Converting a practice to a no insurance accepted model

Not long ago, I was working for a pain management firm with 19 clinics scattered throughout three states. I was fast approaching my three year mark as the travel PA and more recently, the compliance officer. Little did I know that my career path was about to go off-road, into a new world of clinic ownership coupled with the unchartered territory of no-insurance accepted.

What a difference a few months can make. I was approached by our family physician to take over his practice as he was considering taking a full time job with the VA. He had been deployed to Iraq twice with the Reserves in the last few years and his practice had suffered for it. My initial deer-in-the-headlights reaction gave way to a growing enthusiasm to create an affordable, slower paced practice where I could enjoy medicine again. Thus, the idea for a clinic based on the motto of Modern Medicine the Old Fashioned Way was formed.

After extensive research on the self-pay, no insurance accepted model, it became abundantly clear this was the only way to go. But I’m not going to tell you it has been easy. My 24 years of military training helped foster my don’t-give-up attitude. From the time I took over the practice until we launched three months later as completely self-pay, it was a whirlwind of non-stop work from website building to cosmetic updating, new system implementation, vendor negotiations, employee retraining, EMR initiation, existing patient education, price setting, etc., infused with many moments of self-doubt.  There is no manual to go by when deciding to deviate from the traditional system. No organized network of seasoned mentors to call upon for sage advice.  I have relied heavily on prayer, ideas bounced off my wife and what little scraps of information I could glean off the web.

Much of our efforts have been geared towards cutting overhead costs. With a self-pay model, every penny counts. Fortunately, my wife has taken on the role of office manager and is very frugal.  We negotiated our labs down to unheard of prices by offering to pay them directly for all tests at the end of each month.  We charge our patients a modest mark up (still the lowest cost for them around) and they pay us directly at time of service. No insurance means savings for everyone, including our lab.

Unfortunately, we did have to let some of the existing staff go as our patient count has dropped since initiating our transition to self-pay.  This is typical from accounts by other providers around the country that have converted their practices, some as much as a 75% drop in patient count.  We now have an office manager, a full time receptionist and a part time nurse practitioner who sees most of our female patients for their paps/wellness exams. We will need to add a part time Medical Assistant as we grow but we will still keep our labor costs lean. This necessitates that we all pitch in to help where needed with answering phones, scanning records, negotiating referrals, etc.  Since we only schedule two patients per hour, I have the time to do my own blood draws, shots and vital signs, and personally call patients with their lab results. These tasks give me more contact with my patients, which they appreciate.

We are now six weeks into our new model and have had some amazing results. Our first month was almost break even with only seeing 75 patients. I am able to spend more time with each patient than any other time in my career. My patients really appreciate it and I am excited about going to work every day.  Best of all, I am able to fully focus on my patients, with the weight of a thousand government and insurance rules, regulations, and restrictions lifted off my back.  And I do not intend to go back.

Robert Tomsett is the owner of GracePointe Healthcare in Franklin, TN         

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  • mike blackmer

    I don’t understand this article.  Aren’t you a PA?  What physician is overseeing patient care?

    • Anonymous

      Yes, I am a PA.  As TN law allows, I own 99% of my practice with my supervising physician owning 1%.

  • http://twitter.com/FairCareMD Alex Fair

    The fact is Robert (and Julie) that the need for additional staff is vastly reduced in a Direct-Pay practice.  At least 1, usually 2, of the average 4.5 staff members per physician are no longer needed thanks to the greater efficiency of running a no-insurance practice.   These resources can be freed up to perform patient care activities or join another group.  I know one healthcare office staffer who just enrolled in a PA program for just this reason.

    To answer Mike’s question, yes, he does have a Physician oversight member of his practice.  How do I know?  Well, of course because Robert Tomsett, PA-C is one of the many new FairCareMDs going direct using our automated system!

    Thanks Kevin for supporting the Direct-Pay Movement enabling doctors to be paid better and patients to get fair prices for care when paying directly.

    • Anonymous

      “Well, of course because Robert Tomsett, PA-C is one of the many new FairCareMDs going direct using our automated system!”

      You’re kidding, right?  Being a member of what amounts to as “Priceline” for medical care is proof of physician oversight?

    • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

      Kevin, i think blatant commercial posts need to be screened better.  The site is already getting diluted by the many partners and ads that also slow up browsing

  • http://www.facebook.com/robolivermd Rob Oliver

    So let me clear this up. There’s an MD onsite in the office whom is seeing these same patients and signing off on patients delegated right? If not (as it sounds like) this operation is flaunting the whole idea of physcian extenders, which are designated subordinates rather then supposed to be running their own fee for service clinic with ghost supervision.

    • Anonymous

      As per TN Medical Board regulations, my supervising physician reviews a minimum of 20% of my charts every 10 days and visits my practice at least once every 30 days.  I own 99% of my practice and my supervising physician owns 1%. I have 28+ years of medical experience and was trained in the Army to operate independently in very remote areas.

  • http://www.facebook.com/people/Ardella-Eagle/840440226 Ardella Eagle

    I fear that a no-insurance-model will be the only way for physicians to survive in the current economy. Those who have a PPS/PPO plan can file themselves for reimbursement.  However, where will that leave the over 70% population who can’t afford any insurance at all, let alone a private pay physician?  Back in the ‘old days’, paying the doctor with a side of pig in the Ozarks was acceptable; I doubt if a doctor making a house call would appreciate the barter system/

    Even with the relief of overbearing HMO/PPO/prior-authorization/wrongfully denied claims removed, there will be compliance issues that truly private physicians will have to maintain.  What with HIPAA and OSHA and the threat of medical malpractice suits, doctors still need to practice more than due diligence.

    The no-insurance-model is an option as is concierge care, but in my opinion, it will put a huge burden on the public clinics and hospital emergency rooms.  Given that hospitals are closing and Congress is cutting payments on public insurance, this is a recipe for disaster.

    • Brian

      Ardella,

      I think that you’re right that this is the future for many physicians, but it is a vast improvement over the current system.  The fact is that it makes little sense to pay a third payer to pay for our primary (and to some extent, specialty) care.  Anyone that thinks that they are making out well with a $20 copay doesn’t appreciate the way that the third party payer system has increased the cost of care needlessly, through obfuscated administrative costs and stagnated wages. Physicians that can cut out the third payer, negotiate lower ancillary and specialty services, and reduce their overhead, can provide affordable care to those with or without insurance.  High deductible insurance and HSAs have had unremarkable results so far because there are not yet sufficient numbers of physicians operating in this model.

      As for this instance of what appears (after examining their own website) to be a PA operating independently with a shadow physician (himself a full-time VA employee) as an enabler, I guess that’s one for the Tennessee regulators to investigate.

      • Anonymous

        Okay patients pay for office visits…they still catastrophic insurance…not a cure all.

        • Guest

          Well said!  Patients in this type of practice should absolutely have catastrophic insurance if at all possible.  Again, the system isn’t well adapted to this model (yet) but those of us who think that this is the future expect that market forces and consumer demand will change that.

          You are also right that this is not a cure all.  But this type of model goes a long way towards fixing what is wrong with primary care (which adversely affects the entire system).  Medical students don’t want to go into primary care because they realize that (1) the compensation is far lower than what they could earn as a specialist, (2) the insurance system is a nightmare to navigate (http://well.blogs.nytimes.com/2011/08/25/an-insurance-maze-for-u-s-doctors/), and, most importantly, (3) that they won’t be able to practice the medicine they learned in medical school once they get on the hamster-wheel of productivity-based compensation.  A well-run practice in the direct-pay model addresses all of these issues and provides affordable,  high-quality care that can be expected to reduce the need for specialty, emergency, and hospital services.

        • Anonymous

          Agreed and we encourage all of our patients that don’t have insurance to look into catastrophic coverage.

          We have a company in Nashville called Bernard Health that helps people find insurance that is right for their health, financial situation, etc. About 90% of their clients end up with catastrophic coverage and a HSA. It’s where our country is going unless you work for the government. 

        • Anonymous

          It’s where our country is going unless you work for the government.>>>>>

          Sigh…or vote more responsibly.

      • Anonymous

        As per TN Medical Board regulations, my supervising physician reviews a
        minimum of 20% of my charts every 10 days and visits my practice at
        least once every 30 days.  I own 99% of my practice and my supervising
        physician owns 1%. I have 28+ years of medical experience and was
        trained in the Army to operate independently in very remote areas.

    • Anonymous

      Actually, for folks in our area that don’t have insurance, our model has been welcomed with enthusiasm. Our prices, especially for labs, are lower than any providers in our area. And we have done some bartering. No offer for a pig yet but we can hope.

      We encourage all of our patients that have no insurance to look into catastrophic coverage and to set their deductible at the highest level they feel comfortable with in case they have to use it.

      More direct pay practices with transparency in pricing will encourage competition and give patients real choices which will actually improve the current system. I’m not sure how you think this model puts a huge burden on public clinics and hospital ERs. Direct pay practices will not cause more patients to go to these places, they actually give them another choice.

  • Anonymous

    A PA that shuffles his patients off to a NP…great.

    • http://www.gracepointehealthcare.com Robert Tomsett

      I don’t “shuffle” my patients off to an NP.  My female provider is available for those patients who prefer a female provider for their GYN issues.  This is another way we offer exceptional service to our patients. 

  • http://twitter.com/#!/CloseCall_MD Close Call

    I’m all for direct care practices, but I’m curious to the financing of this when the owner is a PA.  How does the physician play into all of this?  

    Is the physician just signing off on records?  And what percentage of revenue is going to the physician for his/her oversight?

    • Anonymous

      I own 99% of my practice and my supervising physician owns 1%. I pay him a monthly fee for reviewing my charts and providing supervision. He is available to me 24/7 for consultation.

  • Anonymous

    I don’t see how this is an example of market forces working to bring down the cost of medical costs.  The $275 dollars for the comprehensive physical is quite a bit more that my doctor charges.  My doctors inflated cash price (the one they charge cash paying customers to compensate for low reimbursements) is $235 adjusted for the cost of living index.  The physical with Mr. Tomsett includes an EKG that is not a recommended screening test, blood work and urinalysis that are also not recommended in asymptomatic individuals.  I find this preying of the fears patients that they need more healthcare to be healthy.

    • Brian

      I agree, I don’t think their charges are very competitive.  Compare with Access Healthcare in Apex, NC:  http://www.acchealth.com/

      Also agree that some of the routine tests that they are perform should not necessarily be “routine” based on current recommendations.

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

        • Brian

          For clarity, I am not Dr. Forrest, but I have seen his practice up close through a shadowing experience (I’m a med student). 

           

          • http://www.gracepointehealthcare.com Robert Tomsett

            Thank you for clarifying!  I have read much from and about Dr. Forrest and his practice. I admire him a great deal for his courage in pioneering the direct pay practice model and have adopted some of his ideas with my practice, including the concept of free “basic labs” with a monthly plan.  He is to be commended for developing a better way to take care of patients while being able to make a decent living.  How to run a business is not taught along with medical training but Dr. Forrest is a physician as well as great business man. My hat goes off to him!    

            I do want to address the difference in our pricing…
            Apex does not have the cost of living or income levels of Franklin. That being said, our lab fees to our patients are LOWER than Dr. Forrest’s. 
            So when you look at his overall average charge per patient, we are about the same. We charge more for an office visit but he charges more for individual labs.
            Bottom line – both of our practices have drastically cut overhead costs by cutting out the third party payer and reducing the number of employees per provider. 
            Both of our practices are saving our patients money and time. We ALL win by cutting out the third party payer!

            As a side note – I enjoy the time I spend with my patients drawing their
            blood and personally calling them with their lab results, and my
            patients are amazed that I am willing to do this for them – just another
            way we give our patients great service.  But many physicians feel like
            they are like a rat on a wheel, having to see more and more patients a
            day to keep up pace with climbing overhead expenses and decreasing
            reimbursements and can’t take any more than a few minutes with their patients.
            My whole point of writing this blog was to encourage other primary care providers to consider doing things a different way.  I am enjoying medicine again and my patients are enjoying coming to our office. No, it isn’t for everyone, but it has been an incredibly positive change for me… sometimes, I even have time to enjoy a cup of coffee and a granola bar with my patients.

          • Anonymous

            $69 in Franklin adjusted is $61 in Apex.

            $49 in Apex adjusted is $55 in Franklin.

            Dr. Forrest in an MD.

          • http://www.gracepointehealthcare.com Robert Tomsett

            e_patient – I’m not sure you are seeing the whole picture. The direct pay model is free enterprise at work – we set the pricing but the market dictates whether we are too high or not. It’s very simple – if we are charging too much, we have no business. 

            You need to list Dr. Forrest’s lab prices compared to ours to get an accurate comparison of overall fees to patients. As I said earlier, his lab fees are higher than ours but overall, the average per patient visit is about the same for both of our practices. And we have had NO complaints about our pricing. As a matter of fact, most patients are surprised at our low cost and we have even had a couple ask if we were sure we charged them for everything.

            Yes, I am aware that Dr. Forrest is an MD. Pricing in the direct pay model is not dictated based on what insurance companies have decided to reimburse for what, done by who. And patients are not locked into who their insurance tells them they must go to. 

            Our patients know I am a PA and they know I have 28+ years of extensive medical experience. As I stated earlier, we have had NO complaints of our prices being too high and many, many thanks for serving our patients with same day appointments, opening early or staying late for them and taking time with them.  If our fees were too high for our area, patients simply would go elsewhere as there are many family practice options in our area to choose from.

            This is the beauty of capitalism – people spend their money where they choose to because of the level of service they receive.  If our pricing is too high or we do not give the level of service our patients expect, we will need to adjust accordingly or have no patients.

            So far, based on patient feedback, our services seem to be far more than they expect based on our pricing. That gives me a great deal of satisfaction at the end of the day as serving my patients is my main goal.     

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

      • Anonymous

        Adjustment for cost of living:  $80 vs $64.  I assume you are Dr. Forrest.  I wouldn’t pay $80 to see a PA.  I might forgo my health insurance benefit for a $64 doctor visit and a good doctor/patient relationship…as long as I don’t get shuffled off to the nurse practitioner on a regular basis and you were up to speed on the rare condition I have. 

        We have a independently nurse practitioner in my area that charges $45 per visit and $65 for a physical for cash paying patients.  She also accepts insurance.

      • Anonymous

        Dr. Forrest – please see my reply above…

        • Brian

          I’m not Dr. Forrest, and I don’t speak on his behalf.  I believe that he has been a KevinMD contributor in the past and posts under his own profile.

    • Anonymous

      We live in a very affluent area. The cost for healthcare here cannot be compared to other areas around the country where salaries and the cost of living are significantly less.

      I did a physical on a guy last week that had called his doctor to get a price on a physical and he was told $900. He was very happy with the $249 he paid in my office. We have had NO complaints about our pricing and many thanks for keeping the charges lower than our patients can get anywhere else in our area. Competitive pricing can only be assessed by the immediate competition. Office visits in our area average $115+.

      I do not prey on any of my patient’s fears and I do not give tests that are unnecessary. I care far too much about my patients and my relationship with them to operate in such an unethical fashion. I treat every patient as an individual and have even talked patients out of tests as they were not warranted. I do not do EKGs on young, healthy patients that do not have a need for it but have included it on our website to let folks know it is available.

      • Anonymous

        I live in a very affluent area.  The cost of living index for the city I live in is higher that Franklin, TN.  If I moved to Franklin TN, I can expect to make 86% of what I do now.  My money would go farther in Franklin, TN.  Office visits in my area can be (not adjusted, doctor set price) $150+.  $275 seems like a lot for a physical especially if I made 86% less.  Clearly $900 is an executive physical.

        Your website implies that an EKG is part of the physical and your statement implies that you will do one on an older patient.  Routine EKG are not recommended for any age and to list it as part of the physical seem ingenuous to me.

        It disturbs me that your education is not intended to prepare you to work independently and the collaboration with a physician is not there.  At least when I see the physician’s assistant in my doctors office, if my chart is reviewed, I have this idea that the doctor knows who I am.  It creeps me out to think someone I have never met is reviewing my chart and deciding critical things about my care.  And if this is ok, why not outsource physician oversight to India or Mexico?  Cheaper to book a flight once a month than to pay for a physician in an area with a higher cost of living.

        I have seen an independently practicing nurse practitioner.  I feel the nursing skills brought to the practice are invaluable and at the end of the day, I know who is responsible for my care.  She only charges $45 for an office visit in my more expensive area.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • Anonymous

    If the threads on KevinMD are allowed to go commercial, shouldn’t there be a ‘conclicts of interest’ declaration posted?  It’s a shame that readers now have to vet authors and posters beforehand to discover what’s guiding their opinions.

  • http://twitter.com/#!/CloseCall_MD Close Call

    This is most likely the form that most private practices will take if they’re not bought out by hospitals or other health groups. 

    Most medical students don’t realize that many physicians are doing this out there.  They also don’t realize that it’s really only FP, IM, peds and OB/Gyn (to a lesser extent) docs who are able to do this.  Unfortunately, general surgeons, orthos, otphos would find it really hard to create a practice like this since many, if not most, of their patients are on Medicare.  As we see payment for specialists ratchet down even further, it’ll just get harder and harder.  500$ for an appendectomy in some areas?  Are you kidding me?  For a surgeon with almost 10 years of medical training to take out an infected organ and sew you back up again?  That’s just a couple of months of cable TV.  It’s crazy.  And for all the talk about specialists having higher reimbursements – they definitely do… but the screw is being turned with Medicare.  I feel sorry for them because they have no recourse… no out… like primary care docs do with retainer practices.

    On a separate note, the ownership by a PA in TN is interesting.  Over 2 decades of experience is one thing.  Could a PA right out school or internship do this too? 

    • http://www.gracepointehealthcare.com Robert Tomsett

      No, I don’t believe a PA or NP right out of school could, should or would do what I have done.  I have been involved in direct patient care since 1983 as a Medic, Paramedic, Flight Medic, Special Forces Medical Sergeant and then I went to PA school.  I’ve been a PA now for 16 years and worked in Primary Care, Emergency Departments, Pain Management and deployed to many remote locations where operating independently was a necessity.  My current supervising physician in this practice has known me for several years and as an Army Reserve physician, he has worked with many PA’s so there is a certain level of trust between us that made him comfortable with asking me to take over his practice.  I speak with him daily about patients, most of whom he knows well and he is available to me 24/7 should I need his advice.   Should he have to deploy again, I have available another physician who has also worked regularly with military trained PA’s and he would provide supervision as mandated by the TN Medical Board. 

      Concerning the comments about specialists not having the self-pay option, I agree with you.  That would be very difficult if not impossible.  When we had our Grand Opening / Open House, several specialists stopped by and lamented how they wish they could do what we have done with self pay.  I have also heard from many Primary Care doctors who have applauded what I am doing and stated that if they could go back and start over, they would do it as a self-pay practice.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    If this is the way the country is going (and I don’t think it is), we are in a world of hurt. This type of service is good for the healthy and wealthy, like the ones this practice seems to be servicing.
    This model is not going to work for the poor, and for people with chronic disease who need expensive meds, specialist visits, diagnostic tests & procedures not listed by the clinic, occasional hospitalizations, etc.

    However, once the new health law kicks in, and all insurance becomes guaranteed issue, I can see the young and healthy using this type of concierge medicine until they get sick, at which point they will just buy regular insurance. No need for HSA or any other backups.

    Since most people are healthy most of the time, this may work well for the concierge clinicians, but the unfortunate spiraling effects on health care costs for those who need care most, should be obvious.

    • http://www.gracepointehealthcare.com Robert Tomsett

      I absolutely beg to differ with your premise that our clinic is only serving the healthy and wealthy.  We purposely did not go solely into the “concierge” type model so that we could offer care to the uninsured and under-insured and this population is the majority of who we are seeing.  I am seeing patients with diabetes, hypertension, etc. and offer a Smart Care Plan that offers even more savings to those who may have to see us more often than 3 or 4 times a year.  We also do not recognize the term or penalize anybody for “Pre-existing Conditions”.  We do have a Premium Smart Care Plan that is available to those who may have disposable income, but I’ve limited that to 100 patients only.   I do everything I can to get folks free samples of meds, negotiate cash prices with local imaging facilities and refer to local specialists who are self-pay friendly to my patients.   If a patient does have insurance, they are free to use it for their medications / imaging or specialty visits.  However, regardless of their economic or insurance status, our patients are coming back to our clinic because of the kind of care and attention we are providing that falls within the realm of “Primary Care”.   They know we care and we spend time with them.  They don’t wait for very long in the waiting room and their care is never rushed when they are being seen.  We are only into our second month as a total self-pay practice and yet we have received several letters of thanks for the care we have given.  And we have been told by many patients as they leave, “This has been the best health care experience I’ve ever had!”  That makes all of us feel very good about coming to work everyday.  And for those who may think this is about money, you are dead wrong.   This model is not likely to make you a rich provider, but it will markedly improve your job satisfaction!

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Since you stated that you live in a very affluent area and that you made house calls, I assumed that the patients come from the community. Just because people are uninsured or under-insured, doesn’t necessarily mean that they are poor.
        As a reference, Medicare fees for the most expensive physical on their books, will pay a maximum of $170 in Tennessee and about $20 for an EKG and nobody pays for phone-refills (you may want to consider eRx) or phone calls. So it seems to me that this self-pay fee structure beats Medicare any given day, not to mention Medicaid, and as e_patient mentioned above is comparable to the prices of regular practices for cash services.
        On a different note, I am sure you do your best to provide good care for your patients, but honestly, I rarely if ever seen a PCP with 40 patients on his/her schedule – 25 is a more realistic number.

        • http://www.gracepointehealthcare.com Robert Tomsett

          House calls are a very small percentage of my practice. 

          I appreciate your research on Medicare fees, but I find it puzzling you would compare our pricing only against what Medicare allows when Medicare is nearly unanimously looked at by every provider as ridiculous in what they reimburse and they continue to cut rates annually.  

          We have not based our fees on what insurance does or does not reimburse for.  We looked at multiple sources including other cash pay providers, online sites that compared rates for a certain level of care in our region, as well as what providers bill to the various third party payers.  We took into account they only receive a portion of that because they are credentialed in with that entity and have agreed to take a reduced rate in order to have patients funneled to them through their provider network.  While it is true that insurance companies do not reimburse for med refills, there are plenty of direct pay providers charging for them. We are not ruled by the insurance companies and do not force patients to come in for an office visit just to get paid more to refill meds. I evaluate the necessity of office visits based on my individual patient’s health needs, rather than insurance reimbursements.

          We are credentialed with no third party payer and have opted out of Medicare/Medicaid.  We only have to set our fees at what patients are willing to pay for the exceptional kind of care and attention they receive.  And since we are in no provider network, we cannot rely on that as a steady stream of patients like most providers do.  We must rely on word of mouth and marketing/media advertising.  The self-pay model dictates we must provide a level of care that outshines or is at least markedly different than the traditional primary care clinics.  We must provide exceptional care above and beyond the norm as our patients have complete freedom of choice. They have not been told by their insurance company that they have to be seen by us and are in complete control of  their hard earned dollars in a very struggling economy.  Much like their favorite hairdresser, mechanic or restaurant, if we are not exceptional, they will take their patronage elsewhere and we lose.  

          The Family Practitioner right next door to me was lamenting just last week about the 30+ patients per day she is seeing to make ends meet.  This includes the self-pay/no insurance cosmetic procedures and laser hair removal she has added to improve her bottom line.  Meanwhile, her office manager is telling me they are scheduling their patients into November because she is all booked up.  She sets aside a few appointments on Mondays only for minor emergency or acutely ill patients.  Otherwise, her patients have to wait weeks or months to be seen.

          And again to clarify;  the $249 physical everyone keeps commenting about was done on a self-employed mid- 40′s man who had not had a full physical in more than 10 years, strong Fam Hx of CAD and CA, had some mild hypertension and was a smoker.  He got a full physical exam to include rectal/prostate exam with hemoccult, UA, CBC, CMP, Lipid Panel, PSA and we did an ECG which showed some LVH.  So I sent him for a local CXR which I negotiated for him for less than $60.00 at one of our cooperating imaging centers. He also was very concerned about low testosterone due to his reduced libido and fatigue so I ordered a testosterone level.   When you are doing your calculating, that equates to a V70.0 and a 99213 at a minimum and don’t forget to factor in the codes for the venipuncture, handling fee and pulse oximeter which everyone codes for, but only certain payers allow.  I took his vital signs, drew his blood and spent almost an hour with this patient discussing his history, my findings and why we were ordering what we did.  You would be hard pressed to find any third party payer and lab provider who would or could do all of that for $249 and do it with no follow-up bills in the mail weeks later.  This patient was extremely pleased with what he got for the price and enormously satisfied with the attention he received as he conveyed it many times to me before he left.  He also stated it many times to our receptionist as she was collecting the fees from him as his doctor had told him a physical in his office with the labs was going to cost him $900.  

  • Anonymous

    more power to you Robert for changing a practice over like you did and making it work, you’re a credit to us all, sbahrych, pac, mph

    • http://www.gracepointehealthcare.com Robert Tomsett

      Thank you! I’m hoping others will follow as many patients appreciate this kind of care.

  • Melissa Carroll

    Congratulations on a successful transition! There are a number of very successful all fee for service practices all over the country, so don’t feel like you are alone. You started on the right path with EMR, website and cosmetic updates. Paying directly for lab testing is a great way to offer lower costs. You may also be able to negotiate on behalf of your patients for lower fees for other services as well. The valued added services you provide by having time to spend with your patients will turn into word of mouth referrals and your practice will continue to grow. There are some organizations that can offer support without having to join a concierge model. The APPA and the AAPP focus on private or cash based practices and have a number of resources available.
     
    Your website will be an important point of contact for new and existing patients; and having a social media presence in the form of a blog or monthly newsletter is helpful as well – and it’s cheap. The main focus should be on customer service – smiling friendly staff and a doctor who is not rushing to get in and out of the exam room goes a long way. Your patients will appreciate your time and the value they are getting. Connecting with your patients on a personal level will do more for your success than anything else. Again congratulations on the transition.
     
    On a side note – I’ve used this model to help manage my finances and avoid paying large amounts of money to an insurance company for service I don’t use and I can’t afford – $700 a month for health insurance is not in my budget.  We pay cash and have access to very affordable care for my family including my four children. I pay cash for office visits, hospital care and immunizations. I have never come across a doctor or other provider that would not make payment arrangements and we have never ever been turned away because we don’t have insurance. The idea that these practices are only out to make money is ridiculous. These doctors have returned to the real reason they went to medical school – to help people, and I appreciate that because it benefits me as the patient.  I can’t image a better way to practice medicine – available and affordable.
     
    The real travesty will occur when government run healthcare kicks in and there is a sudden negative shift in availability. Fewer doctors will be in practice and there will be limited access for everyone, especially those that require a lot of specialized care, expensive medications and treatments. It’s an unfortunate reality that we’ve seen happen in other countries. I am not sure why we are so arrogant to think we can do it better when we can’t manage the programs we have now.
     
    The demographic for self-pay services is not the young and healthy – they are still bullet proof and see no value in healthcare; it’s the baby boomers who do not want to be sick or have had enough of traditional approaches to medicine. They are motivated to take charge of and responsibility for their health and are the most willing to step out of the box of traditional methods and approaches. They are also not wealthy. They are average, hardworking, and afraid of needing very expensive care as they age. And insurance still won’t be free or low cost, private insurance will only get more expensive.

    • http://www.gracepointehealthcare.com Robert Tomsett

      Thank you for your encouraging words!  It has not been easy to convert to direct pay but extremely satisfying for me and my patients. Most of the negativity has come from within the medical community, as you can read below. Thanks for “getting it”!

  • Anonymous

    As a health insurance advisor (aka health insurance agent who sells health insurance), I love this idea of self-pay.  This model will do more to bring consumerism BACK to the health care marketplace. 

    NOTE – patients can still file claims with their health insurance carrier and be reimbursed for the medial bills. 

    I hope Gracepointe succeeds in their quest to go back to the future. 

  • http://twitter.com/gigimcmurray Gigi McMurray

    I’m surprised at the level of attack here. Rob is an amazing and caring provider who assesses each patient’s needs. The list on the website is simply an example. He doesn’t give an EKG  or any other test unless it is needed. 

    I work with GracePointe as the part-time FNP. Someone mentioned that Rob shuffles his patients off to me. Actually, he gives his patients a choice – one thing that is missing in our current healthcare system. Insurance companies have the power right now. I have seen a number of patients cringing in fear over pre-existing conditions and insurance coverage. To give them a choice in their healthcare is a freedom they have not had up until now. 

  • http://twitter.com/chasedave Dave Chase

    Hats of to you for forging your own path. I’m sorry I missed this earlier. I interviewed several MDs who have made the switch to a retainer-based model. They all took an approach that, despite myths that suggest otherwise, appeals to people who have been priced out of traditional insurance being used for day-to-day healthcare. In other words, a significant swath of their patients/clientele were previously uninsured. The post http://www.kevinmd.com/blog/2011/09/overcoming-barriers-building-direct-primary-care-practice.html outlines how others have overcome the barriers to switching to a non-insurance model. I’m unclear why people argue against a model that is essentially a return to the Marcus Welby model of care. Both doctors and patients were happier in that model. Direct primary care simply returns things to a very similar approach where there’s a direct relationship between the primary care provider and the individual.

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