form before the collection letter arrives. That is not a safety net. That is a scavenger hunt with your rent money.

I am not anti-insurance. Keep a policy for the wreck. I am against a hospital that bills first and asks about need second. Direct care keeps everyday medicine on a monthly fee and a posted price. You know what you owe before anyone opens a chart. No application. No presumptive eligibility. No $5,500 hostage to schedule the visit.

44% is not a charity-care rate. It is a billing sequence.

Sources: Tradeoffs / KFF Health News, 7 Takeaways From an Investigation Into Financial Aid at Texas Hospitals (Oct. 15, 2026): kffhealthnews.org/health-care-costs/patient-financial-aid-texas-hospitals-charity-care-seven-takeaways/ Tradeoffs original: tradeoffs.org/2026/10/01/seven-takeaways-from-an-investigation-into-financial-aid-at-texas-hospitals/