Doctors see little of the money patients pay towards health insurance

I was recently struck by two conversations that I had with acquaintances about recent experiences that they had had with their primary care physicians.  The first occurred at my local pool. A fellow swimmer asked me if I took new Medicare patients.  She bemoaned that she was abandoned — her beloved physician of over 20 years had sent out a letter announcing that she would no longer accept Medicare patients. My friend had recently gone on Medicare.  She speculated about her physician’s  motives, but felt personally rejected, or “fired.”   After she explained her situation, I affirmed, “I do take new Medicare patients,” but qualified my response with a description of my concierge model primary care practice, which requires an annual retainer fee from members in exchange for improved access to me and other amenities, including my guaranteed smaller patient panel size.

I started a retainer fee primary care practice after having been in a traditional fee for service practice for 12 years and then after taking a year’s leave of absence from clinical medicine. Many of my old patients sought me out, though currently most patients enrolling in my practice are new patients looking for a better primary care experience.  My swimming friend nodded that she understood and that her mother had a concierge physician–she was familiar with the concept and could see its value, though was going to have to decided whether she could afford it.

My second conversation was at a friend’s 59th birthday party the following evening. The party was held at the upscale home of a middle-aged, gay male couple—friends of my friend. As I chatted with one of the hosts, a self-employed professional, he asked what kind of medicine I practiced. I explained that I was an internist, or a primary care physician for adults, and that I was in solo practice in Atlanta after practicing at the Emory Clinic for 12 years.  As I spoke he announced that he was in need of a new primary care physician. He went on to explain that his physician, who he was very fond of, had converted his practice last year to a concierge model practice—requiring patients to pay a membership fee in order to remain in his care.  He had made the decision not to enroll in the new practice model, in part because he was already paying a high deductible for care under his insurance and he was unsure how the annual fee would impact his out of pocket cost.

Before the host of the party said more (not wanting him to feel awkward with me), I explained that my practice was a similar model. He and I spoke for about twenty minutes about the problems in primary care and the reasons that primary care doctors were seeking out new practice models.  The man with whom I chatted pulled over his partner, who had been cared for by the same physician.  His partner reacted to our discussion—“but this is not a solution for our country’s health care problems.” I agreed, and we talked about cost and discussed new models of health care, including the Medical Home and Accountable Care Organizations, both of which have yet to materialize as answers for doctors like me.  He went on to assert that he felt that one solution to the problems in medicine would be to produce more doctors, while at the same time to lower the cost of educating them.  Personally, I doubt that producing more doctors in general, will improve primary care, nor will it reduce cost; though, better incentivizing primary care career choices would be helpful.

These conversations illustrate that for the American populous the main problems in health care today are access and affordability.   For primary care physicians the problem is not so simple.  The “system” has failed to support our work in a manner that is conducive to providing the care that we feel patients deserve. Patients may or may not be aware of the impact of this failure on our practice of medicine.

Most Americans equate spending money on health insurance with spending money on their physicians. Primary care physicians see relatively little of the money that consumers put toward their health insurance premiums. Our fees and reimbursement rates are relatively low in comparison to the exorbitant fees for tests, procedures, ER visits, and hospitals stays. As our overhead expense has increased, in part because of the administrative hassle involved in getting money from health insurance companies, we have responded by increasing the number of patients seen per day and our panel sizes to the point where many (including myself) feel that quality of care and the patient-physician relationship is compromised.

“Concierge medicine” and the abandonment of Medicaid, and now Medicare, by primary care practices are a reaction to these pressures, which have changed the nature of general practice and offer solutions to protect the personal aspects of the physician-patient relationship.  However, clearly these motives remain poorly understood by the average American consumer, who is faced with rising out of pocket medical costs to pay for health insurance, and increasingly feels burdened with excessive health care expense.

The disconnect leaves doctors like me in a conundrum. Do we continue to work within the confines of a system that has failed to protect primary care as an honored specialty? Do we compromise the care that we deliver in order to preserve access?  Or, do we jump ship and force change by creating new models of care—models of care that patients are increasingly seeking out as they recognize their value? It can be a difficult position to be in.

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

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  • http://twitter.com/drtwillett TheresaWillett MDPhD

    Thank you for the nice summary of the disconnect between patients and primary care doctors regarding the healthcare crisis. My mother is on medicare and suffered, I believe, unforgivable delays in cancer care due to lack of physicians in her area (a large metropolitan area, in fact). As a primary care pediatrician myself, I have spent many an extra minute or two discussing these issues with patients as I fell farther and farther behind in my 10-15 minute physical appointments. A very difficult time indeed!

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    The benefits of a small practice that has and gives extra time to its patients is invaluable. The American Academy of Private Physicians ( http://www.aapp.org) has assembled some data on the health benefits these type of practices bring to patients as has MDVIP the first concierge national franchise of primary care practices. Many have discussed the marriage of concierge practices with high deductible health plans with Health Savings Accounts so that health care needs for the deductible are paid in pre tax dollars. The high deductible keeps the costs of the premium lower and employers and employees should theoretically be attracted to these. The problem is we have now trained several generations of individuals used to first dollar or near first dollar coverage for health care. If they have to pay a co pay or a deductible on anything they think the policy is terrible .This is quite understandable in today’s tough economic times when every dollar counts. The unfortunate thing is when the same mantra is ushered from individuals who do not think twice about upgrading to the latest smartphone or tablet, travelling and dining in the best places but complaining about co pays and deductibles as if they were on an entry level salary. The availability of your concierge physician and that physicians ability to be your advocate in an increasingly complex and confusing health care system do not cost much more than a latte daily at a place like Starbucks. There is a story told in the medical profession about a wealthy member of the royal family choking in a public restaurant on a bolus of food. A physician approaches him, identifies the problem and saves his life by performing the Heimlich manuever. The appreciative individual recovers , thanks the doctor and asks ” how much do I owe you for your services.?” The doc answers, ” Half of what you what have paid me when you were choking.” Healthy people are reluctant to spend money on health care until they are ill. At that time they choose the person on the plan

  • buzzkillersmith

    The answer to your conundrum is…no answer. Have you read Orwell’s Animal Farm? One of the animals’ answer was to work harder. Your call, doc.
    That said, this is a pretty good Kevinmd post, and I don’t write that often. Keep it up, Dr. Mav.

  • http://primarycarenext.blogspot.com/ Keegan Duchicela

    Great post. No easy answers. We have failed to educate people about how medical care is truly financed in our country. This is primarily because we have failed to educate ourselves. Knowledge of our health care system is abysmal among health care professionals.

  • EmilyAnon

    This question is for the concierge doctors that don’t accept insurance. If I understand correctly, there is an annual fee and then additional fees for any scheduled appointments or hospital visits. After paying you for the these appointments, can the patient then bill Medicare/insurance on their own with the possibility of getting something back? Also, what happens if the patient needs a CT or blood work. Would you be able to give that patient a prescription so they could go to an imaging facility or lab that accepts their insurance? Thanks.

    • http://www.facebook.com/SpitefulLadies Darla Laughlin

      Medicare and Medicaid will never reimburse a patient.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      I believe it depends on whether the physician opted out of the Medicare system or not. If the doctor opted out then the patient can not recover fees paid for evalaution and management service rendered by that doctor. I believe if you are referred for tests that are appropriate or to other docs accepting Medicare as participating or non partcipating ( which is different from opting out of the system) your charges are recoverable to the extent Medicare covers that service( I need to check on this part of it but believe this is how it works) . The evaluation and management services provided by the doctor who opted out of the Medicare system are not recoverable.

    • Juliet Mavromatis

      Thanks for reading. There are various models of concierge medicine. In one model the annual fee covers all the work done in a primary care office in one year (visits, blood work and ekgs, etc). Typically in this first model the concierge doctor does not contract with health insurance. In another model the concierge doctor takes health insurance, which is billed in the usual fashion for each service. In this second model the annual fee goes toward better access and amenities within the practice, and allows the concierge doctor to take more time with each patient. The doctor becomes able to afford to see fewer patient per day because he or she is not totally reliant on health insurance revenue. Subspecialists
      and hospital visits are not covered under the concierge arrangement in either case.

  • sFord48

    Our insurance premiums for a catastrophic plan take a huge chunk of our income…more then we put away for retirement, more than we save for our two kids’ education. Add in Medicare/Medicaid taxes and the money dished out before the deductible is met, this matches the cost of renting a three bedroom house in my area.

    For all of that, I have to pay extra to see a PCP? I think I understand just fine

    I see my PCP once a year to renew my prescriptions. If I have an acute simple problem, I see a nurse practitioner at a walk-in clinic…it’s a lot cheaper. If one of my chronic conditions needs more attention than a medication renewal, I see the specialist that diagnosed it. I coordinate my own care, something I learned from necessity. I consult Dr. Google and the nurseline provided by my insurance company to determine if a visit to primary care will just result in a referral. I see a gynecologist for all female issues…no extra fees and more likely to offer all services.

    I have forgone medical care for financial reasons. That concierge fee can best be saved for the next time I need expensive care.

    • http://www.facebook.com/profile.php?id=100001040698529 Lymphoma Survivor

      So what’s your point? I don’t get it. Are you complaining? Or are you happy with the US health care system?

    • Guest

      it is idiots like you that under value the role of primary care. Docs train for 10 years, so you dont have to use Dr Google. I hope one your specialist re-evaluates your treatment for narcissism …it is not working

  • http://www.facebook.com/SpitefulLadies Darla Laughlin

    I know Medicare and Medicaid don’t pay physicians well, but they do require that the primary care doctor be seen for every single referral including ordering labs and scans of any kind. Having previously been on Medicaid, it was a pain in the butt every time a specialist recommended a treatment I had to return to my primary and wait for them to issue the recommended order or treatment. I saw my primary care physician 2-3x month. At least physicians who do accept Medicaid and Medicare are guaranteed regular patients because they have no options without their signature.

    • swatdoc

      In Alabama Medicaid patients get 14 office visits a year that includes office, ER or therapy. So you see your doctor that often here you would be out of visits in 4 months. Then come to my officeout of visits and cant payso I can treat you for free or refuse to treat you and in all likelyhood you will go to the ER there sticking them with an expensive bill. Most specialists around here either refuse to see medicaid patients or make them wait months to be seen. The feeling of entitlement by Medicaid patients constantly amazes me they expect and demand the best care including specialty visits and everything better private insurers provide. When we can’t immediately get them into the office to be seen they go to the ER. Many of these folks that applauded the new ACA will expect the same care will quickly find out that with a payment fee schedule at or less than Medicare they will have health insurance but no healthcare. Most of the primary care doctors I know are retiring orplanning on doing other types of medicine (80 plus % nation wide are considering retirement) they are going to get out because they cant afford to take medicare or medicaid now. The medicaid/aca/medicare patents will be rationed and prevented from access to the best healthcare. This is the problem when the government takes over the system. As government requlation and controls gradually force us into a single payer system by regulating most private insurers out of the business we will all be on the same single payer system. Concerge medicine will allow the affluent to get better healthcare. The “entitiled” medicaid and lower income patients who helped vote the politicians in that were going to give them “FREE” healthcare are going to be in for a rude awakening. It breaks my heart that our system while not perfect is the best most advanced and dynamic system in the world is going to be “dumbed” down to fit the government model.
      And by the way the politicians that wrote all these laws aren’t worried they will have their own special plan all the rest of us will have to deal.

  • thesnowdog

    Mystified as to why people say there is no answer. Clearly the solution is to get rid of the skimmers. I would be happy to turn over to providers what I pay in premiums as a healthy adult for a five-figure deductible.

  • CorpAvenger

    Great Article Doctor!!! Dead On Target! I am my wife’s practice manager jack of all trades only employee at her solo micro family practice and we are on the verge of needing to abandon the system or the practice of medicine entirely. As we continue to fight the good fight against the likes of the worst among us, mainly the greedy insurance carriers, big pharma, software vendors owed by GE and UHC, and other Parasitic middlemen who return little if not, nothing of value to the system or care, just their own lined pockets. FACT: Primary Care only costs or consumes a mere 5% of all healthcare dollars spent! Really. Meanwhile solid and valid, significant research has shown that increases in spending for primary care, mainly to pay doctors better so that they will feel able to slow down and take better care of less patients on a smaller panel, of just 1-2% will SAVE us, 20% on the other 95% of those same healthcare dollars spent. FACT! But Instead we continue to spend lots of money on lots of BAD things like extra non-coordinated care, extra divided up care with way too many specialists instead of primaries who feel that they have to time and will be properly compensated for simple health improving and cost saving things such as: Small in-office Procedures, Pay Small Office Docs the same larger amount that we pay large hospital docs when one combines the Smaller Facility Fee with the added Fees paid to that Facility and then let those two model compete on an equal footing. To pay small office docs so much less and then complain about how they don’t provide certain “Extras” is so disengenuious and unfair. Pay the “After Hours” fees In Full that almost no carriers ever pay so docs can afford to stay a little late and see one or two last minute problems at the end of the day. Remember there is staff and G&E to be paid, perhaps a sitter to pay extra (yes We’re People too with families and lives outside of our offices just like everone else), pay a real covers the costs and hassle for a doc who is willing to get in the car, turn on the lights and the heat or AC and see a patient at night or over the weekend if they are home and available. Many times it is not safe for my wife to go in alone with a new patient who might have mental health problems or even a record and we live in an average working class ‘Burb. Pay doctors a real office visit like fee for doing phone and internet based medicine, and even if it turns out that the patient needs to be seen in office or go to the ER because it might or is an issue that is not safe or able to be handled like that, there still needs to be a Real pays a living fee for the time involved including documenting the encounter and perhaps even middlemaning the pass-off of the patient to the hospital. Most importantly the average Primary Care doc loses right off the top $68K simply for being a pawn stuck in the present game!!! Yes, $68,000 dollars LOST never to be seen again, in their time, staff time and the like simply to fight insurance carriers (and doing so is Completely Uncompensated, NO Payment for fighting for you what so ever) so you can get the test, therapy or medicine the doctor and you already agreed that you need and want. That does not include the cost of extra computers, software or upkeep for such things and that does NOT include the similar amounts of money lost to the present “Billing” system which also needs paid staff, supplies, postage, software and access fees (yes we pay fees simply to have access to systems to submit what is really YOUR insurance claims for you) and the battle simply to get paid for what we have done, you the patient know we have actually done for you already and yet, “where is the money???”. When you combine this kind of insane costs and lack of payment for work and services actually already rendered and supplies actually consumed, with the fact that every American has lost 40% of their wage earning capacity in just the past 8-10 years and that fees paid have not kept pace just as wages have not either, is it any wonder that docs have few if any choices but to either leave the present Broken System that only works for the Parasites but not the patients or the care providers??? BTW, that 5% spent on primary care does not mean that all of those dollars end up in our pockets either. Again look at all the parasitic loss listed above from claims lost and never paid, fighting the barriers to your care uncompensated and the like, the huge cost of billing, tracking, fighting, attempting to collect balances from the patient after the carrier says “Go Fish” to both sides… You have no idea how many people, Middle Class Community connected people who would never actually steal or not pay their cable or G&E bill, feel it is perfectly fine to cheat their doctor and not have to pay what is not covered by their insurance plan… Assuming docs are all “Rich” when most primaries are barely hanging on by a thread, at least those that don’t run the Hamster Wheel… How ethical is it to stick a service provider with a valid bill for services that you requested and authorized by coming in and asking for care in the first place? And yet more and more people who are your police officers, teachers, truck drivers, youth sport coaches and even work in large hospitals and draw a firm salary with good benefits feel it is perfectly fine and ethical to hurt their private practice doctor like that…. It is time to make any and all “Care Management” and other similar barriers to care completely “illegal” and to make having doctors fight for your med’s and therapies similarly illegal and a paid at full doctor lawyer like hourly fees to only be paid by the insurance carriers. If it were to cost them money, really hard dollars to have to pay for our hassles, to absorb the costs that they and their policies impose on the system and doctors they would quickly cut this garbage out…. All citizens say and know that they trust their personal doctor and not their insurance carriers when such barriers get thrown up in front of both of them, so why is this still legal or part of the equation even??? Primary Care Doctors, IM’s, FP’s and Ped’s all study how to best Manage Your Care and know a heck of a lot better what is in your best interest than your insurance carrier does. Remember twenty different carriers could have an equal number us supposedly “Scientifically” supported policies on any given med, therapy and the like…. Well they can’t all be correct now can they? In a Med Mal suit much of what happens is to determine if the care provided was up to “The Present Standard of Care” or not…. Well how can we take best care of our patients when we are constantly fighting simply to be able to provide what we believe and know to be the proper standard of care??? We can’t and we all know this to be true. So it is time to get rid of the Parasitic Interlopers and find a way to properly direct all of these dollars where they really belong…. In the coffers of those that provide the care as well as returned to the American People and Businesses as direct savings from cutting out these greedy Parasites and Piggies Feeding of the Trough that they have stuffed themselves silly at all of our expenses….

    • buzzkillersmith

      You’re still in the anger stage. In time you will get to acceptance. Your wife chose the wrong specialty. The die has been cast.

    • NuMoo

      I would love for you to become the next president of the AAFP!

  • CorpAvenger

    How come the paragraph breaks one puts in don’t carry over when posted???

  • http://www.facebook.com/profile.php?id=100001040698529 Lymphoma Survivor

    There is a very simple answer. The rest of the civilized world discovered it a long time ago.

    As hard as it is for some people to embrace, socialized medicine is the only answer.

    Fee-for-service medicine doesn’t work. It only encourages fraud, the performance of unnecessary tests and procedures, and the over prescription of drugs.

    And I won’t even mention the for-profit health insurance industry which siphons 25% of health care dollars out of the health care system.

    Eventually the health insurance industry will price itself out of the market and the whole system will implode. My only concern is how many people will die in this country unnecessarily before that happens.

  • LibertyHawk

    My apologies. The copy/paste function cut out part of my previous posting.
    That is the health insurance industry game where they have all the money, power, and discretion to dictate terms to the rest of us.
    We have a health insurance affordability problem. The primary reason is that health insurance is not TRUE insurance. Take the personal “maintenance costs” out of health insurance and it becomes significantly more affordable.
    One answer to the health insurance affordability problem, is to define “affordable”, a set price
    Please insert where “That is the health insurance…for” is. At the word “for”, the posting continues correctly.

  • LibertyHawk

    Simple Answer:
    NEVER equate health insurance with healthcare. Healthcare is what medtechs, nurses, physicians, EMTs, hospitals, imagery centers, pharmaceutical companies, medical device companies, inventors, researchers and other people DO to affect and improve your health situation.
    Health insurance is only ONE means of paying for health products and health services. Do NOT confuse the two or let your politicians confuse the two. That is the health insurance industry game where they have all the money, power, and discretion to dictate terms to the rest of us.
    We have a health insurance affordability problem. The primary reason is that health insurance is not TRUE insurance. Take the personal “maintenance costs” out of health insurance and it becomes significantly more affordable.
    One answer to the health insurance affordability problem, is to define “affordable”, and set a price for each metropolitan area and region (to account for different cost of living factors involved). Have the health insurance industry compete on the basis of the quality of their service, the features of their product, and the value to the consumer. The BASIC AFFORDABLE health insurance policy would have greater participation and coverage for more people, AND that basic policy could be customized with additional riders to meet our individual health insurance coverage needs and budgetary requirements.
    Socialized medicine, its bureacracy, societal cost, and dictatorial terms is definitively NOT the answer.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      I believe not allowing insurers to sign up doctors on delivery panels is step one. Step two is the insurer being asked to make accessible an easy to read and understand document which clearly explains the product and clearly outlines what it pays for each common service. Then let the consumers decide on costs and coverage. Set up on line and published reviews of the insurance companies performance. At the same time, as a clinician I have no problem posting what my fees are for a service and letting the consumer decide if my prices are competitive. Patients would easily be able to say that for an established patient visit Dr X charges $50 for a 99213 or $75 for a 99214. At the same time the various insurance companies would list what they pay for a 99213 or 99214 . That form of data would be helpful for consumers. All the insurance polices should cover basic growth benchmarks, checkups and immunizations for kids and adults plus an annual checkup.

      • sFord48

        So what if I want a 99213 because I can’t afford a 99214 right now? What if doctor A has a better price for a 99214 but doctor B has a better price for 99213? Are prices determined beforehand so I can make a choice? What if I want a 99213 for problem C and the doctor wants to talk about emerging problem D instead? What if I don’t want to pay to talk about problem D because doctor B can do it cheaper?

      • http://www.facebook.com/profile.php?id=100001040698529 Lymphoma Survivor

        So Doc, what do you do when there are complications? Do you negotiate while the patient is on the table? And what if the patient doesn’t like your offer, do you sew him/her back up, and suggest they get a second opinion? And do you still charge them?

        An what about emergency operations? What good does knowing the price beforehand do? How do you tell the paramedics what you’ve negotiated and where to take you when you’re unconscious? What good does transparency in costs do in that case?

        The argument for transparency in pricing is just specious at best!

        Your other two suggestions may have some merit, but remember for-profit health insurance companies are not in the business of paying out claims. In fact, it is just the opposite, and they would easily find ways to work around it. The easiest being the old tried and true approach of delay, delay and further delay, hoping the patient will eventually give up, or just die!

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