Why primary care doctors need to practice insurance free medicine

I never thought I would be in academic medicine for so long.

When I was hired about 12 year ago, I figured I would stay in academics for a few years and then join a private practice Internal Medicine group. Now, I can’t even fathom that idea. One of the reasons I have stayed at my institution for so long is that I love teaching and the academic environment.

However, a second reason is that the “real world” for primary care medicine is a scary one. As a salaried employee in a large practice, I am somewhat sheltered from the harsh realities of running a business in the current health care environment. Yet, I hear horror stories from my colleagues in the community that are struggling to survive. With reimbursement rates from insurances so low, and administrative burdens so high, many older physicians have retired and younger physicians have adopted new models of delivering care. These have various names such as “concierge medicine” or “boutique practices.”

Though I have no intention of leaving any time soon, I know that the current model of a small group of primary care physicians who accept insurance is simply not sustainable. Yet, I have a hard time imagining myself practicing in one of these new models, or even attracting patients to my practice. Retainer medicine is one model, where primary care physicians are able to see a much smaller panel size (and thus increase access) by charging patients an annual fee, which ranges from hundreds to thousands of dollars.

Though the model makes financial sense, the word “retainer” sounds too legalese for me and likely not easily understood by the lay public. I would prefer something like “membership fee” similar to something would pay to join a club. However, “membership medicine” or “club medicine” just doesn’t seem to have a good ring.

“Boutique” practices often use a retainer model, but boutique can also refer to primary care physicians who charge for extra services such as laser hair removal or Botox injections. There are many primary care physicians who still take insurance that have started using these kind of practices or have found other ways to meet their bottom line, such as selling nutritional supplements. Though there is no question that the public has a demand for these services, providing them for a fee as a primary care physician seems to carry some conflict of interest, since none of these services show any benefit in overall health.

“Concierge medicine” is another term used with retainer models and boutique practices. This implies some sort of preferential treatment, but also usually is associated with “executive physicals” and a battery of unnecessary testing and high technology that again provides little in the way of proven health benefits.

Some physicians have continued to practice normally, but simply do not accept insurance. They have figured out that they can sustain a primary care practice if they simply refuse to accept the substantially reduced rates that insurance companies give them. These are often referred to as cash only practices. Yet, the term “cash only” seems to imply (at least to me) something shady or under the table. In addition, most patients who see cash only physicians, pay for these services using a credit card, making the name somewhat illogical.

However, the reason that all these new models of medicine exist boils down to one single reason: health insurance. Rates from insurance companies are so low, that the only way a primary care physician can make ends meet is to increase volume to the point that both access and care delivery suffer substantially. In addition, the administrative headaches which include fighting to get tests/medicines covered and arguing over claims once submitted, make the practice of medicine less than enjoyable.

The oft-quoted study (that I co-authored) showing that only 2% of medical students are interested in primary care internal medicine, is often used to support the argument that primary care physicians need to be paid more. While the need to substantially reduce the growing income discrepancy between primary care physicians and specialists is critically important, the study actually showed that educational experience, nature of patient care and lifestyle were the primary factors influencing career choice, not income. This was regardless of students’ medical school debt. In other words, it was more about the hassles of primary care medicine and less about the how much money they would make, that led students away from careers in primary care.

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care is “insurance free medicine.” The term “insurance free medicine” captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance.

Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like “boutique,” “concierge,” and “cash only” might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. Previously, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies.

With more frequent use of the term “insurance free medicine,” patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

Though I have no immediate plans to leave the world of academia any time soon, I could certainly see starting an insurance-free practice if I ever did.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.

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  • http://webseitz.fluxent.com/wiki Bill Seitz

    “Self-pay” seems like a clear term to me.

  • JD

    As a patient, I’d be happy to pay my primary care physician for the predictable costs of annual care (exam, appropriate tests, occasional sick visit).

    I’d also prefer to pay for health insurance that covers only catastrophic, emergency or unexpected serious illness (example: leukemia, multiple sclerosis, etc.) care. At the moment, however, that is not how the system works.

    Why isn’t health insurance like car insurance? I pay for oil changes, timing belts and tires out-of-pocket. The insurance pays if I’m flattened by a drunk driver.

  • David Allen, MD

    That’s a nice name for the concept – and really gets to the heart of the problem; thanks for that. In addition, all the other terms/phrases have been used as a pejorative at one time or other.
    Also, you’ve thought a lot about this for someone who intends to stay in academia…

  • jsmith

    What Bill Seitz said.

  • David Allen, MD

    JD,
    The main issue is your state insurance regulators. They have demanded that health insurance cover numerous things – so that now you, the reasonable person who wants catastrophic care only, can’t get it. If you don’t like it, demand that they get their hands out of the system!

  • http://www.mcgath.com Gary McGath

    The concept of paying for routine primary care practice with insurance is inherently broken. It’s like having car insurance that pays for oil changes. “Insurance” is supposed to pay for unexpected costs that don’t regularly occur, but somehow it’s changed to an indirect and inefficient way of paying for routine services. Not only is that costly, it breaks the economic link between patient and doctor; the doctor’s “customer” is the insurance company, not the patient.

    Obamacare can only make that worse.

  • Fray

    I solved the problem of drive by visits with my PCP by moving my care to a naturpathic physician. All my basic health care needs are met and I am treated with respect. I pay cash…a fraction of what a cash only primary care physician would charge. For anything complicated, my NP sends me to a specialist.

  • http://www.ourhealingspace.com/practitioners/adamdrapkin.asp Adam Drapkin

    Well written. Excellent article. The insurance industry created a need for them by allowing the health care industry to charge such ludicrous fees, and now they control the industry.

  • JD

    >>If you don’t like it, demand that they get their hands out of the system!>>

    I doubt my insurance company will listen to me, as I have an individual policy and have absolutely no bargaining power as is. I also have no choice, because only two companies sell individual plans in my area.

  • Blake

    I have wondered when things would get so bad that patients would start to visit less qualified providers in order to avoid their frustration with the current system. I thought the physician avoidance would come through NPs, but after Fray’s post, I now wonder if it will come through naturopathic physicians, at least for the upper-middle class. I am sure that they spend more time with their patients and do a better job counseling about diet and such, even if they aren’t trained to handle the diagnosis and management of real disease. They wont ever replace the need for physicians, largely because the absence of a residency puts naturopaths closer to being a mid-level provider than a M.D. But, that doesn’t mean that M.D.s can’t learn something from how they run their practices.

  • Fray

    “even if they aren’t trained to handle the diagnosis and management of real disease.”

    1. My FP isn’t the best to treat the cause of muscle/skeletal problems. My PT is better and finding muscle imbalances that caused the injury and treating them so they don’t resurface. My PT even helps prevent injury while my FP pushes the pain killers.

    2. My FP doesn’t encourage wellness without a pill.

    3. My FP doesn’t deal with emergencies…off to the urgent care or the emergency room. Walmart is definitely more cheaper than the ER.

    4. My FP isn’t the best provider for my atypical asthma. He got it wrong the first time and instead of a proper treatment plan, he told me to quit running. My pulmonologist kept me on the track and will even see me during a flair up.

    5. My FP can only treat my depression with drugs. A psychologist can help me understand the underlying cause for a drug free solution.

    6. A nurse practitioner with help from the radiologist and lab is more than qualified for cancer screening and much cheaper.

    7. My FP offered pills when I was having trouble with insomnia. The CBT I found on the internet solved the problem without medication.

  • Surgical Resident

    Blake,

    I think even putting “mid-level providers” in the same sentence as naturopathic “medicine” is an insult to all the PA’s and Nurse practitioners out there. You might as well go to a wizard for your problems.

  • Frank Bauer

    On the whole I like this post for it’s declaration that new business models are needed in primary care. I do, however, take issue with the linked paper purporting to explain why medical students avoid primary care.

    As a medical student I can tell you, based on a great number of conversations with other students, that financial reasons most certainly are a cause of reduced primary care recruitment. And these financial reasons also most certainly include exorbitant debt.

    I strongly dislike this paper because it has been used by many to justify the yearly 5% increases to medical school cost of attendance. The reason being that since debt is not the culprit behind poor PCP recruitment, hey, what does it matter if cost of attendance increases?

    The reality seems to be that poor recruitment is a multi-factorial problem, with all the pieces described in this article.

    I’m on board for making new business models, but most definitely not on board for statements downplaying the harsh reality of medical student debt.

  • j.

    The good physicians are better than any PA, NP or ND. My FP is both a PharmD and MD and is a self-taught naturalist. He understands medicine enough to know that it is not an “end all” and does use prevention, lifestyle changes, and natual supplements as first line, unless progression of disease demands allopathic intervention, and even then will recommend supplements. For example pain relief: he recommends a three supplement combination of Vita D3, Zyflamend and Neprinol, which works better than some prescription medications without the “drugged” feeling, and patients love the fact that they are not taking a “drug”. He spends at least 20-30 min per patient. Because he is not able to make enough money to even paint his house on the insurance reimbursement and he is retirement age, this year he will be putting a membership fee on his practice and may also going “insurance free”. He doesn’t see any other way as he is taking a well below average salary. He wants to continue doing medicine the “right way”, but sees the need to make ends meet and save for retirement when he finally is able to retire.

  • csmith

    Set aside 10% of insurance premiums as a capitated payment to primary care. If healthcare spending is $2.1trillion for 300 million people that would equal $700 per patient on average going to primary care physicians. That would more than double primary care revenue and your physician would be glad to call in prescriptions, exchange emails, do web visits to get your business, etc.They could also implement chronic disease management and extended office hours with this money thereby preventing many urgent/emergent care visits.

  • Blake

    I think it’s funny that I somehow offended both sides of the spectrum with what was my attempt to be moderate and unoffensive.
    Fray– All of your counters can be summed up by “a specialist does it better than my FP”. I find that hardly informative. FPs often don’t do the things you listed because they frankly don’t have the time for it and because FP residencies were designed to be “jack of all trades, master of none”. Most programs were designed primarily for rural areas where there are few of the specialists you mention. Also, contrasting your FP with those examples–many of which used M.D.s (the pulmonologist (MD), the NP with help from a radiologist (MD), ER = MD)–says nothing of the value of MDs;it simply says that you don’t like your FP. Even still, the fact that an FP can do all of those things you listed is a merit to the field, while naturopaths can do very few of the things you listed. That isn’t to say naturopaths can’t do anything; I’m not trying to be inflammatory. I know naturopaths are trained in acupuncture, massage, nutrition, counseling, and some didactic training in pathology. I am also sure that they offer those services respectfully, at a leisurely pace, and always with a smile on their face. It would be great if many MD practices could learn to do that on a regular basis. But the fact is while that acupuncture, massage, etc. are helpful and can be preventative of disease, very little science indicates that they are of much value in the primary treatment of disease. That’s also while focusing on the good stuff and neglecting all the homeopathy, iridology, and other unproven methodologies they use.

    Surgical Resident– you’re right. It was a poor comparison. Mea culpa.

  • DR PJ

    Speaking as a physician who had to close her primary care practice for teens & young adults recently (after 6 years of being a very viable practice) due to cash flow problems generated by poor insurance reimbursements, I can tell you that having a “private-pay-only” practice, where I have streamlined my services a great deal to lower my overhead, has taken quite a bit of stress off me. However, the major problem I see with discussions about the “high costs” of healthcare is that no one seems to know exactly how many dollars are being poured into the insurance companies’ coffers to pay huge salaries and bonuses to their employees and how many dollars are actually going to pay providers for seeing patients. For example, one employee of the major insurance carrier in my area said they were offered “unlimited overtime” by their company (at higher pay per hour, of course) because they were “so far behind” on processing and paying out claims. However, they actually sat on a huge number of my practice’s claims; denied payment on many others for vague reasons; and did other things to hang onto money that it forced me and other physicians out of business. Besides, what competent CEO offers employees “unlimited overtime” and expects them not to abuse that privilege?? Are the insurance companies being held accountable for what they are doing? I don’t seem to be hearing about it if they are. In fact, some people I know who work with insurance companies are actually starting to feel ashamed for what their companies are doing with healthcare.

  • jsmith

    Ten per cent for primary care? Now that is one heck of a great idea to this family doc. I’d have to stop posting on blogs. I’d have my butler do it instead.

  • http://www.drmintz.com Matthew Mintz

    Thanks for all the excellent comments.
    @ David Allen: “Also, you’ve thought a lot about this for someone who intends to stay in academia…”
    Very true! I am in charge of the primary care rotation for our 3rd year students. From their feedback, they enjoy the rotation and learn alot, yet almost none of them go into primary care. Changing the image and status of primary care is important to me even if I stay in the ivory tower of academia for the next few decades.
    @Frank Bauer. I absolutely do not mean to diminish the importance of student debt. My school is one of the most expensive medical schools in the country, and debt is a huge concern for my students. However, the data would suggest that loan repayment for students choosing primary care fields (already part of the stimulus bill that passed and part of proposed legislation) will not be enough. Though some may choose this option, many students figure that with the current difference between specialty and primary care medicine, that they can make up this difference in only a few years. In other words, the current state of primary care (unglamorous, too much paper work, insurance hassles, etc. and low pay) is so bad that even loan forgiveness will not be enough for most students to choose it as a career.
    @csmith. I like your idea. It is simple and makes a lot of sense. Please email it to your representatives.

  • Diora

    Why isn’t health insurance like car insurance? I pay for oil changes, timing belts and tires out-of-pocket.

    One difference is that in some cases these oil changes, timing belts, etc. are a lot more affordable. Even routine tests start adding up when you get older to a lot more than the cost of normal car maintenance.

    But let’s say for a moment that one of your routine tests returns false positive or at least ambiguous results. A cancer scare can result in a bunch of tests and maybe a biopsy, maybe even surgical biopsy that can all add up to a large amount. If you end up having cancer, you get your catastrophic care insurance. But what if you have no cancer? Great, right. Except for, you no longer qualify for your catastrophic care insurance since you are healthy.But the cost to all the tests to rule out cancer – especially if some of first tests return one of those “cannot rule out” results, and you get more and more test or end up caught in an endless cycle of testing.

    Forget cancer scare, an ER visit for say chest pain or even if you fall and hit your head may cost you closer to the cost of a new car than car repairs but still not qualify you for your catastrophic care insurance especially if you turn out fine.

    Commonly prescribe “preventive” drugs that so many people over 50 take also add up to a nice round amount.

    So, yes, if it were the issue of just doctors’ visits and cheap tests, I’d have no problems with paying for it out of pocket. But all the other things that can pop up really add up.

  • Fray

    “Even still, the fact that an FP can do all of those things you listed is a merit to the field,”

    My FP isn’t trained in manual therapy.

    My FP isn’t trained to design an exercise program to prevent injury.

    My FP isn’t trained to do a bronchoscopy.

    My FP isn’t trained to give dietary advice.

    My FP isn’t trained to read the mammogram.

    My FP isn’t trained to do CBT.

    Sure he can do a PAP, but so can a nurse practitioner.

    What is it my FP can do that I can’t get done cheaper and better somewhere else? Why would I pay for care with a FP?

    Perhaps my naturpathic physician isn’t the best one to diagnose chronic health problems, but she is the best one to prevent them.

    My naturpathic physician can help me with the recommendations from my pulmonologist…and can send me back when things get complicated-cheaper than my FP.

    My pulmonologist has the expertise to customize my treatment at the same price as my FP who uses a textbook treatment plan.

    “FPs often don’t do the things you listed because they frankly don’t have the time for it and because FP residencies were designed to be “jack of all trades, master of none”.”

    So my FP doesn’t have time for me and doesn’t have the expertise. I have suffered long enough with chronic issues that my FP failed to diagnose and treat.

    Time for yoga that my NP recommended. Much cheaper than the pills my FP recommended.

  • j.

    I agree that it is a bad comparison. The Family Physician is the diagnostician of Medicine as they are usually the first professional to see the patient’s symptoms and unlike any other professional must work in context of patient’s values, evidence and their experience. Not all hoofs are horses, and only those with the training can pick out the zebras. Also, preventative care is only as good as the person putting together all of the screening test results with family history, social history and symptoms and running all of it through the filter of training and experience. When it comes to the best outcomes studies have proven early diagnosis saves healthcare dollars and lives. Now if only all of that was paid well enough to incentivize the brightest among us to do primary care and do it well.

  • Surgical Resident

    I think that continuing to glorify a naturopathic “physician” is a huge disservice. There is a reason that most states don’t mandate insurance coverage for them, chiropractors, etc.

    Do you know what the difference between herbal medicine and regular medicine is? It’s that pharmaceuticals have to be tested in a population for safety and efficacy. Herbal’s do not, period. People then say, “oh but is natural, so it must be better.” Wrong, many common drugs are natural (or started out natural) as well, but once you prove they are beneficial they are considered medicine.

    It really bugs me when people start spouting out alternative medicine garbage. If the stuff has been proven in clinical trials then it is not alternative medicine; it’s just medicine. Acupuncture and manipulation may make you feel better, but statistically you are no better off.

    Sorry, I really think you are insulting all the PCP’s out there.

  • Fray

    “It really bugs me when people start spouting out alternative medicine garbage. ”

    It really bugs me that doctors don’t have any respect for treatment that doesn’t include popping prescriptions drugs. I don’t take any herbal medicines and the only vitamin I take was recommended by my pulmonologist.

  • JD

    >>Even routine tests start adding up when you get older to a lot more than the cost of normal car maintenance.>>

    Obviously, health care costs more than routine car maintenance. Accordingly, my health insurance currently costs about 4-5x my car insurance (I’m young and healthy, and I benefit from a safe driver discount).

    >>But let’s say for a moment that one of your routine tests returns false positive or at least ambiguous results… what if you have no cancer? Great, right. Except for, you no longer qualify for your catastrophic care insurance since you are healthy.>>

    Umm, no, not quite. Suppose I actually follow my physician’s recommendations and do not demand tests that would be of marginal benefit to me based on my age and risk factors (examples: mammogram, annual pap smear, cholesterol screening, CBC/Chemistry). Currently, I am subsidizing all those people who demand these tests or whose physicians order these tests partly because the real costs are hidden… insurance “pays” for them.

    But to respond to your point, I would have no problem paying for the screening test itself. False positives are a medical indication for follow-up, BTW, and would be covered by a catastrophic plan (after deductible – I like health savings accounts, too).

    >>an ER visit for say chest pain or even if you fall and hit your head may… still not qualify you for your catastrophic care insurance>>

    Those are catastrophes, if the ER is utilized appropriately. I think patients would be more likely to see a PCP or urgent care physician for colds and sprains if they were financially motivated.

    >>Commonly prescribe “preventive” drugs that so many people over 50 take also add up to a nice round amount.>>

    Sure. People over 50 already pay higher insurance premiums than I do, too. They should. So should women who become pregnant; I think there should be routine and catastrophic pregnancy policies. (I am pro-choice but think early abortion should be out-of-pocket, incidentally – it’s already affordable simply because it is frequently paid for out-of-pocket, insurance or not).

    The fact is, health care costs money. At the moment, those costs are hidden. I think most patients would be astonished to see what percentage of health insurance goes to subsidize insurance companies (including people who do nothing but contest and deny claims, and are given financial incentive to do so) and pay employees of hospitals and physicians who do nothing but interact with insurance companies.

    Who do you think is paying for prescription drugs, cancer scares and visits to the emergency room now?

  • Surgical Resident

    “It really bugs me that doctors don’t have any respect for treatment that doesn’t include popping prescriptions drugs.”

    As my name implies, I operate on people I don’t just have them pop pills. You’re missing the point. If something is proven to be effective than it is medically indicated. I don’t care if that is psychotherapy, vitamins, massage, etc. The fact that it has been proven effective is what makes it fall under medicine. Alternative medicine, on the other hand, has no such requirement. It has no regulatory body, it has no quality control. Therefore it should not be reimbursed nor given the same respect as a PCP.

    Heck, I’m a surgery resident, you’d think I defend FP’s and IM’s all the time by my post.

  • http://hellohealth.com/physicians/ Hello Health

    Wow, great post.

    Primary care doctors are in jail now, trapped on the treadmill of insurance-paid medicine. We’re working hard to empower them to free themselves, with a bundle of technology, financial support, marketing and operational support to build the kind of direct pay practice so many of you are supportive of in the post and in the comments.

    This isn’t spam, we’re very much for real. You can check us out on the web here.

  • Fray

    “If something is proven to be effective than it is medically indicated. I don’t care if that is psychotherapy, vitamins, massage, etc”

    Don’t forget diet and exercise….and a neti pot. This is what my naturpath does…recommend remedies that are proven effective…My FP only offers prescriptions. My NP can prescribe the same drugs as a doctor if needed.

    “Therefore it should not be reimbursed nor given the same respect as a PCP.”

    The original post was about paying cash for care, not insurance reimbursement. I can get medically proven treatments, appropriate screenings, better preventative care, and referrals for massage, vitamins etc.for a fraction of the price. I even get a bonus of having an expert on alternative care if I chose.

  • Fray

    “The fact that it has been proven effective is what makes it fall under medicine.”

    My pulmonologist (who has a medical degree) suggested I take vitamin D to prevent a whole list of ailments. Of course, this is not proven safe or effective.

    My FP, when I complained of insomnia, suggested melatonin. Of course, this is not proven safe or effective.

    My surgeon suggested that taking large quantities of vitamin E would alleviate the pain in my fibrocystic breasts. Of course, this is not proven safe or effective. He also wanted to cut half my breast off, even though the medical literature doesn’t recommend surgery for fibrocystic breast changes.

    My naturpath, after doing a sputum culture, prescribed an antioboitic that was effective against the bacteria hanging out in my lungs. I got better.

    So Surgical Resident, who do respect more?

  • ninguem

    JD – “…..Why isn’t health insurance like car insurance? I pay for oil changes, timing belts and tires out-of-pocket. The insurance pays if I’m flattened by a drunk driver…..”

    There is such insurance, it’s called high-deductible health plans (HDHP) with health savings accounts (HSA).

    They were about 20% of the private market, now closer to 30%.

    With five years experience with real-world use, the data is showing the plan really does save cost, with premium savings reflecting that.

  • ninguem

    And Fray is giving a great argument for them. If you don’t like your FP, fine. Don’t go. Get a HDHP with HSA, self-refer to the consultants, and either find insurance that covers the naturopaths, or at least you have HSA savings to pay for those services, instead of going to first-dollar insurance coverage that’s not being used if the FP is skipped. Since the first-dollar-coverage policies are usually going to require you to go to the FP you seem not to like.

  • JD

    >>There is such insurance, it’s called high-deductible health plans (HDHP) with health savings accounts (HSA).>>

    Not one of the plans available to me. As I mentioned, I am self-employed, must purchase an individual plan, and only have two companies from which to choose.

  • ninguem

    So am I, and I do have it. Probably depends on specific state insurance rules. You’re making the argument for the Shadegg bill. Buy across State lines if not available in your State.

  • joe

    “My naturpath, after doing a sputum culture, prescribed an antioboitic that was effective against the bacteria hanging out in my lungs. I got better”

    Ahh medicine 101. Then again did you have a pneumonia or chronic bacterial bronchitis? Do you know? For all you know it could it have just been viral infection, the “bacteria” in question may just be normal flora, and your antibiotic use and improvment was just happenstance. If one did a sputum culture on me, I would bet you one would find multiple organisms. That doesn’t mean i need an antibiotic. Look you don’t like docs, I get it. Go to your ND and have her/hime refer you out when something is really wrong. But your insults towards FP’s (I am not one by the way) shows a complete lack of understanding of their training and skill set. Believe it or not, most FP’s have actually have had training in wellness, diet and exercise. It’s just a little hard to shove that into a 10-15 minute appt with 5-6 other things to address. I don’t agree with either (actually most of us docs don’t agree with the “business” of medicine, isn’t it blatantly obvious?). That is one of the purposes of the cash-only model. I suggest you go to your ND and leave out the FP if you base all of your respect on ordering a sputum culture.

  • Fray

    “That doesn’t mean i need an antibiotic. ”

    This was my second round with haemophilus influenza . The first time, my pulmonologist did a sputum culture and prescribed six weeks of antibiotics. For my second round, my FP told me it was post nasal drip because he didn’t have time to read my chart….didn’t understand that people with cough variant asthma have normal peak flows…didn’t understand that normal temperature isn’t always 98.6….two months of a low grade fever and productive cough…followed by depression…considering colloidal silver…wonder if I would turn blue…contemplating suicide…call FP-no appoinments available…sputum culture showed the massive infection…NP prescibes antibiotics…nebulizer to help breathing…psychotherapy for depression…looks for food allergies…neti pot…check in with pulmonologist…pulmonologist is impressed with the inflammation.

    My original point is that I can find cheaper care elsewhere. For $70, I can talk to a nutritionist for an hour. For $40, I can be evaluated by a physical therapist for muscle/skeletal problems and for another $40-begin treatment. For $150, I can talk to my therapist for 50 minutes. For $160, I can spend 30 minutes with my pulmonologist discussing my asthma. For $80, I can have a complete physical with a nurse practitioner…with lab work. For $60, the nurse practioner can sew up my knee after I fall off my bicycle. For $70, I can talk to a personal trainer for an hour. For free, I can follow a CBT approach for insomnia that I found on the internet. For $90, I can consult with a naturpath to sort out my chronic health problems. For $160, I can wait 2 months for see my FP for 10 minutes for simple problem. For $250, I can see my FP for insomnia and get a referral for a sleep study. For $300, I can get a physical with my FP…no lab work. For $3600 retainer fee, I can have a FP to sort out my chronic health problems.

    Regarding diet and exercise…The only diet advice I ever got from a FP is to drink Carnation Instant Breakfast for a weight loss problem. He also told me that 220-age was a good predictor of maximum heart rate.

  • http://www.patmosemergiclinic.com Robert Berry

    For readers who might be interested, I have posted below an article that I wrote in April 2004 for a medically related magazine about the “insurance-free” medical practice I started in 2001.

    Starting an Insurance-free Medical Practice

    My Personal Experience

    Over three years ago, I left ER medicine to start an insurance-free medical practice. For some time I had been examining the feasibility of starting a part time clinic primarily for the uninsured. Of course, I wouldn’t refuse anyone else willing to do payment at the moment of service; so, I chose this acronym, PATMOS, as the name for the clinic. By avoiding all contracts with third party payers, I could avoid the crushing costs of settling relatively small claims and thus provide more affordable primary medical care to all point-of-care payers.

    As an ER physician, I knew the people the charts classified as “self-pays.” In a small community such as ours, I had purchased goods and services from many of them. They were in a real sense my neighbors, and for the most part they were hardworking tradesmen and small business owners – too poor for $10 co-pay insurance and too rich for Medicaid. Like the Apostle John banished to Patmos Island, they were effectively political exiles within our healthcare system.

    Most doctors refuse to see them. With practices set up for insurance, the uninsured tend to disrupt patient flow. Many cannot pay for tests and procedures sometimes needed to exclude potentially litigable misdiagnoses. The uninsured simply take too much time with too much risk for uncertain payment. No wonder physicians turn them away and refer them to the ER.

    But the ER, as we all know, isn’t an appropriate place for these patients either. Charges are higher, work-ups more extensive, and few physicians are willing to see them in follow-up. Self-pay patients, I learned, are neither destitute nor derelict. I felt certain that these farmers, carpenters, plumbers, beauticians, cleaning ladies, small business owners and their employees would appreciate and value medical care at fair and honest prices. They didn’t have the time to wait at government clinics and did not like the quality of care they received there. They urged me to start a practice and promised that they would come see me if I did. I thought that maybe over time this clinic might replace my income from the ER, and I could then jettison increasingly wasteful and dehumanizing bureaucracies from my practice of medicine.

    Because of the charitable nature of the clinic, I had considered making it a non-profit to take advantage of tax breaks and to raise money for my own salary. After several discussions with my attorney, I had pretty much decided against it. He pointed out that dealing with a board would probably be about as frustrating as every other bureaucracy I had encountered since my residency. In addition, even though I would be the one building the patient base, the board could dismiss me whenever it wished, and the years I would have invested might well end in futility and bitterness. Since the sick and injured we will always have with us, I reasoned that it was more prudent in the long run to depend on them for my income rather than on fickle donors and ever-changing tax laws. The long-term risks did not appear to be worth the short-term financial security a non-profit might offer.

    The idea of making the clinic non-profit became academic very quickly as my plans to make the clinic full time were realized sooner than I had expected. For various reasons, the president of the hospital had my ER contract terminated abruptly. I simply did not have time to start a practice and raise money too. Had I pursued the non-profit option, the idea of this clinic might still be committee. At that point, I had to make a decision – either obtain ER work at another hospital or start the clinic full time. For better or worse I decided on the latter, and the clinic was up and running within two weeks of my dismissal.

    More preparation time might have saved me substantial expense from misadventures since I not only had to start a practice from scratch and see patients, but I also had to learn how to run a small business on the fly. Had I not been kicked out of the nest, however, the clinic might have remained just a vague longing. Fortunately, I had already made a list of all equipment and medicines I was using in the ER.

    PATMOS is located in a village of 16,000, in a county of 60,000, in a state where only 10% are without insurance (one of the least in the nation) and 25% have Medicaid (one of the highest in the nation). The demographics are definitely not in our favor.

    In addition, there is a government run clinic in town, two others within 15 miles of town, and a charity clinic in a town 25 miles away. No large company in our community to my knowledge has yet to adopt a consumer driven health plan such as an HRA or an HSA where employees are motivated to find low cost healthcare. I compete daily against 10 to 20 dollar co-pays and regularly have to disabuse patients of the notion that timely, quality medical care costs practically nothing.

    Given a market so stacked against us, how have we been able to survive these last three years?

    The answer, of course, (as any other successful small business will tell you) is by providing value and service at fair and honest prices. I realized quickly that I had to let my core clientele – the uninsured and people with high deductibles – know about the cost breaks of a clinic not taking insurance. Although it ran counter to my own feelings of professionalism, I broke with convention (although permitted within the by-laws of the Tennessee Medical Board) and made my fees public in newspaper ads and flyers. Visits for poison ivy and sports physicals cost $25; for sore throats, coughs, and sinus infections $35; and for simple cuts just $95. Timely, quality medical care from a rare physician today who actually enjoys practicing medicine – priceless. And we gladly take Mastercard.

    We have worked out discounts with various other providers in the area so that a CBC and lipid panel are $20 to the patient; a complete chemistry and TSH are $25; a chest X-ray with an interpretation is $70, and an MRI with an interpretation is about $500. Costs to the patient here are about 60% those of other physicians’ offices, 40% of the local urgent care, and 10 to 20% of the local ER’s.

    Not wishing to turn Medicare beneficiaries away from my clinic if they wished to pay me at the time of service, I was forced to opt out of Medicare, effectively preventing me from working in any ER to supplement my income. Such is the logical consequence of an illogical regulation.

    The biggest mistake I made was starting out with grander visions than this town was ready to support. I employed an ER nurse and paramedics, providing a mini-ER for the uninsured – once even helping to resolve mild diabetic ketoacidosis (bicarb was 17) in a 12 year old with IV fluids and an insulin drip over 8 hour period (whose mother absolutely recoiled at the thought of taking him to one of the local ER’s). I took care of some pretty serious infections with several days of IV antibiotics, leaving a heplock in patients and bringing them back repeatedly. On occasion, I cooled off an unstable angina with a nitroglycerin drip, IV beta blockers, Lovenox and had them admitted directly to the CCU at a tertiary care hospital 25 miles away (which has a cath lab), bypassing its ER and the ER’s here in town.

    There were many such professionally satisfying cases when the practice operated as an “EmergiClinic.” However, this also forced me to hire expensive staff and made me rely on an office manager who, although having every appearance of sharing the clinic’s vision, was embezzling from it practically from day one.

    The financial realities, the lack of a compatible partner willing to opt out of Medicare, and the need to reconstruct the books to provide accurate records for the IRS forced me to scale back our operation.

    Today, I have one full time employee and one part time – approximately 1.3 full time equivalents. The clinic is open 35 hours a week – 29 hours walk-in and 6 hours scheduled appointments. We have nearly 5000 patient charts with (at last count) approximately 51% uninsured, 38% commercially insured, 8% Medicaid recipients, and 3% percent Medicare.

    One physician contemplating quitting medicine was quoted in last summer’s Time magazine issue, “The Doctor is Out” as saying, “Our income is completely controlled by the government but we have no control on our expenses.” In contrast, I rely on appreciative neighbors for my income, and by avoiding contracts with third party payers I have a handle on cost. My overhead is about one-third that of the typical family practice and requires about 3 employees fewer. In absolute dollar terms, the savings produced by our clinic over other clinics that offer similar services but accept insurance is about $200,000 per year – over 40% of the typical family physician’s gross income.

    My break-even volume is about 1.2 patients an hour. My average volume over the last 6 months has been about 3 patients an hour, which makes my net income before taxes a little less than what I was making in the local ER. At 4 patients an hour, I would be making about 50% more than I was making in the ER.

    The greatest benefit of an insurance free practice is just that – being free. Free to take care of patients as I would want to be taken care of rather than the way an insurance bureaucrat wants me to take care of them. Free to refuse care to the disruptive and unappreciative. Free from increasingly wasteful, capricious, and dehumanizing bureaucracies. Free from having to read, understand, and comply with arcane contracts. Free from betraying the confidence of my patients from unannounced audits of my charts by insurance companies. Free from arbitrary documentation requirements. Free to set my own schedule and hire my own staff. Free to reconnect with the pure, spiritual purpose for which I entered medicine – the care of persons who value and appreciate my knowledge and skill.

    I have made many mistakes, but I have few regrets. I have learned that it is easier to change the course of a moving wheel than one that is stationary, and I am convinced that if I’m not making at least some mistakes, I’m probably not making any progress either.

  • Michelle

    Insurance-free medicine might be a good idea for primary care, and for relatively healthy people, but regardless of health, how is it a wise decision for the non-super-wealthy whose finances would be devastated by severe accidental injuries or cancer or anything else requiring extensive hospital care? Or does this really only apply to primary care, with the assumption that people should have insurance for hospitalizations, pregnancies, etc. on the side?

    Sorry if I missed something obvious…I’m just trying to understand!

  • http://www.patmosemergiclinic.com Robert Berry, MD

    I was talking about primary care…and perhaps most out patient visits. This would take care of itself if we eliminated the tax preference for employer based insurance. Most people would purchase high deductible policies and would take care of their routine, non-catastrophic care out of pocket.

  • joe

    ” For $160, I can wait 2 months for see my FP for 10 minutes for simple problem….”

    Here we go again. FP’s don’t make a $160 for a 10 minute appt. I simply will show you why

    $160.00 for a 10 min appt X 6 appts/hr X 8 hours/day X 5 days/week X 50 week/yr (lets give him two weeks off) = 1.92 MILLION dollars. In reality, the average salary of an FP is around 150 K per year (maybe a little more). What’s wrong with this picture fray? Does the math add up? Even by cutting the visits by 50%, and taking into account practice expenses it doesn’t add up. The simple fact is your FP is a hamster on the wheel of business. It’s blatently wrong and clearly he/she wants to get off the wheel. Why should you argue with that? Do you honestly think an FP or anyone can have a good honest discussion of diet and an exercise regimen in 10 minutes? What planet do you live on? Clearly he/she is not addressing it because of lack of time. Also, typically NP’s bill insurance at 85% of MD’s so you math there doesn’t really add up either.
    Look, don’t go to your FP if you don’t want to. It’s a free country. But to sit here and complain about medical financial issues you don’t seem to completely understand, well thats wrong.
    Let your NP/ND take care of your “wellness” and when something is acutally wrong, they will refer you out. In the end the buck doesn’t stop with them and they know it.
    PS: This is the internet and I am not going to get into diagnosis, but H influenzae. It is actually part of normal flora. It is an opportunistic pathogen often seeking an opening after viral infections. H. influenzae in your sputum may of may not indicate an infection depending on clinical circumstances
    Good bye, this discussion is going nowhere.

  • JD

    >>I was talking about primary care…and perhaps most out patient visits.>>

    As you mentioned, because your overhead is lower, you can charge patients an actual, reasonable price.

    In contrast, if I were to pay any primary care physician in my area out-of-pocket, I’d be charged an inflated rate billed to the unfortunate uninsured. For example, a few years ago, I noticed that a primary care physician billed my insurance company $360 for a half-hour appointment (appointment started on time and took the expected 30 minutes – no quarrel there). $360 is not, of course, what the physician was actually paid by the insurance company, but it most certainly is what what I would have been billed had my insurance not covered the visit. At the time, out of curiosity, I called the physician’s billing office to inquire about the price of the visit and was told he was trying to “increase his profile” – i.e., if reimbursement by insurance companies were to increase, he’d be able to negotiate the highest possible price.

    The actual, “ideal” fee for the visit likely lay somewhere between the $360 billed price and actual insurance reimbursement. This is why high deductible plans alone are not a satisfactory answer for people like me… I’m just not going to pay any physician $720/hour out-of-pocket for a primary care office visit.

  • Surgical Resident

    look Fray, you are free to spend your money how you want, period. I think the point is that no one in their right mind would want to mandate coverage for natural/herbal medicine (I hesitate to even use the word medicine).

    You clearly have no concept of what medicine is or how it should be practiced. I mean, 6 weeks for an abx, seems excessive. I would also argue that any naturalists without formal medical training has NO business writing for abx since their is a significant public health concern. As far as your contempt for FP’s and PCP’s, remember they are physicians and should be paid more than a NP. What if that NP did not think about that cut extended into your joint (and hence should have been injected) or what about the scar formation across a joint?? I’m sure he/she did okay with your laceration, but the point is that FP’s go through years of training to have those things in the back of their minds. I know a few NP’s that would never recognize those risks, and I think they are fully competent in their roles.

    I think you have this idea that medicine is black and white. For example, sputum culture shows this therefore prescribe this. Of course this can’t be farther from the truth. Just look at the diagnostic criteria for pneumonia. When a physician is trying to do the right thing for you, but you want a certain thing/drug (even if there is no proven benefit), he/she should not provide it. Especially if insurance/government are involved (fraud anyone?). And again, you can’t look at cost comparison all the time. I can teach a PA/NP to take out a gall bladder for probably less than half what I will charge but what if there is a complication? Who will fix that. Remember you pay for their knowledge and ability to fix/prevent/recognize complications.

    Sorry for the rambling, I will stop. Fray head on over to Orac’s blog.

  • http://www.patmosemergiclinic.com Robert Berry, MD

    If there were only high deductible plans, then all primary care doctors would take direct payment. They would not only have to compete on quality, but on price. If your doctor charged $720/hr, he would probably have very few – if any – patients. You would take your business to a physician whose fees were more reasonable, as you would with any other service for which you felt you were being overcharged. This is the beauty of the free enterprise system. It forces those who provide goods and services to provide quality at reasonable prices – or go out business. Primary medical care is no different. We simply do not need third party payment for routine medical care.

  • Fray

    “PS: This is the internet and I am not going to get into diagnosis…”

    Well, joe, you already have decided that a naturpathic physician can not possibly gotten the right diagnosis and treatment without knowing the entire situation. Do you feel that way about the pulmonologist? My FP made a similar mistake…and one of my biggest regrets is trusting someone who didn’t have the time to care.

  • Fray

    “I mean, 6 weeks for an abx, seems excessive”

    So you question a board certified doctor on his recommendation.

    “What if that NP did not think about that cut extended into your joint (and hence should have been injected) or what about the scar formation across a joint??”

    My spouse fell off his bike, went to his primary care physician’s (an MD) office and was stitched up by an nurse practitioner-no doctor involved. If it’s such a bad thing for nurse practitioners to practice medicine, why do doctors use them? Of course, we paid a doctors fee for a nurses treatment.

    “Remember you pay for their knowledge and ability to fix/prevent/recognize complications.”

    And that’s great but during that moment when I needed my FP to consider a zebra (and this has happened more than once) or to look ahead and prevent a complication, it didn’t happen. I check in with my pulmonologist twice a year…he even remembers that I run and asks me about competition. He was the one concerned about bone loss…complications of being thin. It was the infectious disease specialist that saw depression, not the FP.

  • JD

    >>If there were only high deductible plans, then all primary care doctors would take direct payment. They would not only have to compete on quality, but on price.>>

    Sure. That’s my point: at this time, in this market, a high deductible plan is not the answer for someone like me – even if I could find one that were otherwise appropriate (and as I mentioned earlier, I have only two companies to choose from in my state).

  • Surgical Resident

    okay I’m done, throwing in the towel. I obviously cannot compete with someone so smart that they can predict when these “zebras” are going to be present. Good luck with all of your wellness problems.

  • j.

    In answer to questions of affordability of high deductible plans out of pocket pay for Primary Care:
    You are not paying full fee, only the allowed amount your health insurance “allows” to be paid on your visit. So you are getting a discount through your insurance even though you are paying more than just your usual copayment. And if you have a HSA account you can use that money to pay for the out of pocket costs of the deductible payment. So
    with most High Deduct. plans the bill is run through the health insurance company and the physician’s office is told by the health insurance how much you owe, and unless they have invested in “time of visit real time pay” software this can take a month or two, then the physican’s office must pay for a statement to be sent to you to tell you what you owe. Usually what is “allowed” is about 50 to 60 cents on the dollar, therefore the physician billing the insurance for more than what he would normally charge, is only trying to get more than that nominal payment for the professional work done. What other secondarily educated professional would take this B.S.?? Primary Care Physicians go into the profession because they are benevolent, but when benevolence is constantly being expected and taken advantage of and not appreciated or respected, then at some point one has to take steps to survive. Your plumber to save your pipes is paid more on the dollar with less training costs, less overhead and less regulation headaches or administration costs than a primary care physician is to diagnose and treat a life threatening condition. Boy our priorities are messed up aren’t they? We will pay more for a car tune up to keep our car going than an annual physical to keep our bodies going. When they are gone the specialists are going to miss them as they will be forced into doing primary care and the public will wonder why all of a sudden the specialists are going concierge, cash pay and those that don’t seem distracted and in a hurry all the time.

  • Fray

    “So you are getting a discount through your insurance even though you are paying more than just your usual copayment.”

    I often see complaints about insurance reimbursements not being adequate. A high deductible doesn’t help the doctor by increasing cash flow or eliminating insurance billing overhead. I went to a cash only specialist. He gave me a receipt with a code and I filed the claim myself. No discount.

    “Remember you pay for their knowledge and ability to fix/prevent/recognize complications.”

    “okay I’m done, throwing in the towel. I obviously cannot compete with someone so smart that they can predict when these “zebras” are going to be present.”

    If you can’t find a zebra then what’s the point? Or perhaps that is my point… a specialist can find the zebra better than an FP and since they cost the same for an office visit…

  • DR PJ

    This is all interesting discussion. Fray, I’m very sorry about what happened with your health, and all the frustrations you endured. I truly hope you’re doing better now.
    Dr. Berry, your clinic sounds wonderful. With my streamlined, private-pay-only practice, some of the best rewards I’ve gotten (besides the “freedoms” you mentioned in your article) have been the grateful thank-you’s from patients because I took extra time to discuss their needs. That’s priceless, and it is even better when they refer their friends or acquaintances to me because I’ve been able to help them when no other doctor had the time to carefully address their issues. No one can really adequately describe the pressure-cooker that being entangled with insurance plans feels like–especially if the physician is also responsible for overseeing employees’ concerns and making enough to keep the office open. That’s what was going on with my former practice that I closed in 2008, after insurance reimbursements became so poor. And, to top it all off, I found that no one at the state or federal level was really holding the insurance companies accountable. They may say they are, but when it comes down to it, chances are they won’t do anything to stop such practices as wrongfully denying payment on legitimately-filed claims or processing claims (even electronically-filed ones) in an efficient manner. It seems that the burden is on the healthcare providers to do all of the work, and MAYBE we can get paid–when dealing with insurance companies.

    Dr. Berry, you’re right–it is very freeing to be out of that pressure cooker!

  • j.

    Fray said, “the specialist can find the zebras better than the FP”. Ok, you pick a neurologist (say for a really bad headache) and since he is used to seeing the “zebras” he goes straight to the MRI that costs thousands of dollars to your insurance company, only to find out that it is your sinuses and not supposed to be a neurology appointment at all and then you go to an ENT (another specialist) that ordered a CT of your head and treats your sinuses with Nasonex and Saline spray, which your FP is very well trained in doing. If you had gone to the FP he probably would have diagnosed sinuses without the MRI because he sees sinus infections all the time and even if the head needed a scan to confirm chronic sinusitis he would have ordered a CT which is much less expensive than the MRI. Plus the visit codes for the specialists cost your insurance company more than primary care.

    Your unlimited access to self referral to specialists who do not communicate with one another and duplicates tests is what is bankrupting Medicare and the reason healthcare is in trouble.

    Also the Bach study showed that an elderly patient can see as many as 14 different specialists and with not one of them being a primary physician. Then who collects the medical records into one place and monitors all medications and checks for interactions? No one, as this is the uniqueness of primary care.

  • JD

    >>You are not paying full fee, only the allowed amount your health insurance “allows” to be paid on your visit. So you are getting a discount through your insurance even though you are paying more than just your usual copayment. And if you have a HSA account you can use that money to pay for the out of pocket costs of the deductible payment.>>

    This is all academic for me, as neither of the two companies from which I have to choose my individual plan offer HSAs.

    My original point remains: why not remove insurance companies entirely from primary care and charge patients appropriately and fairly? Taking the cost of the insurance company and all personnel associated with filing claims would of course drop overhead and, as someone else mentioned, allow the market to control costs as physicians’ prices would become transparent. If I were paying out-of-pocket, why should I have to pay the insurance company to negotiate prices for me?

  • Fray

    “Your unlimited access to self referral to specialists who do not communicate with one another and duplicates tests is what is bankrupting Medicare and the reason healthcare is in trouble.”

    During my zebra episode, my FP consistently sent me to the urgent care clinic…in a different building…no communication between them even though they were part of the same system. If he had been in the loop, he would have noticed frequent episodes of chronic cough that urgent care treated with antiboitics (this urgent care was staffed by doctors) I did visit my FP finally waited during a particularly bad episode. He that my my coughing wasn’t an big issue and that I should stop running and begin a walking program. I self referred myself to an allegist/asthma-who got things under control, realized more was going on, and referred me to a pulmonologist who then recommended a consult to a infections disease specialist (they communicated very well). When it was apparent the weight loss I was experiencing needed attention, I went to my FP, wasn’t up to speed, even though all specialists had sent him a report. He spent most of the appointment reading my chart and didn’t referred my out. When I asked about nurtrition…he said drink carnation instant breakfast.

    I wouldn’t go to neuologist for a headache…and the sinus trouble I do have is treated with a neti pot…and the discovery of a food allergy…something I discovered through my naturpath.

    I do go to my physical therapist for supposedly muscle/skeletal problems…The last time I went to my FP for an injury, he gave me a presciption of naproxen…After years of pain and some research, I asked him for some exercises…and he referred me to a orthopedic surgeon…I found a good doctor that specialized in sports medicine…referred to PT, discovered years of not treating the problem had left permanent damage.

    I chose my FP for an ear infection…something any nurse practitioner could have diagnosed. I was given antibiotics and when the fluid didn’t clear, I was referred to a ENT (which was a waste of time and bankrupting the medical system.)

    “Then who collects the medical records into one place and monitors all medications and checks for interactions? No one, as this is the uniqueness of primary care.”

    I do. I know every test I have had and the results. I remember what the doctor has told me and I keep a copy of those medical records and bring them just in case clarification is needed.

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