Many have commented on my laments at the difficulty of practicing primary care in the US. One of the recurrent themes centers around whether or not physicians should just stop accepting insurance altogether.
One reader commented:
For me, the doctors I see most frequently simply don’t take insurance. Less office staff, more doctor time. I pay a 30% out of network copay, which often doesn’t work out to much different than what my office visit charge would have been anyway. those doctors take phone calls during the day, call back at night, etc. The minor difference in cost is worth it!! they are always booked and seem to be doing fine financially. In this area, in certain specialities, if a doctor is any good, they have opted out of insurance.
If you can’t get an incentive system with the insurance companies, I would consider the no insurance model to be a good one.
And another:
We sit and wait for someone else to fix the system do not become proactive, and wait each year for the bad news from the insurer, medicare, etc.
Patients….fire your classic insurance company, opt for a very high deductible or a major medical polilcy.
Doctors….stop taking insurance except for surgeries, hospitalizations and/or major workups.You will see how fast the insurers belly up and change their tune…..Americans unite, we do not need them…
In his editorial in USA today, Kevin Pho points out that over 40% of Texas physicians don\’t accept new Medicare patients. Truly, if the recent Medicare cuts had not been stopped, our practice would have lost money on many things we do and would be forced to strongly consider doing the same.
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The business argument for quitting insurance is solid. I would not need billing staff, could give upfront fees to patients, and could set my rates as I saw fit. I would not have to do authorizations for procedures – passing any hassles off to other physicians. In my market, I could even charge an annual fee for the many IT services we offer above and beyond what most practices offer.
Ironically, I could also start not charging patients if I choose. Since I am a Medicare provider, to no-charge a non-Medicare patient would be considered fraudulent. Why? Because I am not also extending that discount to my Medicare patients.
So why don\’t I do it? Why do I hang on to the arcane, complicated mess of medical insurance?
If you ask a patient who their doctor is, they will almost always refer to their primary care physician. I am their doctor and they are my patients. As a physician, I have taken on the task of helping my patients navigate through their sicknesses as well as working to prevent them. This is the reason I chose primary care: I wanted to build long-term relationships with my patients. I wanted them to see me as their doctor.
Specialists deal either with a single body system (such as heart or lungs) or perform procedures the patient needs on the short-term. They do build long-term relationships with some patients, but it is only the sicker, more complicated patients. Even then, they (hopefully) send their notes back to the patient\’s PCP, so someone can know and understand the over-arching needs of the patient.
Dropping insurance would come at a cost: I would lose a large number of my patients. I like a lot of them. I have helped them through tough times and have enjoyed having many of them. They aren\’t all demanding. They aren\’t all frustrating. They are just caught in the same mess I am in. It is very hard to cut them loose in a time when the PCP market is shrinking.
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This is a big reason as to why the trust between patients and doctors is going down. Physicians are being forced to decide between money and patients. They are being forced to look after themselves when their job is to look after others. This contradiction is not lost on the patients and causes doctors to become suspect in their eyes. The focus on the business of medicine has taken the focus off of the practice of medicine. This is why many patient feel \”like a number.\”
It amazes me that I would even consider dropping insurance. The cost would be huge. I would lose many long-term relationships. They would feel jilted and betrayed. It would appear that I am \”all about the money.\”
Even though my income would go up if I did, I am not ready to do that to my patients. It is emotional, not economic.
Let\’s just hope that things change before I am forced to stop being their doctor.
I’m noticing lots of doctors, esp big name specialists in NYC not taking any insurance but writing off the difference between the out-of-network insurance reimbursement and their charges. This could be a way to go for some providers, but I doubt it’d work for PCPs considering the already low reimbursement rates.
What I think is that people need to start seeing PCPs as the ‘manager’ of the specialists, instead of basing importance/value based on amount of specialized training one has. For me my neuro-onc happens to be the main go-to for all NF related things but my PCP still knows everything about NF and other things going on with me so really, he’s just as important as my neuro-onc but my insurance co dosn’t think so. BTW, if he ever goes cash-only I’m totally following but not the neuro-onc.
I’m noticing lots of doctors, esp big name specialists in NYC not taking any insurance but writing off the difference between the out-of-network insurance reimbursement and their charges. This could be a way to go for some providers, but I doubt it’d work for PCPs considering the already low reimbursement rates.
What I think is that people need to start seeing PCPs as the ‘manager’ of the specialists, instead of basing importance/value based on amount of specialized training one has. For me my neuro-onc happens to be the main go-to for all NF related things but my PCP still knows everything about NF and other things going on with me so really, he’s just as important as my neuro-onc but my insurance co dosn’t think so. BTW, if he ever goes cash-only I’m totally following but not the neuro-onc.
And that is why insurance companies feel like they can take advantage of all of us. Insurance companies lack compassion. They are increasing their profit margins by bullying both doctors and patients.
One problem with the huge deductible major medical plans: they arent much cheaper. We shopped around. With our regular, fairly low number of visits, we would have paid more to doctor and insurance combined than if we just got the insurance our company provided.
And that is why insurance companies feel like they can take advantage of all of us. Insurance companies lack compassion. They are increasing their profit margins by bullying both doctors and patients.
One problem with the huge deductible major medical plans: they arent much cheaper. We shopped around. With our regular, fairly low number of visits, we would have paid more to doctor and insurance combined than if we just got the insurance our company provided.
I have pretty good health insurance, thankfully. Yet I don’t have a PCP, and I haven’t, at age 36, had a physical in years.
Why? Because I hate the rigamarole, and I hate not knowing how much I’m gonna pay. I hate having to find a doctor. I would love to have a PCP like Dr. Rob or the FP in this article below–and Dr. Rob, have you thought about converting to this type of practice? Seems like a win for everyone involved.
http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1016.htm
I have pretty good health insurance, thankfully. Yet I don’t have a PCP, and I haven’t, at age 36, had a physical in years.
Why? Because I hate the rigamarole, and I hate not knowing how much I’m gonna pay. I hate having to find a doctor. I would love to have a PCP like Dr. Rob or the FP in this article below–and Dr. Rob, have you thought about converting to this type of practice? Seems like a win for everyone involved.
http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1016.htm
You’re singing my song, Dude. But eventually what happens is that our duty to ourselves outweighs our duty to our patients; then we go cash-only. Many patients leave; we wring out hands at having abandoned them. Then, later, they come back, because what you (and I offer) is real, and worth paying for.
January 1, 2011: that’s my Quit Date for insurance.
You’re singing my song, Dude. But eventually what happens is that our duty to ourselves outweighs our duty to our patients; then we go cash-only. Many patients leave; we wring out hands at having abandoned them. Then, later, they come back, because what you (and I offer) is real, and worth paying for.
January 1, 2011: that’s my Quit Date for insurance.
There may be an easier way to solve the financial woes. I went to see my neurologist this morning. The staff took my co-pay, and then told me the doctor was out sick. I was so shaken up after waiting six weeks to see him that I didn’t even think to ask for my money back. What could be better than getting paid for not seeing patients.
There may be an easier way to solve the financial woes. I went to see my neurologist this morning. The staff took my co-pay, and then told me the doctor was out sick. I was so shaken up after waiting six weeks to see him that I didn’t even think to ask for my money back. What could be better than getting paid for not seeing patients.
Great post. I’ve had difficulty explaining to my non-med friends, especially one whose background is in economics, why the free market business model that works decently well in other areas doesn’t really apply to medicine. Even though you’re writing from a primary care perspective (and certainly that’s been the hardest hit by the current reimbursement incentives), I think the same arguments apply for specialties too. There was a New York Times article a few weeks ago about dermatologists running two-tiered practices; the cosmetic, pay-up-front patients even get their own swankier waiting room, because God forbid they should have to be anywhere near those horrible people with acne and eczema!
I’ve added you to my blogroll — keep ’em coming!
Great post. I’ve had difficulty explaining to my non-med friends, especially one whose background is in economics, why the free market business model that works decently well in other areas doesn’t really apply to medicine. Even though you’re writing from a primary care perspective (and certainly that’s been the hardest hit by the current reimbursement incentives), I think the same arguments apply for specialties too. There was a New York Times article a few weeks ago about dermatologists running two-tiered practices; the cosmetic, pay-up-front patients even get their own swankier waiting room, because God forbid they should have to be anywhere near those horrible people with acne and eczema!
I’ve added you to my blogroll — keep ’em coming!
Interesting post! I have been an employed physician throughout my career, but I have been contemplating starting my own office as a solo practitioner. I might try it in a few years, and this would be the way to go. One of my former colleagues has started his own office with a cash-only practice. He is a unique fellow who should do well with this mode of practice: http://ronmorrellmd.com/ is the link to his practice.
Interesting post! I have been an employed physician throughout my career, but I have been contemplating starting my own office as a solo practitioner. I might try it in a few years, and this would be the way to go. One of my former colleagues has started his own office with a cash-only practice. He is a unique fellow who should do well with this mode of practice: http://ronmorrellmd.com/ is the link to his practice.
[…] of a Distractible Mind has a very well written post on the mess that is medical insurance. One of my very good friends outside of medical school has […]
A lot depends on your local insurance market. In my area, there are a lot of “managed care” plans (including Medicare managed care) out there that market themselves aggressively to the employers; then for the employees they turn out to be pretty reasonable compared to other options since they are subsidized. Then the insuree/employee is locked in; they can’t get a test or hospitalization or ER visit approved unless it is ordered by an “in-network” provider. So it makes no sense for them to pay out of pocket to see a PCP out of network no matter how good a service they get. A cash only doc can find him/herself squeezed out of the market. On the other hand, if you lived in an area with lots of non-contract workers (waiters, bartenders, fruit pickers…) a cash dr might be a great fit in the community and really find a niche/supply a need.
A lot depends on your local insurance market. In my area, there are a lot of “managed care” plans (including Medicare managed care) out there that market themselves aggressively to the employers; then for the employees they turn out to be pretty reasonable compared to other options since they are subsidized. Then the insuree/employee is locked in; they can’t get a test or hospitalization or ER visit approved unless it is ordered by an “in-network” provider. So it makes no sense for them to pay out of pocket to see a PCP out of network no matter how good a service they get. A cash only doc can find him/herself squeezed out of the market. On the other hand, if you lived in an area with lots of non-contract workers (waiters, bartenders, fruit pickers…) a cash dr might be a great fit in the community and really find a niche/supply a need.
I see exactly where you’re coming from. Pretty much everyone I know, if asked “who is your doctor?” replies with the name of their GP/PHP, or the member of that practice that they see most often. They signally do not reply with the name of a consultant in a specialty.
I see exactly where you’re coming from. Pretty much everyone I know, if asked “who is your doctor?” replies with the name of their GP/PHP, or the member of that practice that they see most often. They signally do not reply with the name of a consultant in a specialty.