The theory is that if a doctor is skilled enough, he or she can fill up their practice with private-pay patients without having to rely on an insurance panel.
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Well, I seem to see the logic in the idea that quality health care will be sought after. Considering the hassle of collecting payment from the diverse groups of insurance companies as well as copays and patient due after insurance coverage, why wouldn’t the best doctors choose to take self-pay patients? Cash up front, no hassle.
Of course, that “good” doctor will soon lose his skills if all he takes on are healthy rich people. You have to see and treat real pathology to be “skilled”. Alot of that pathology is not present in the aerobicised, latte-drinking, tennis-playing moneyed gentry, who could afford to pony up cash for a “good” doctor.
I would think the ideal is to be able to be selective about relationships with carriers, like maybe limiting to three or four of the better ones and maybe one that gives you access to interesting problems.
I distinctly remember one of the Ferrengis saying that about Dr. Bashir of Deep Space Nine.
Dr. Bashir could not possibly be any good because he didn’t charge anything.
I worked in a cash up front practice where I actually took most of the payments from the patients myself.
I have also worked in group with traditional model billing and insurance.
I have also worked in a capitated group.
and, I have worked in a public hospital with all Medicaid or uninsured patients.
I don’t know if the cash only practice attracts the better docs–I think it attracts the ones who think they are better.
But I can definitely say that I did my best work in the cash model clinic. Our culture makes a lot of money and it’s role in any relationship is a major shaping factor of the relationship. When the patient handed me their hard earned cash, it really focused my sense of obligation to give the best of my full attention and earn that. It also focused their attention on making the most of each visit. It cut both ways.
I will never work in a capitated practice again–the administration actively tried to make us inaccessible to limit care–even to the point of not having the phones answered. I would leave medicine first.
It is easy in salaried government/charity clinics to fall into seeing oneself as a benevolent giver of gifts, and for patients to become plaintiffs seeking the granting of gifts. That is not a good doctor-patient relationship either. It undermines personal responsibility by the patient who may have no skin the game but their time.
There are some good reasons that docs like to distance themselves from payment, One of the less laudatory reasons is that many prefer the positions of benevolent benefactor to the more intense and humbling sense of obligation that comes when someone hands you their hard earned money–maybe even from a second job that they took so they could see you–and then trusts you to earn it. It also removes the opportunity to say “Look what I have done for you!” for then you know that you have done nothing more than what they paid you to do for them. They, not you, are responsible for whatever benefits of treatment occur for you are only the agent that they hired with their blood and sweat.
I find that very humbling. When working in that situation, however much I may kick small dogs and snap at my wife, I treated my patients with utmost respect and attention and truly appreciated their patronage and trust.
Anon 7:30 said very well how cash pay affected HIM as a doctor. And I thank him for his honesty and reflection.
I also have worked under different systems. I also felt the cash paying patients deserved my best effort. But I think they are the crowd that has already made a healthy choice, Personal responsibility. Sort of like preaching to the choir. Not all, of course, but most. And further, I cannot say I did any better for them. It would take more analysis than is available. How can one know? It was, I agree, humbling.
But do we build a system to maximize physician performance or patient behavior? I agree that the “Irresponsible” systems are not healthy, for true health is a reflection of accepting responsibility. And the cash paying patient has already done that. My interest, my “saves”, the cases that most satisfied me were not the codes with a recovered pulse and consciousness or the early detected cancer, but the young man or woman given respect and attention who went on to lead a humble responsible life. I believe primary care physicians who know their communities and patients intimately can have this kind of leverage. Like the teacher, the coach, the pastor.
It shouldn’t be all about the physician.
Bravo Anon 7:30 PM well said.
I wouldn’t say that good doctors are the ones who don’t take insurance.
Rather, I would say that the good doctors are the ones who should stop taking insurance.
Insurance and manage care reimbursements are trending down, requiring primary care doctors to spend less and less time with their patients. Insurance companies place so many hurdles towards collecting money – you have to purchase expensive software to bill them, then you have to submit the claims, and then you should avoid coding for “depression” or “obesity” or “tobacco abuse” – all bad things that good PCP’s take care of but which greedy HMO’s/PPO’s don’t want to pay for. And then despite all that they always conveniently manage to “lose” your claims, even though you submitted them electronically. OR, they will refuse to pay for the office visit because you also coded for a procedure like pulse oximetry or cerumen disimpaction. Or they will just pay you in checks written out for 1-3 cents. Yes, United Healthcare, this means you.
Cash based care offers so many advantages. First of all, it puts the onus of responsibility on the patient to follow the doctor’s advice. Gone will be the days of expecting to get a doctor’s opinion for free, and then quietly deciding not to take the Lipitor he spent 45 minutes convincing you to take because your nutty herbalist wife disagreed. Gone will be the days of disrespecting the doctor when he tries to help you – if you don’t like him, then stop coming and paying for his visits.
“Wellness” doctors (who are mostly quacks who sell useless supplements) make so much money doing things that are not beneficial to their patients. Why shouldn’t a doctor who practices evidence-based medicine, who actually takes care of his patients when they get admitted at 3 AM to the hospital ICU, not get paid for his time?
It never ceases to amaze me that there are people (including some doctors) who look down on the idea of being paid for honest work. The reality is that if doctors don’t get paid to do the work for which they were trained, they will just find other, less-than-ethical ways of getting money – things like opening “alternative medicine” and “wellness spas” where they sell useless products and claim to be interested only in “prevention.” As in, if you get sick and go to the hospital and need to be admitted, then you are SOL – you will get an impersonal hospitalist who just sees you as a business commodity.
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