Business model woes traps doctors and impedes health care

If you are a physician, therapist or any other helping professional whose business model relies on third party manged care reimbursement you are engaged in the world’s worst business model.

Let me start with a story to set the stage.

Imagine you are a bright, idealistic college student. You’re good at academics, want to make a difference in the world and have hundreds of career options in front of you.

After lots of thought and planning you invest $100,000 in a graduate education. After all is said and done, you are in school anywhere between 2-12 years past your college graduation. You train to change people’s lives, heal what pains them. You make a difference and you sacrifice your life goals to prioritize your career. You may delay getting married, having children, taking vacations.

You do good work, finish school and training proving yourself and set out to make a living practicing in your area of expertise.

The first order of business is to figure out how you will get paid for all of your good work. The standard business model is accepting payment from a third party.

This third party decides how much your work is worth.

The third party sets limits on how much work you can do with each customer.

The third party can reject your invoices at any time for any reason.

The third party prohibits you from discussing your fees with other providers of the same service.

There are many of these third party payers and they all pay different, seemingly arbitrary rates.

The third party can change what they pay you at any time.

If you don’t follow all of the rules of the third party they don’t have to pay you at all.

The business model requires you to rely on an outside source to determine what you work is worth, set your rates and reimburse you on their terms. They can change the rules at any time. Outside forces constantly and consistently determine your bottom line. You have no choice, no chance to test price points. If you want to add a new service that isn’t recognized by the third party, they don’t pay you. The third party tells your customers that you are responsible for accessing their funding on their behalf, so no one knows what they really pay you or what your services are worth.

If you have any entrepreneurial spirit at all, please re-read the above paragraphs and tell me if you would sign up for this business model. Honestly, it’s ridiculous, don’t you think? Who in their right mind would invest $100,000 and years of their life in education, training and business and then turn over all hope of a profit to an outside entity?

Why don’t health care providers do anything about the model?
Doctors, therapists and other health care providers are not business people. We are not trained to pay any attention to how we get paid or who pays us. Many of us work in organizations that take care of all the administrative silliness so are have no idea how broken the system is. We are trained to do work that “insurance will pay for,” or to “find something that the insurance will reimburse.”

Nice, huh? Your doctors are trying to find things wrong with you so they can get paid. It’s not their fault. It’s the business model and no one questions it.

Those who understand that business model, CEOs of insurance companies think it is a great business model. They call the shots, they are in charge, they have the power and they make lots of money managing your business and our health care. Those in power never want to give it up.

As providers we are also brainwashed that if we don’t accept this crazy business model our patients will be harmed. “How will they afford care? Who will take care of them?” But, in the USA, we don’t want to provide a public health plan to help out those who are less able to afford care, so providers are put in a bind: take the lousy capitalist model that puts you in a subservient position to third party payers, or be a guilt ridden, selfish person for not buying into the model and getting the respect and pay you deserve.

What can we do about it?
Create different business models. Take ownership of our careers. Declare, “We’re not going to take it anymore!”

Imagine what would happen if doctors, therapists, dentists, and all other helping professionals declared this at once? What if we only worked with third party payers who treated us with respect? What if we only accepted insurance that had a real person answer our calls and handle our questions? What if we dropped insurers who pay us insulting rates and make us fill out 5 pages of busy work to access that cash?

And what if we informed patients that it is their insurance company that restricts their care, pays low rates, makes us wait on hold for hours? Or how about we put the onus on the patient to submit all insurance claims, understand how complex and time consuming it all is? It’s their care after all. [And don't tell me the public 'can't figure it out.' They figure out auto insurance, life insurance, home insurance. They can figure it out. Now we just enable ignorance].

Do you think the public would speak up? Complain to their insurance company, employers, government officials, congresspeople and senators? Well, yeah, they would. Would health care policy need to change if the providers of care stood up and demanded respect, a fair system and lower overhead costs?

Let’s not agree to business models imposed upon us. Let’s educate ourselves about business and empower both the medical profession and consumers to be proactive in how health care is accessed and paid for. If we are told that health care is a business, and entrepreneurs run the system, let’s even the playing field so that the competition is fair.

We have a choice.

Susan Giurleo is a psychologist who blogs at the BizSaavy Therapist.

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Comments

Dr.Nick
It’s called concierge care. Providers would become the bad guys and be blamed for lack of health care access for evrupne who couldn’t afford to pay. The government as payor would be no gentler a taskmaster, except for cutting the amount of bureaucracy that staff would need to do.
http://www.huffingtonpost.com/julian-l-alssid/finding-a-cure-for-the-he_b_503774.html Vanessa
One aspect of the health care reform debate that hasn’t been discussed much is how increasing the ranks of the insured will place increased demand on the health care industry, which is already experiencing worker shortages. Julian Alssid with the Workforce Strategy Center has an interesting article in Huffington Post about the issue…
http://www.huffingtonpost.com/julian-l-alssid/finding-a-cure-for-the-he_b_503774.html
http://fertilityfile.com IVF-MD
Excellent post!
As a whole,physicians were insidiously lured into accepting this new system by the prospect of being shielded from competition. Subconsciously we were lulled into a false sense of security that now, since only us MD / DO’s can “legally” do certain things, then we can enjoy a certain degree of complacency, shielded from competition that would otherwise hungrily strive to do things better and cheaper than us and take away our business fairly. In reality, once you buy into the system you begin to learn it’s the third-party-controlled nightmare that you describe.
In actually, there are at least four fields of medicine left (cosmetic surgery, vision correction, concierge medicine and assisted reproduction) which still have a relative amount of liberty and what you see in these cases is that while we still struggle just as much to make it day to day, the NATURE of the struggle is a lot more fun (for lack of a better word) and palatable.
It’s no cakewalk, because we struggle every day to think of new ideas of doing things better, to outdo our friendly competitors by offering better service and getting efficient enough to do this at lower fees. This is a 24/7 challenge, but when it’s all said and done, you reap what you sow. My heart goes out to my colleagues in other fields who struggle as well, but with a DIFFERENT type of challenge. Instead of competing to capture the satisfaction and approval of patients, instead they are forced to struggle to “game” the system to pretty much figure out what is reimbursed better and then adjust their decisions accordingly (or to ignore the rules of the game in favor of noble motivations, but then pay the price revenue-wise).
I agree with most of what you’ve said and if all doctors banded together to get things back to how they were decades ago, medicine would be even more rewarding than it is now. You can’t argue that it’s still rewarding to help people with their health problems and to help them achieve their life goals, but I will agree that the red-tape and the bureaucracy can be demoralizing. Is this ever going to change? I don’t know, but the quality of life of everyone in this country, providers and patients, is dependent on the direction that we go as a nation towards more individual freedom or more political control. Stay tuned.
http://bizsavvytherapist.com Susan
What’s difficult is we have business people dictating health care, but the providers take on a “factory worker” role. We do a highly skilled job, but the model is hierarchical. The larger entity of “health insurance” determines the outcome of our work. So we are left in a position to constantly react and be at the whim of the third party. I argue if we individually and collectively turn that on its head, where the providers develop a business plan that can partner with third parties when the relationship is mutually beneficial, everyone becomes more empowered. Physicians can do their great work without the frustrations and obstacles that impede optimal care. With this shift, of course, there would be growing pains, but ultimately the long term benefits would outweigh the short term difficulties.
http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD
Susan,
I like your analysis but I’m not sure about your solution. Perhaps you are just being wishful, but any advice that proposes that every member of a certain group act at “once” is surely going to fail.
Perhaps you have already implemented my advice, but I would say that if you change your own practice, then you have improved your situation immensely. If each physician decides to not participate with insurance, or to go the concierge route – then they will be creating a better model and showing others the way. I, personally, haven’t done this yet (as I’m a member of a larger group) but I applaud those who have. For each physician who, for example, doesn’t accept Medicare or Medicaid, we will see the gradual realization on people’s part that insurance doesn’t ensure access – and the realization that a third-party payer system can be flawed. The more who do this, the less they will even want insurance.
Of course, if states still mandate that insurance companies cover lots of non-catastrophic care – then they take that choice away from consumers. If a consumer can’t buy catastrophic coverage only, using their own money to pay for outpatient care and all the rest – then he/she will surely want to use that expensive coverage to see physicians and to obtain medications. In order for common sense patients to choose wisely, they must first be able to choose.
http://hcbreakfastclub.posterous.com/ Umair U. Khan
I’m surprised your post makes no comment on how hospitals take full advantage of this system as well. They are professionally managed organizations that have a major role to play in balancing the cost structure of the US healthcare system.
Vox Rusticus
The rules are stacked against the doctors and the government keeps things that way. Unless you work for a very large employer, where it is possible for the employer to negotiate with an insurer on more equal terms, any attempt to organize with other providers brings out accusation and even prosecution as an antitrust violation (in ways that never occur when a single insurer dominates an entire regional market, go figure.)
Labor unionism doesn’t offer a satisfactory model, at least so far. Perhaps the best comparable example of what could work for doctors are professional sports players associations.
http://hematopoiesis.info/ Alexey
When you said about 100k investment you mean US I guess. US system make business from medicine at any level, starting from medical education.
But this blog not only for US people and US medicine. In other countries you can get MD absolutely for free. Medicare, health system in US is nothing more then greedy money suckers, doesn’t care about human life.
Physician is not a businessman. He/she souldn’t be motivated by money and have conflict of interest. Salary in 300-500k USD is ridiculous. You can get all of goods in this life for salary 100-200k/per year.
If you feel entrepreneural spirit you can get private practice outside of big hospital as many internists here do. You can invent a new diagnostic method, medical device…. get patents and sell it, becoming serial entrepreneur.
Sorry kind of spontaneous thoughts….

anon
You’re probably right, but many doctors here get both the 100k investment (which is actually low… for physicians it is closer to 200k), and the 100-200k salary per year. This is part of our frustration.

http://www.drjohnm.blogspot.com DrJohnM
Susan,
This is one of the best blogs I have seen since reading KevinMD. Congratulations. Spot-on for sure. There are many in our doctors lounge who believe strongly in organizing more. This would obviously strengthen our positioning for bargaining.
So few talk of the declining numbers of talented young people choosing medicine. I believe they should, and your early points on the business model clearly underline the significant hurdles to successful private practice.
These words should be spread. They are important descriptors of the plight of modern day doctors.
Congratulations,
JMM
Cynthia
Apparently, doctors are under the impression patients buy insurance because we want to torture the medical industry. We actually buy insurance to be sure our doctors can get paid should we have an illness or injury. Medical cost have risen to such ridiculous levels that very few, in fact probably only other doctors, could afford to pay out of pocket. When I say afford to pay, I mean at the current insurance negotiated rates. None in the middle class could pay the rates listed as to what would be collected without insurance.
Also, it is completely unrealistic to ask patients to sign forms agreeing to pay for services that are not priced. My husband was asked to pay a bill up front for a doctor recently. We have BCBS federal plan and this was a preferred doctor. When he asked what the bill would be he was told-”We have no idea. We just have three codes. just pay us your yearly deductible.” We are supposed to pay 30 per visit copay. They wanted 300. The actual bill turned out to be about 130. We were supposed to pay 30 but paid 50. The doctor was paid by the insurance a few weeks later. We still have not been refunded the over payment and it has been about three months.
My son needed a 3 hour outpatient hip surgery a little over a year ago. I called the surgeon’s office to verify he was still a preferred provider. The office staff verified and made the appointments and he had the surgery. Meanwhile behind the scenes the doctor had subcontracted the closing portion of the surgery to a physician’s assistant group. According to the doctors staff the doctor was solicited by this group with the enticement that he would be able to process more patients in a day and thus increase his earnings. They further said the doctor was told the group would write off the patient portion and only collect the insurance portion thus the patients themselves would not pay any additional cost. Of course, when this turned out to be a lie and the patients received an extra bill for between 4,000+ to 13,000+ dollars for their portions the surgeon left the patients to deal with the mess. I eventually got the problem resolved after 6 months of stress and torment. I do not know if others got it fixed or not. I still worry about it as the physician’s assistant group is fighting BCBS through litigation. Additionally, I would have never allowed a physician’s assistant to perform part of the surgery had I been informed. I consider this a violation of trust. It is not the fault of patients that we no longer trust our doctors completely to be looking out for our best interest. You can thank your fellow doctors for the creation of cautious medical consumers.
My most recent medical experience is precisely one related to one of the suggestions made in the article. I scheduled an orthopedic consult with The Orthopedic Center. I was returning to a doctor I used previous and 2 other family members have also used this group even though one was at the Huntsville AL location rather than the Madison location. The doctors are part of my preferred provider group. When I arrived I was asked to complete updated forms. There was a form asking me to agree to pay the insurance portion of the bill if it was not paid within 60 days. I talked to the staff and told them this is new and I don’t agree to sign. I explained that I would be happy to make calls or facilitate payment in anyway I could if they ran into problems. They asked me to wait while they checked. They came back and said I must sign or not be seen. I went home and made a call trying to speak with my doctor to ensure he was aware of what was happening. I was called back by staff saying, the doctor will not be calling you back I had waited about three weeks for this appointment.
The orthopedic issue I am having is the result of an old injury. It causes me a significant level of discomfort and some loss of function. However, when there is no way for me to know ahead of time how much the visit, x-rays, MRI’s, or surgery that will ultimately be decided on will cost- I am unwilling to make myself legally liable, even temporarily, for the insurance portion of the bill. I do not think any doctors are forced to be preferred providers with torture. It is immoral to get the patients in the door by presenting oneself as a preferred provider and then trying to force patients to undo the contract between patient and doctors and doctors and insurance companies with forms. The end result is doctors will loose patients. Some of us would rather cope with pain and function loss rather than obligate ourselves to paying a bill that we are not responsible to pay and most of us can’t pay.
The only possible outcome is that patients will be forced to go without care.

Anonymous
When I say afford to pay, I mean at the current insurance negotiated rates. None in the middle class could pay the rates listed as to what would be collected without insurance.
Of course, the medical providers’ “list prices” include the bureaucratic costs of dealing with insurance companies. I got two flu shots (seasonal and 2009 H1N1) this season. I got them at the first available places, which happened to be a local pharmacy for the seasonal and the doctor’s office for the 2009 H1N1. The local pharmacy was $25, self-pay. The doctor’s office billed around three times that to my insurance and received about twice from the insurance company.
In other words, there is a lot of extra cost built in, because the providers have to carry a lot of bureaucratic costs dealing with insurance companies (and insurance companies also have bureaucratic costs). These extra costs can make it prohibitive to self-pay at a typical provider who normally does things on an insurance basis.
Theoretically, a self-pay patient would pay less if there were a reasonable selection of providers who charged lower transparent prices due to not handling insurance billing. But there do not seem to be too many such providers, presumably because market of self-pay patients is mostly the tiny number of very rich or the somewhat larger number of poor people who would not be able to pay anything.

http://bizsavvytherapist.com Susan
@Cynthia,
I hear your frustration. But your description proves my point. Right now doctors are often not able to tell you what things are paid for or not. Heck, as a psychologist I am on ONE provider panel and the reimbursement rates change so fast, I can’t predict what I will get paid from month to month.
Imagine what that is like for a doc who takes 20 different insurances, and provides 20 different procedure a day? It’s impossible to accurately track, even with a full time staff.
So, if doctors become more business savvy, price out procedures accurately and can be transparent with patients telling them what everything costs (which is difficult to do now), then we are all more empowered.
Patients will need to work more directly with insurance companies to figure out what is covered and for how much.
As a provider I do not work for an insurance company. The contract is between the *patient* and the insurance company. If the insurance doesn’t cover something, your problem is with the insurance company, not the doctors.
The whole system is inefficient and expensive because no one really knows what the insurance company is up to–including docs.
But if you get a procedure, you ARE liable for the cost and if you need to haggle with your insurance company about it, that is due to the insurance company’s procedures, not the doctor’s. Some docs are preferred providers, but not everything gets covered. And since we don’t have universal health care in the US, medicine is a for-profit business. If you get any service in this country, you are liable to pay for it. Many doctors don’t like being in this position. Many work for low or no pay in some instances to help people in need. But at the end of the day, they provide a service that uses expensive equipment, lab tests, etc. Those costs need to get paid some how.
Doctors just want to help people get well. They should be paid for their expertise, but no one wants people to be in pain and stop care because they can’t afford it.
I think that is what all the bru-ha-ha in Washington DC is all about now. Something has to give.
jrm
Cynthia, if you had read the article, you would know that there is no such thing as an “insurance negotiated rate.” There is no negotiation. The rates are imposed, with the implicit threat of loss of patients if the rates are not accepted. There has been no significant increase in these rates for about 10 years–if you factor inflation in, this amounts to a significant decrease. There are many physicians (not just primary care, Kevin) who have to worry about paying their help and their bills. That situation is not conducive to good patient care.

Cynthia
jrm,
I think you are missing a key point of what I am trying to communicate. The average household in the US in 2008 was about $52,000 (http://quickfacts.census.gov/qfd/states/00000.html). There are those of us that have been raised to be responsible and not purchase what we can’t afford. Would you obligate yourself to pay for a house if you did not know the price. Many times medical bills exceed the cost of a middle class home. The most responsible patients will be the ones that suffer. The irresponsible will sign with no intention to pay. They will understand that by the time any litigation to get the money from the patient would be enforced the insurance would have paid their share anyway. The only real power it gives the doctor to collect in 60 days is the patient’s word and ability to damage their credit report.
I have two grown sons not covered under my family policy. One still in college, one that graduated Dec.(still looking for a job as a teacher). I purchased individual policies for each. The total is close to $500 a month to keep them insured. I make this sacrifice to be sure my children will get medical care and that the doctors will be paid. This is in addition to our own insurance cost and medical expenses.
I do agree with the fact that insurance has some power to manipulate or coerce doctors into signing preferred provider agreements to a certain extent by offering the lure of participating patients. However the worst thing that will happen to a doctor if he makes a stand is some loss of income and clients. I always check the directory of preferred doctors to select my doctors. Doctors should not pass the stress to the patients. If they want to do away with the insurance middle man they should offer some viable alternative- not pretend to participate.
Nothing I have seen offered as a solution seems viable. I would like to suggest a solution for doctors to ponder.
Take the profits from the practices and invest in the medical insurance industry. That way every time they win so do doctors. Maybe then patients can still get the care they need and doctors can maintain the desired income level they are trying to achieve. My mother and sister are both registered nurses. I understand medical work is challenging. However it is hard to believe today’s doctors care for patients so little that they are willing to strong arm patients in this manner.

Anonymous
I have two grown sons not covered under my family policy. One still in college, one that graduated Dec.(still looking for a job as a teacher). I purchased individual policies for each. The total is close to $500 a month to keep them insured.
What type of coverage? If they are generally healthy, catastrophic coverage is likely a better choice for them, and likely to be less expensive that what you are paying.

Cynthia
I do not pretend to be an expert as to what forms of insurance are available but I did attempt to be frugal in my selection based on cost. My oldest son was denied for coverage as he had a recent surgery for a secondary issue related to Legg-Calve-Perthes. The only way I was able to keep him insured was through the temporary continuation of coverage offered through the federal government. I selected the plan with the lowest cost even though it has the worst coverage and admonished him to engage in no risk taking including participating in sports until he has his own coverage. For my second son, I was able to get a BCBS individual policy but the price quoted was raised by more than 70% as they informed me exceeded their weight restrictions by 20 pounds. Needless to say I told him to modify his diet immediately and get more exercise. I have been telling him this for years but it is hard to help from hundreds of miles away. My husbands family does tend to be over weight.

Anonymous
Tell the second son that you will pay the premium amount as if he were not carrying 20 pounds of extra fat, and that the premium penalty for being fat is on him. That should give him more incentive to lose it.
Cynthia
Already did that but since he is still in college he does not yet have any income nor does he have a car as I told him we could not afford the extra expense.

JPB
There is also the problem that many doctors charge the self-pay patients a MUCH higher rate for an office visit. If doctors want to get the insurance companies out of their offices, they will have to return to historic practices. This meant that patients paid for office visits themselves and that the price of an office visit was reasonable, disclosed in advance and the same amount for everyone! (It is dishonest for an MD to accept $60 from an insurance company but turn around and charge a self-pay client $200 for the same service.)
Lisa
Many of the mental health providers in my area are cash only. My insurance plan doesn’t cover out of network providers. Last year, I was severly depressed, considering suicide and was concerned enough about the cost that I chose not to seek help. My fear was with the suicide ideation, I would lose control of the costs.
And then there was the time that I thought I pulled a muscle in my calf. After a week of hobbling around, I went to the internet to find if perhaps there was something more. When I read the description of DVT, my thoughts were I couldn’t possible have a DVT. Not wanting to spend the money on a doctor’s appoinment, I waited another 3 days before I sought a consult. The doctor at the urgent care confirmed what I thought about the pulled muscle but said it was prudent to rule out DVT. Would I have paid for the ultrasound if the radiologist was a cash only practice? $450 for a pulled muscle?
Greg
JPB: you write: “It is dishonest for an MD to accept $60 from an insurance company but turn around and charge a self-pay client $200 for the same service.”
Actually, what you’re proposing is illegal for the doctor to do. The doctor charges $200 to the insurance company so that they can pay him the significantly discounted $60 for the visit. If he/she asked for $60 for the visit, they would pay him much much less.
The problem is, if he asks $200 from the insurance company and $60 from you, even though the insurance company will pay him $60 anyway, he is guilty of insurance fraud. So he has to charge you the same fee he “charges” the insurance company, though they pay him basically 1/4th of that charge.
It’s total madness!

JPB
You’re right, it is total madness! I wasn’t aware that the insurance companies and the government were the cause of this practice!! Thank you for relating this.
I still think that it is time to get the insurance companies out of doctor’s offices. The question is how? Anytime someone proposes a change to any entitlement, the howling begins….

Evinx
Susan
You stated, “Right now doctors are often not able to tell you what things are paid for or not.”
I realize this is true but why?
Every pharmacy can immediately tell a patient what the cost will be + how much of their deductible remains, etc – regardless of insurance carrier or Medicare (supplement) etc.
Why can’t the rest of the medical community do so?

Anonymous
Every pharmacy can immediately tell a patient what the cost will be + how much of their deductible remains, etc – regardless of insurance carrier or Medicare (supplement) etc.
Why can’t the rest of the medical community do so?
Insurance billing at the pharmacy typically comes down to just finding out whether the drug is in the low copayment category (typically generics), high copayment category (typically brand names), or not covered. Medical procedures can involve a large number of codes for each sub-procedure which would not be easy to check at a glance or single query to the insurance company.

Vox Rusticus
JPB:
I agree with you. It only makes sense that a cash-pay patient get a preferred rate (meaning, of course, cash pay up front.) It stands to reason that the patients who pay by means of lowest risk of default should get the lowest rate, lower than any other patient for the same service. It is too bad that the federal government makes that illegal. They demand the lowest rate if you accept Medicare, below cost for some services. Unfortunately letting everyone get that rate goes nowhere good.
What would be fairest is for Medicare to permit balance billing. If I can offer the service at the Medicare rate without losing money, great. If I need to charge more to make a reasonable return, I should be able to, and none of my cash-paying patients should have to pay more than the same amount. But the way things work now, the government gets to select which items I have to provide at which price, even at my loss.
Cynthia
Also, if doctors state on the form that we are agreeing only to charges incurred for the exam date visit, rather than with the practice indefinitely, We would be much more inclined to sign. We as patients are suspicious that signed forms can be used against our interest indefinitely!
Cynthia
All doctors should read and internalize how little discretionary spending we actually have once our basics are met. Doctors, please read the article at this link and perhaps you will understand whom it is that is being extorted- http://fdlaction.firedoglake.com/2010/03/19/fact-sheet-the-truth-about-the-health-care-bill/
We appreciate you but we have to survive too, Take it out on the ones that are guilty but not on us! We are just trying to be responsible within the current situation. We must protect our families. If you don’t understand that, you are not human. I drive a 1997 Toyota so please do not think it is because I mismanage my assets.
http://domainwerx.com Carl
Great article! As a citizen, I’ve been perplexed that doctors seem totally absent from the healthcare debate. I mostly hear the representatives of the “Party of No” screaming and shouting and spreading lies, as well as their enablers in the media. There are also rational politicians and pundits, who seem to get less attention.
But no doctors, it seems. Why?
It’s a shame, because I think if the doctors, dentists, and therapists would unite behind a sensible, patient-focused plan, — and insist upon it and be willing to fight for it — the American people would support it. Doctors are trusted and respected, the other folks mostly just tolerated, if not despised. So why aren’t the doctors fighting for what’s right and would benefit both them and their patients?
I’m sure there’s a lot I don’t know about or understand about this issue, and there’s not a lot of room for nuance in responding to a blog post, but I would really like to see the doctors out there fighting for a better business model for themselves and their patients.
W
Wondered about the doctors’ opinions in this geographical area also. They’ve been very quiet.
As for the form Cynthia describes…I can’t imagine any doctor signing a legally binding agreement that guarantees the patient a perfect outcome prior to a procedure — for very good reason. But a patient should be expected to guarantee payment — essentiallly, hand over a blank check — without knowing what number will ultimately be filled in?
Very strange world this has become.
Ebs
It’s simple. if obama care passes, i will notify staff tomorrow no new medicare patients. what i would like to do is initiate access fees for all patients; probably $100. Looking to future, dont see how i can afford not to. my 18th yr of practice, busy medicine doc seeing 20-30 per day, with 17% medicare base. i barely make ends meet at end of month. with the proposed legislation, we all will need to be in concierge med (which i support) or have access fees (unless you like never raising your staff salaries, never building equity for capital improvements and investment for ancient equipment) or dare i say a raise for me and my family for first time in 10 years. So, HERE IS THE QUESTION does anyone know about access fees and things to stay clear of or how to?

Cynthia
Ebs, As a patient I can not imagine how concierge med could ever work. Do doctors propose patients pay an access fee to every type of doctor they might need to visit for every family member? Simply put every thing is so specialized it would require multiple access fees for multiple types of specialist. Some areas my family has personally needed in the last five years are orthopedics, pediatrics, internal med, ob, genetic testing, transplant, surgical, and dermatology providers. I am sure there are more that are just not immediately coming to mind. The average middle class person simply does not have the means to pay an access fee to cover all possible areas. I do sympathize that you have found yourself in the trenches with the rest of the nation. Unfortunately, when the economy is bad sooner or later it tends to reach all areas.

David
Ebs. Be careful how you do it. Check out MDVip for the easy route. Or learn from them what to avoid at least, even if you don’t convert your practice and sign up with them.

Ebs
Thanks David for the advice. MDVip does it best i beleive- not sure i have the Kahunas to take that full plunge right now however..i thought i might entertain this hybrid getting my feet wet. regardless, i have put in a local request from cpa/attorney to navigate any potential legal problems. right now its just a brainstorm, but i dont see private medicine surviving for anyone under the current system. the slow to adapt docs will be wondering what happened…

David
Cynthia,
You are right that the economy matters, of coarse. I am a specialist but in speaking with those in my region who have gone concierge, their practices have been surprisingly resilient even on the face of the bad economy.
As a specialist we can always be disease specific. For example, in neurology you can focus on headache, or multiple sclerosis, or Stroke. Your patients will mainly be drawn from these specific diseases and will get super-specialized care in those areas. It is a win- win for those patients and those who provide the expertise.

Cynthia
David, So can you tell me what that means for the average family. I simply do not see how the average person can anticipate what coverage they will need. Would patients need to contract with expected categories of need at the start of a year or could they sign up once they had a dx- provided they have the assets? My husband and I are frugal to the extreme and also extremely responsible. Additionally, how would paying these concierge fees to individual doctors provide us with any protection from hospitals, labs etc from draining our assets and sending us into bankruptcy in the case of extended illnesses? If doctors can require patients cover the insurance portion of the payment if not reimbursed within 60 days, hospitals, labs etc. will also. We are in a better situation than many as we have never bought on credit other than our home and some autos. If we do not see it as viable, particularly as we have a huge respect for doctors and the services they provide, I promise you that 90% of the middle class will not either.

David
Cynthia,
People would typically sign up once a diagnosis is made. Often such patients have more difficult to treat conditions or simply want a very high degree of specialization or want more time with their physician. For primary care, many people are elderly or have multiple medical problems that are difficult to tackle in a single ( typical) office visit.
I’ve seen patients who never see physicians, but only their nurse practitioners and are fine with that. Others push to try to see the world’s expert in their condition. I think every person and situation is different. There certainly is a market there though.

Cynthia
David,
My sister is an RN that is routinely offered extra money by family members for various reasons-a little extra TLC, have an extra demanding family member etc. She always explains to patients and family that she is paid by her employer. She tells them all patients are entitled to equal care and if one patient gets extra care -the next patient get less care. She views it as immoral and unethical.
If doctors start accepting extra money for special care, I do not believe any ethical code could be modeled around this practice. It would likely spread to all areas of health care.
Old, desperate, or dieing people will negate a life time of saving if they think there is a chance- but what happens then? When the money runs out they no longer get to be in the special club. The more I see stuggestion like this-the more I realize some doctors have lost their moral compass.

http://bizsavvytherapist.com Susan
The idea of an “access fee” is worth considering. As is the idea that people can have different price points depending on the type of practitioner they see. Many businesses use registration fees –when I register my son for camp, I have to pay a $30 registration fee, in addition to the tuition.
Whether we like it or not, reform or not, patients are going to have to pay more for their health care. The days of $15 co-pay for all the care you need are over. It’s not sustainable. And, in retrospect, it’s a ridiculous expectation. In NO other industry does anyone expect to pay $15 for access to a valuable service. You car insurance doesn’t offer you $15 oil changes and tire rotations.
My thinking is that all health care professionals will need to take the cards we are dealt in terms of reimbursement and develop sustainable business plans. This might mean developing our own concierge-type groups that have a hybrid of reasonable yearly fee, accepting some insurance reimbursement and self-pay options. This will require transparent fees and payment options. Also important will be additional services such as nutrition classes, weight loss programs, diabetes management, parenting courses, mental health support, and support networks, etc. Maybe access to these classes is dependent on the yearly registration fee. The model will be very different–combination of preventative care and treatment for current conditions.
Patients will need to become informed consumers. There will be more options. But people do this type of leg work for all other services they access in the US, so I’m assuming they can adapt.
Change doesn’t mean “worse.” We need to be open minded to the possibilities and develop creative ways to benefit patients and make a decent living.
http://bizsavvytherapist.com Susan
Cynthia, If you think everyone in the US has access to “equal” care that may be where your frustration comes from. Those who can afford great insurance get better care than those that don’t. And this isn’t going to chagne with the new “reforms.” These reforms give people access, but no guarantees they won’t have huge deductibles or limits on certain types of care. *That has nothing to do with your doctors’ desire to provide excellent care*.
The public needs to divorce their thinking that doctors limit access. They don’t. Your insurance makes those decisions on your AND your doctors’ behalf.
New business models might even the odds of people being healthier overall.
http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD
Cynthia,
I, of course, cannot agree with you at all. Is there something more moral about continuing to practice in a situation where you are likely to bankrupt your practice? Where you cannot provide good service because you must see 30-50 patients per days just to break even? Physicians have no obligation to loose their lives or their lively hood in order to ‘serve’ their patients. I neither demand sacrifices nor expect them from others. I trade with people – service for money – which is the most moral system around.
Your sister can accept the money with a clear conscience. She is going above and beyond the commonplace, and people appreciate it and try to help her financially in their appreciation. Should we stop tipping the hairdresser, the waiter, or the bartender? Aren’t they ‘just doing their jobs’ too?
We could discuss this more, but suffice it to say that we have differing views of morality. I advocate the trader principle (value for value, a la Ayn Rand) as the normal method of dealing with people. There are emergencies and unusual circumstances in which this may not hold up – but as the routine, daily method – I prefer voluntary associations and trade with others. This is capitalism and leads to tremendous prosperity. The altruistic ethics states that someone else’s need is a moral claim on your work or productivity. When that ethics is enshrined in law, the result is communism and socialism – essentially that your purpose is to serve the state and others and you have no right to your own life. Choose wisely!

H
David Allen-value for value, a la Ayn Rand
It’s interesting how individualist we have all become. I certainly hope you were not educated in a public school. The David Allen I found on the internet went to a public medical school.
I should really quit being an socialist altruistic educator and go for the big bucks. Those freeloading students that take taxpayer money for my services. Certainly everyone would have more prosperity if students were responsible for the cost of their entire education.
I also find it ironic how many MD’s are offended because I can’t possibly get quality care from a nurse practitioner but then think it’s ok I forgo care because of cost. You all should be applauding me for making a market decision a la Ayn Rand.
I don’t understand, if you truly believe that capitalism leads to prosperity, how you can continue to take Medicare. Why have you fail to live your values and criticize everyone else? Clearly your goal is to make money at all costs and it is more lucrative to you to stay in your group practice then go the capitalistic route.

http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD
H. (I like the name). Nope, didn’t go to public school. But I would have had no moral qualms about doing so.
I don’t support tax-payer funded education – but that doesn’t mean it is wrong to work in a public school or to be a student in one.
I’m not offended in the least that you like getting care from an NP. More power to you! Every physician is not in lock-step with every other physician.
Interesting that you think I should drop Medicare to be consistent with my ethics. I think it is the same mistaken view that says I should in no way take from or be involved with any public institute. I will say that the decision to be involved with Medicare is complicated, but involves remuneration amounts, hassle-factor in dealing with that particular ‘insurance’ company, as well as risk (since jail time is a possibility in dealing with this particular entity). If it doesn’t make sense for my practice, I may in fact have to drop it. I am currently making changes to my practice (getting out of the group) so don’t assume too much in your analysis!

H
“but that doesn’t mean it is wrong to work in a public school or to be a student in one.”
But ultimately, by choosing to work in public education, I will never have enough money to pay for medical care out of my own pocket. I must rely on insurance and the call made be the author of this article is for providers to accept cash only. So where does that leave me? I surely can’t afford medical fees for anything more than a hang nail. Please just stop the rhetoric on how cash only makes my health care cheaper and better. Cash only will price me out the market.
“Interesting that you think I should drop Medicare to be consistent with my ethics.”
Yeah, I do. To say that you don’t believe in these things, advocate for their demise and then profit from them is hypocritical.

http://fertilityfile.com IVF-MD
Mr. or Mrs. H, you are certainly entitled to your choice of choosing a physician who takes cash only, one who accepts insurance, or one who would accept a bushel of tomatoes for payment. You get to judge which of them is offering better care for a better price. The burden is on the concierge doctor to wow you so much with the amazing service and to get his prices down to a very competitive level so that the patient voluntarily pays a little extra for that 5 star service. Alternatively, some doctors can choose to have a clock-in-clock-out Collect-my-government-check-vacation-and-pension package mentality and cut a deal to be part of some public option and be guaranteed a steady stream of patients without having to be so much of a customer-service fanatic. To each his own.
Would it also be fair that you give parents a choice as to whether they want to support your school system, a different school or to not participate at all?
There’s nothing wrong with having public options as long as they are true OPTIONS and not coercive. One criticism of the public education system is that it gives people no choice to go with another system that might give them what they want (ie higher literacy rates, better vocational training, more convenient hours for parents, a curriculum more in sync with the beliefs of the family, nicer drinking fountains, whatever it is that the students and parents value) as opposed to being FORCED to pay into this one-size-fits-all system.
Social goals can best be achieved by voluntary cooperation rather than by force and coercion. I respect your right to choose to go into government-run education as you have. Can you perhaps respect our rights to choose the education that we want for our kids?
I would pledge to render the best medical care I can for you, but if you don’t like it, you have the choice to go with other private or public options.

H
“Would it also be fair that you give parents a choice as to whether they want to support your school system, a different school or to not participate at all?”
I am not involved in K-12. I work with nursing students who have a choice be there or not. It’s a public institution and tuition is subsidized by the state and federal government. Without public funding, many of our students would be unable to continue their education.

IVF-MD
Fair enough. Would it also be fair to suggest that with the booming economy resulting from tax relief to the economy that a lot of people who rely on being government-dependent would be able to be happily self-sufficient AND that a lot more voluntary charity would be given? (Especially when you strip away the horribly inefficient burdensome layer of bureaucracy that no doubt exists)

H
Dealing with 5 chronic conditions isn’t a catastrophe? Do you have any idea how much money it cost to diagnose them? If I had catastrophic insurance those years instead of the more comprehensive plan, I would have not sought medical care.
I don’t berudge you your opportunity to make a profit from your talents. Just don’t pretend that I can afford what you want me to pay. At least be honest and say that some people will have to do without health care.

http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD
H,
I think five chronic conditions (assuming you had the insurance before you got most of them) would qualify. Catastrophe might better be viewed as a number than an admission to the hospital. Let’s suppose you have a 10,000 deductible for that catastrophic insurance. Then that would come out of your pocket, and anything beyond would be covered by the insurance company.
I do think that if everyone were out there, shopping around, using their own money – that the cost of medical care would come down substantially. In addition, doctors would have to tell you that, in most cases, Plavix isn’t really all that much better than aspirin (unless you have cardiac stents placed) or that having a second MRI this year to make sure the MS hasn’t progressed may not be worth the $800 that will be charged for it. As it is, with the malpractice climate – and the lack of attention to cost on the part of the doctor and patient – people spend money very easily and do their part to increase the price of things.
I’m not saying any of this would occur overnight. Perhaps that is what you are focusing on – what will happen to you tomorrow or this year. I’m speaking about changes which, if slowly implemented, would gradually transform a marketplace for the better.

H
” Let’s suppose you have a 10,000 deductible for that catastrophic insurance. Then that would come out of your pocket, and anything beyond would be covered by the insurance company.”
So I make $21,000 a year and I have a $10,000 deductible. Five of the last seven years I easily surpassed $10,000 in medical fees. So during those 5 years, I am supposed to live off $11,000? Since I pay 20% of the cost of my medical care, I am very aware of how much things costs and whether they are necessary.
“Perhaps that is what you are focusing on – what will happen to you tomorrow or this year. ”
Thinking back to the situation I was in, where one of my chronic conditions took 3 years to diagnose, when the 20% was hard to deal with financially…
Of course, having a $10,000 deductible and being hospitalized for a week around New Years makes that a $20,000 episode.
Anyway, since it is in your best interest to perform a lot of procedures and you clearly are motivated by profit, how do I know the medical advice get from you is in my best interest. Clearly, one who feels we should all pursue our selfish goals would have no problem recommending unnecessary treatment. Maybe that $150 mammogram is unnecessary but my guess is if you made a profit from it, you would have no qualms using fear to get me to agree.

David Allen
H-
You don’t know that the medical advice you get from me is in your best interests, except that, on the whole, giving good advice is what makes or breaks the reputation of physicians. Physicians usually only make money from tests that are performed in their own offices. So you might be leery of physicians who seem to utilize testing in their own offices to a degree beyond the norm.
You also write: “Clearly, one who feels we should all pursue our selfish goals would have no problem recommending unnecessary treatment”
That would be a non sequitur. I believe in rational selfishness. I do not believe that dishonestly is in my long term best interests. People who are rationally selfish (which is actually the majority of Americans, although they don’t realize it) believe that character and long-term goals are important. You might wish to look more into Ayn Rand’s novels and ideas to see that there are some very logical, insightful, and practical ideas regarding what it means to be moral.

http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD
H,
I don’t know what other physicians have in mind, but real reform would involve disentanglement from the entire third party payer system for non-catastrophic care. It is because so many people have insurance and Medicare that they use for routine care that you get priced out of the market. I don’t want you to be priced out of the market. I wish you were allowed (by states, for the most part) to buy catastrophic care only and save all that money you give to the insurance company so you can instead shop around and pay for what you want. That is part of the idea behind Health Savings Accounts – although they don’t really allow for catastrophic only plans (which would may them much cheaper).
If you are interested, I can direct you to multiple physicians who have up-front, low-cost pricing. There is even an insurance-free ER which posts its (rather cheap) prices right on their wall!
Regarding my supposedly hypocritical stanze, I’ll go you one better. If I were 65 years or older, I would probably sign up for Medicare! The government has effectively destroyed the private market in this segment of the population. Since I paid into the system (much more than the average person of my age, by the way) I certainly would not forgo the benefits! There actually wouldn’t be many options for me – and they are getting worse as the days go by.
I declare my right to make a profit, to keep what I’ve earned, to be proud of my labor. There can be good people in bad systems – so I don’t begrudge you your salary nor do I feel badly that my talents can provide me with a reasonable living.
H
“The burden is on the concierge doctor to wow you so much with the amazing service and to get his prices down to a very competitive level so that the patient voluntarily pays a little extra for that 5 star service.”
I would rather continue to see my nurse practitioner and take that little extra cash and donate it to our local food bank.

IVF-MD
In some cases, so would I! Wouldn’t life be grand and the world a better place if you and I had the freedom of choice to do that in all scenarios and not just with concierge doctors!

H
“Wouldn’t life be grand and the world a better place if you and I had the freedom of choice to do that in all scenarios and not just with concierge doctors!”
I have the choice of a large corporate medical center clinic, a small corporate medical clinic, a group of three independently practicing physicians taking insurance, two solo physicians taking insurance, a cash only fee for service physician, physician that has a membership fee, a nurse practitioner, and various alternate health providers ie naturpathic physicians, chiropractors, chinese medicine. We have plenty of people who can’t afford care. Wouldn’t it be great if those cash only doctors really reduced their prices instead of charging more than insurance companies.

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