Lately I\’ve gotten hooked on watching the Discovery Channel\’s reality TV show, The Deadliest Catch. lt\’s astounding to me what these guys go through to catch crab in the Bering Sea.
One of the recurring themes on the show is the new crop of \”Greenhorns\” – new recruits to the profession of working crab boats – that try to show they can hack \”the world\’s most dangerous job\” each year. They often come with bravado and brashness, thinking that they can prove to the world just how tough they are. Reality hits quickly, and most greenhorns don\’t make it through the year. The more the bravado, the more quickly they seem to wilt.
Welcome to health care 2013: my reality TV show. Here is something my family just got from our insurance company:
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$1200 per month? This is double what we have been paying all along. Compared to this, the $50/month that I charge (maximum $150/family) seems pretty reasonable. This plan is, after all a high-deductible insurance that doesn\’t cover a whole lot of services, so a practice like mine that focuses on avoiding unnecessary tests, medications, and use of medical services would make a lot of sense, wouldn\’t it?
But people are scared and confused by what has been going on with the affordable care act. They are getting letters like this, and (like me) don\’t know how they can afford to do this. I have to admit, the irony of this happening as a result of something labeled \”affordable\” is not lost on me or my patients. It\’s also a tough irony to see how a practice like mine, which was built to offer access to truly affordable care, is being hurt by the ACA.
Today I got this from a patient who recently signed up:
I am sorry to inform you that due to our circumstances, and the ACA it is not feasible for us to use your service. We would still not qualify for appropriate coverage because we don\’t have hospitalization. We will just go to prompt care or the Emergency room if necessary. Actually I hope everyone drops their health insurance and goes to the emergency room, and show the socialists how we can totally decimate their ideas of forcing some to pay for others. If I didn\’t have so many personal issues right now I would have stayed with you, but if I would still be penalized for not being in an exchange, it doesn\’t make sense to keep going. Some months we don\’t even go to the doctor, so I must say Thank you, for your work with us, and I hope you are able to weather the storm, and we wish you success.
While this sentiment is fairly strong, it is fairly representative of people\’s feelings on this issue. Other direct care providers have reported a significant drop in the number of people signing up.
The solution, I am told, is to combine what I am doing with a \”wrap around\” high-deductible plan, and that \”will meet the ACA requirements\” and get the person out of paying the fine. Many/most of my patients are interested in this possibility, both for themselves and for their businesses (as a very large percentage of my patients are owners of small businesses). This would benefit all parties, it would seem:
- This would be a huge gain for me, as it would give my practice an inside-track to a large number of patients.
- It would be good for the patients, as it would give them the ability to avoid the fines while maintaining high-quality care.
- It would benefit the small businesses as they\’d be able to insure their employees or at least be sure their employees weren\’t getting socked with huge insurance bills (see above).
- It would benefit the insurance companies, as I would be far more focused on avoiding spending up the patient\’s deductible, reducing unnecessary testing, and keeping the patient out of the ER/hospital. In short, they would reduce the risk, which is speaking in a language insurance companies know well.
This is where, just like it does to a greenhorn on The Deadliest Catch, reality hits. It\’s not as easy as I thought. I thought the contrast of my practice\’s simplicity with the complexity and confusion of the ACA would have people seeking alternatives. Enter me stage left with heroic bravado, here to save the health care system! But I am met with the same smirks and sneers thrown at the greenhorns by the weathered deck hands.
None of my patients know what to do, and I could probably get several hundred covered lives\’ worth of business for an interested insurer. I could make some employers happy and the lives of a bunch of employees happy as well. But when it gets right down to it, I am met with blank stares. How crazy, wanting to do things in a better way! How crazy, trying to improve care quality while saving money! How crazy trying to offer truly affordable care! Don\’t I know that there is no cutting into line here, and that I\’ll have to fill out all the proper forms and stand at the end of the line until my turn comes?
I\’ll still hit the street and try to get answers for my patients. I\’ll still be calling more insurance agents trying to put something together that doesn\’t make a mockery of the word \”affordable.\” But I suspect my hopes for gaining some advantage by the provision in the ACA for pairing practices like mine with wrap-around plans is not reality.
These crab pots are coming back empty.
I enjoy reading your blog. Although I’m sure there is a lot that I still don’t know about the issues you raise, I have seen a couple of sites that seem to be pairing with health plans in an exchange and/or offering corporate plans. Check out Baskin Clinic in OR and Qliance in WA.
Then again, is your core customer the person who is looking to get full coverage insurance by the ACA or the person who already has health insurance but supplements it by choosing to go to you. It may be worth losing the 20% of patients who need to get a full comprehensive plan to serve the 80% of people who want your services as a luxury. Plus, who gets into this to deal with insurance companies again?
I’ve been reading your blog since you started your transition. Please stay the course! I would have signed up with you if I could. There are no doctors doing this in my area yet and I desparately want it. The cost of going to the doctor has gone up tremendously over the last few years and that is with insurance. I have a high deductible catastrophic plan so I am very cost conscious of every fee. Your type of practice would be worth it to me.
I believe you became a doctor because you would not accept defeat. You have endured years of college and then medical school, to learn to treat conditions and illnesses that, in the end, will always be fatal. Even a healthy life will always end in death and that is not defeat.
A 50-year old man enters your office after his first heart attack. Three arteries are completely blocked and he has horrendous hypertension: give up now, and he’ll be dead of another heart attack in less than six months. Not acceptable, you say! He has surgery to clear the blockages and begins medication to bring his blood pressure down; that man lives another thirty years to see his grandchildren have children.
A baby is born blue and not breathing; the umbilical cord is wrapped around his neck. He is not breathing: give up now, he’s almost dead already. Not acceptable, you say! You administer CPR and he takes a first breath…and another, until his loud crying fills the delivery room and his little body becomes a healthy, lively pink.
A woman comes into your office suffering from chronic illness and pain. She’s seen many doctors and been diagnosed with several uncommon conditions. She is looking for a primary care physician and has been turned away by several; some don’t believe her and others believe that her illnesses are too difficult for them to treat. Not acceptable, you say! You take her into your care, learn about her conditions and manage her illnesses with the help of her specialists. She becomes stable, able to function most days, her pain diminishes and her quality of life improves.
You did not become a doctor because it was easy. You worked within a system that increasingly separated the doctor from the patient and reduced the person you cared for to illness codes and decision trees. Not acceptable, you say! So you strike out on your own to create a new place, a new system of real caring for real people instead of just patients.
That man was my grandfather. That baby is my son. I am the woman. You may not be the doctor who treated us, but it was a doctor just like you: someone who cares. Don’t give up, don’t accept defeat: you ARE making a difference in so many real people’s lives!
Keep plugging away Dr. Rob.
Also, a national ideal is (should be) to pay for POOR people’s healthcare–not old people’s, not middle income people’s, not Red Sox fans’ etc. That is the issue with the whole
Just a patient, but I think you might have a point here. I may be missing something about what Dr. Rob is trying to say, perhaps because of my constant dread of the impending Alpacalypse, but there is no way I would consider going without some sort of true health insurance that covers things like hospitalization for deadly llama bites (at least one person in GA had to undergo post-exposure prophylaxis on account of a rabid llama, I spit you not). I would still be interested in a practice like Dr. Rob’s because it seems sometimes that there is nowhere within the current insurance paradigm that allows me, a young patient with multiple chronic illnesses and a list of medications that requires me to take my socks off so I can count them, to find a doctor who has both the time and training to look at the big picture and try to integrate all the parts. However, there’s also nothing that obligates any of Dr. Rob’s colleagues to consult at a loss or perform anything but the most urgent procedures if I can’t prove that I can pay.
I do, however, recognize the irony of the "Affordable" Care Act and the difficulty of trying to improve access to and payment for healthcare delivery. The Law of Unintended Consequences is a [this word has been deleted because there are crias present].
Dr. Rob,
Those of your patients who are Christian may find it helpful to look into the healthshare programs that qualify as Obamacare substitutes. The monthly shares are relatively low and the "deductibles" per "incident" are much lower than the thousands required for premiums and deductibles of a lot of Obamacare exchange plans. I recommend Christian Healthcare Ministries, but there are two others (Medi-Share and Samaritan). I ran a lot of numbers because I would like to belong to a practice like yours and CHM was a lot better for my situation than the now catastrophic plans masquerading as comprehensive insurance offered on the exchanges.