Direct pay is the solution to real world cost transparency

In an environment of increasing regulation, government mandated red tape, and shrinking reimbursement, health care practitioners find themselves caught between a rock and a hard place. They are being forced to see more patients to make ends meet and both parties are poorer for the process. Not necessarily in just a monetary way. Patients  are beginning to feel frustrated and disengaged from their mutually frustrated and disengaged providers. Both parties feel short changed by insurance companies who demand more of each while delivering less to both.

The whole conundrum inspires both parties to dream of an alternative universe where clinicians could concentrate only on patient care and where patients could feel they had obtained a service worthy of their hard earned cash. In this mythical land, it is the patient who would be allowed to keep charge of that most intimate of human possessions,their health and well being. Patients would more enthusiastically embrace the care and advice given to them by an unhurried professional whose only concern is  what is best for their clients. In this place, patients would be seen and treated as individuals, not populations.  No third party could be privy to their confidences, nor exist to place idiotic constraints on the provider while holding the payment carrot  in front of their noses as incentive to substitute acts of expedience for acts of clinical judgement and commonsense.

Providers would be able to see fewer patients, spend more time with each of them and, thus, be allowed to preserve more personal enthusiasm for their professional duties by being allowed to reserve more energy for their families, friends, and personal pursuits. Everybody could go home happy. Patients would feel they’d gotten their money’s worth and leave empowered to make informed decisions regarding their health care. Providers  would be able to tally their income for that particular day to the proverbial penny removing the suspense that surrounds the reimbursement game. Sound like “The Impossible Dream?” Hardly.

This, my friends, is the real life world of cost transparency as provided by “cash only” or “direct pay.” Such models  are popping up with greater frequency, founded by a few of us rebels who have decided not just to think outside the box, but to kick in its walls and rebuild it altogether.

Fourteen months ago, my nurse and I made the choice to bypass third party payers and to contract directly with our clients. We have been rewarded with a thriving practice of people who are delighted to pay cash up front knowing that there are no hidden costs to worry about later. Overhead is minuscule in this model which automatically slashes costs by less than half. We provide our patients with a price list upfront and they reward us by listening to and following the care and advise they have purchased. I have noted this phenomenon in monitoring the progress of our chronic patients who exhibit marked  improvement at each follow up and the small percentage of return visits for acute conditions that do not respond the first go round.

What does this tell us about   direct payment for services rendered? It’s simple. People tend to be more engaged when they are in control. Up front knowledge  of costs tends to do this. It removes the anxiety of watching the mailbox for a bill they must budget in order to pay. They do not  have to spend their visits distracted by trying to add elusive figures in their heads while their provider is distracted by the same mental gymnastics.

Because the only contract is between me and  my patient, I work directly for them. I  am able to spend more time in the exam room so that when they leave they more thoroughly understand their options and are more likely to follow the treatment regimens and advice because they have received. Direct pay makes people far more likely to be compliant because they occupy the driver’s seat. When  they pay up front they know that I work only for them. I do not waste their time by clicking boxes or agonizing over diagnosis codes to insure payment. I do not charge their insurance $300.00 while hoping to perhaps realize a profit of $39.99 after overhead some ninety to 120 days in the future  that is, if every I is dotted and T crossed on their claim form. I do not have to  pay people to beg third parties to make good on the services for which patients have already paid in premiums for the privilege of hoping a third party will see the logic of medical necessity and open their tight fisted wallets. I do not feel obligated  to order unnecessary tests to satisfy a health policy’s idea of protocol. I do not lump my patients into “populations,” because this model allows me to see them as individuals with their own unique set of circumstances. Price transparency fosters mutual respect and allows me to provide holistic care that is truly “whole.” It creates productive team work between the patient and myself that is beneficial for us both.

Someone called me a visionary the other day and asked where I’d gotten my idea. I smiled and answered, “Hippocrates.” You see, when something very old is made new again, people tend to either approach it with  suspicion or ponder is relevance in disbelief. After all, we are schooled to embrace progress so that any step backward into the past is considered suspect. They shouldn’t be concerned because, as I have discovered, it is sometimes the oldest and most simplistic of  ideas that have the ability to provoke change, and dare I use the word? True reform.

Kim Byars is a nurse practitioner and founder, Byars Family QuikCare.

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  • mmer

    It’s interesting that those claiming that we have “the best health system in the world” (which is categorically false) are also ones who support “the free market.” A “free market” demands, at its root, price transparency, of which there is little in healthcare – this is not because of “big government” but because it behooves market players to obscure the way prices are generated in healthcare. Here, there is a role of government, paradoxically to make markets more free by making market players follow rules which promote price transparency and deliver this information to patients. Surprisingly (GASP), freely acting market players may not like this, saying it is “proprietary information” or even that it would “violate HIPPA” (or a variety of other obtuse responses) – really, this is about keeping the market a shadowy one for the benefit of the financiers, paper pushers, and unnecessary bureaucracy, and to the detriment of patients and providers.

    //Both parties feel short changed by insurance companies who demand more of each while delivering less to both.//

    Ahh, the wonders of “the free market” at work again! I suggest we look long and hard at whether we want the philosophy of maximizing shareholder value to be driving patient care. If you consider patients cogs and docs lever-pushers, all there to increase “efficiency” then by all means, this philosophy will work for you! Under a “free market” for insurance, what financial incentive is there to provide universal health access? To extend insurance to patients with pre-existing conditions? To increase funding for preventative care and public health?

    • Trina K.

      There is no “free market” in either health care or health insurance, and there hasn’t been for decades.

  • openyourmind

    Wow!!! Your article is great. But that is not all the wow. Your facebook page is incredible! You NP clinic looks amazing! I know the folks in your town are so grateful for you. I’m sure everyone will agree. The healthcare service you provide is just amazing! I hope more direct pay healthcare clinics like yours open in the future!

  • guest

    I do have to say that I find it interesting that a nurse practitioner would be opening a direct pay private practice. Didn’t the whole idea of nurse practitioners providing care independently come about as a result of the belief that they would improve access to care by providing more economical services to the part of the population that is medically underserved?

    • Noni

      It is curious. If her patient population can afford direct pay wouldn’t they seek the services of a physician instead?

      You make a great point, but look at how they come here and moan that they do the same work for less pay. They don’t care about the patients. They want physician $$, plain and simple.

      I live in a pretty affluent city. I see no independently practicing nurse practitioners.

      • openyourmind

        I don’t give a rat’s arse who it is. I certainly don’t want to see any health care professional who feels entitled. Such as, “if they had the money, wouldn’t they see me.” You kidding me? And as far as physician $$ – the moaning just won’t stop. It’s not up to you where people spend their money. They can spend it on some guy who performs miracles, spits in their eye, and makes them well. What’s it to you? There are lots of choices – deal with it.

        • Noni

          That’s fine, but I personally have had horrible interactions with midlevels. I also think they want the responsibility and respect of a physician without the hard work. Sorry, I see no congratulations due. If you do, then that’s fine. Leave the rest of us to our own opinions, thank you.

          • Trina K.

            Let those who don’t care to see midlevels, stay away from midlevels and direct their healthcare dollars to doctors only. But free up those who’d like to see midlevels for some things, to go ahead and see those midlevels. Choice is good.

          • Cyndee Malowitz

            Physicians have monopolized healthcare for long enough. It shouldn’t be lost on anyone that greed (on the part of physicians) invented our profession. It’s fine and dandy when the NPs work for physicians and generate $$$$ for them. God forbid if that same NP opens a clinic and takes those patients with him/her. Then all of a sudden we’re not “good enough” b/c we’re practicing at a different location. If a patient chooses a NP over a physician, then so be it.

          • Cyndee Malowitz

            Jealous much?

          • Guest

            Not really! As long as I can choose who I see then I don’t care who does what. Quite frankly, with the general dumbing down of medicine NPs=PAs=MDs and DOs in no time. God help any of us when we need actual expertise. Trust me, these midlevels do not know what they do not know. They are also unbelievably arrogant, so if you see one, be careful. My last FP had me see his NP first. She effed up the diagnosis and treatment, and I got worse. He saw me the next time and set me on the correct course.

          • Kim Byars

            Hi there. I am curious. Would you be kind enough to share some of your experiences with mid-level “arrogance, please. A a dedicated NP, I am always interested in patient perceptions and eager to correct any negatively perceived behavior! Thanks!

          • Kim Byars

            I’m sorry if your interactions with mid-levels have been unpleasant, but please don’t lump us all in the same pile! Every NP that I am acquainted with does not “want the responsibility of a doctor.” They accept the responsibility of a nurse and take pride in this. The idea that we do not contribute “hard work” to our professional success is simply wrong! Follow an RN thru a 12 hour shift and it will become readily apparent just how hard they do work. It is this dedication and experience NP’s bring into advanced practice. I respect all opinions and the right to choose what is best for you, but I beg you do a bit more research before making blanket statements meant to include our proud profession. I cannot comment on PA’s as they have their own educational and clinical requirements, but I am sure there is among, this audience, members of that profession who would be equally inspired to educate and enlighten! Peace. KB

      • openyourmind

        Anyone interested in congratulating this woman on a job well done? If it would have been a doctor writing this, you would have fallen all over yourself to praise and jump on the bandwagon. She has done so good for herself, her patients, and her community. I have read this blog for years. Some of you regular posters remind me of the spoiled group of cheerleaders who “know” they are always right. Keep living in your hole. For God’s sake congratulate the woman.

        • Cyndee Malowitz

          They can’t stand the fact that a paying patient would choose a NP over a physician.

          • Guest

            I’m a physician, and I think it’s great. It’s nice for people to have choices. Cyndee, I don’t always agree with your opinion but I really do respect what you do.

      • Cyndee Malowitz

        You would be blown away by the number of patients who’ve come to me (a nurse practitioner) and asked if I could be their primary care provider. I just had one yesterday – highly educated patient with good insurance. He complained about his primary care physician ordering all sorts of needless, expensive tests (tests that put cash into the doc’s bank account).

        People aren’t stupid – they know when they’re being taken for a ride. I’m so sick of the public being taken advantage of and I’m sick of attitudes like yours.

        If I compete head to head with physicians and become more successful, then GOOD FOR ME. It’s called COMPETITION and if you don’t like it, then you are free to move elsewhere. BTW, the Federal Trade Commission is all over this.

        • Stephen Sutherland

          There is a weakness in our primary care system where the physician might be excellent or the physician might be really bad.

          In surgery, you would find out who is bad right away because they are too busy in court to take patients. I think there needs to be consistent patient feedback systems and the feedback system needs to be more centralized and systematic.

          Such a system would increase performance – because people perform better when they know they are being monitored.

          A physician can provide bad service and likewise an NP can provide bad service. Anecdotes do not tell the story correctly.

        • Guest

          I think that’s great. I personally prefer no PCP but I’ve got connections to get me tests if/when I need them. I could see why people would choose NPs over MDs/DOs, but the ones I’ve had to see were totally clueless.

          Sadly, with the way medicine is going in general I think docs will be no better than NPs/PAs. So, I will just avoid all of them. Anyone with a brain will take care of themselves, eat well, exercise, and avoid “healthcare” as much as possible too.

    • Trina K.

      As far as I know, it wasn’t the nurses saying “Let us practice independently, and we’ll see the Medicare & Medicaid patients that doctors won’t see anymore”. That was the “visionaries” in the government saying that, as a way of reassuring the population that there’d be no problem with adding 17 million people to the Medicaid ranks while not increasing the number of doctors.

      I think it’s great that nurses are spreading out into direct pay practices. I think it’s great when ANY medical provider takes steps to get the government and the big insurance companies out of their examination room and their back office.

      I don’t like the idea of the poor being forced to see “midlevels” rather than doctors, because the government or the insurance company wants to save money, but I do like the idea of NPs and PAs being allowed to set up a direct pay practice and “give it a go”, with patients who want to see them being allowed to; and those who don’t, not forced to.

  • Kristy Sokoloski

    The issue of suggesting that direct pay is the answer is a dead horse being beaten on a regular basis. And as part of that dead horse one of the things that doesn’t seem to be made quite clear is that if you have a direct pay practice you will have even less people getting the healthcare they need not more. The reason? Because most people can’t afford to do direct pay. I know that several of my friends and family members fall in to this category where they would not be able to get to the doctor. Dentists have already tried this and as a result most people can’t get to them for regular cleanings, and yet they wonder why people don’t come to them regularly in order to keep their teeth working right. Direct pay will cause further disastrous consequences. We need something a bit more long term to work better to make sure that everyone has access to the healthcare they need.

    • openyourmind

      That’s true too.

    • guest

      However, if you had medical insurance with coverage only for catastrophic costs, you would likely be able to save enough from your paycheck to cover routine medical costs. The reason it feels like direct pay is not affordable is because all of us are paying a significant part of our pay towards inflated insurance premiums.

      • LIS92

        Of course, another dead horse that needs to be beaten again is the erroneous belief that catastrophic insurance removes provider networks, claims, contracted prices, etc from the picture.

        • guest

          Well, of course the only system that will truly remove those things will be a single-payer healthcare system.

          However, since our country does not seem to be ready for that, the next best thing is to cut the insurance companies out of as much business as possible, by having a lower-cost insurance policy, and paying your doctor directly.

          • LIS92

            While I have a lower cost catastrophic insurance policy, I don’t pay my doctor directly.

          • Kristy Sokoloski

            And by cutting out the insurance companies as you suggest, that then will make it even worse. Because the minute that you do that you then cut out the majority of the population from getting care. I have medical issues that need to be monitored by doctors just like Suzi Q and some others who regularly post here and if the insurance company was cut out then I wouldn’t be able to get to the doctor either. Too bad that this is such a complex issue that affects all of us in one way or another.

          • Guest

            If you want someone else to pay for your medical care, you have to accept whatever it is they’re willing to pay for.

          • LIS92

            I pay $15,000 a year for medical care. Why do you think someone else is paying for my medical care?

          • guest

            How can you be paying $15,000/year for a “lower cost catastrophic insurance policy??”

          • LIS92

            Insurance premiums for my family, medicare/medicaid taxes, copays for medication and the deductible…I have a kid with medical problems and my spouse and I both have chronic health problems.

            Add another 3K with orthodontics and glasses.

            Of course, we patients are just a bunch of free loaders and don’t deserve quality medical care.

          • guest

            You must know it’s somewhat disingenuous to include Medicare/Medicaid deductions from your paycheck in your “medical care” costs, since everyone else pays those, too.

            But having said that, did you never stop to think that if you didn’t have to pay out any of that $15000/year but could save it to pay your doctors directly, that you would be able to buy a lot of medical care?

            P.S. Orthodontia to fix crooked teeth is entirely elective and isn’t really “medical care.” It’s an expense you are choosing to incur.

          • LIS92

            So you are recommending I forgo medical insurance so I can pay for my care directly to get my money’s worth?

          • LIS92

            And my son’s teeth were hitting the roof of his month and causing sores.

            Clearly, all medical care is elective and I could save that $15,000 and buy a new car every year.

          • M. O’r.

            Orthodontia is not an elective procedure.
            Occasionally, yes. But generally, NO.
            Where are you getting your information?

          • Margaret Houlehan

            All roads lead to Single Payer. It will happen, state-by-state. We will finally join the rest of the industrialized world.

          • Guest

            And THEN where will the rest of the industrialised world seek come when they need top notch health care? At the moment, victims of socialised medicine come to America… now we’ll all be equally lousy!

          • Margaret Houlehan

            Except that we are 37th in most outcomes. Hardly “top-notch.”

      • Kristy Sokoloski

        Actually, I disagree. Most people now even with the kind of insurance that you speak of are not able to save enough from the paycheck to cover routine medical costs. Nor would they be able to cover the cost of having additional testing that may come after routine screenings (that are supposed to be covered at 100% by health insurance if the insurance plan covers it that way) if something out of the ordinary is found). The premium that a number of people pay when it comes to insurance is much cheaper per month than if they had to pay by direct pay. Most people live from paycheck to paycheck so it makes it impossible for them to get routine medical care because they can’t afford insurance if they have a job that doesn’t offer any kind of benefits either from the start or got cut.

  • Suzi Q 38

    I don’t mind this notion of direct pay if I get better treatment.
    I can afford to pay cash, as long as the fee is reasonable.

    • Kristy Sokoloski

      Suzi Q, that’s great that you would be ok with doing that if the criteria that you just stated were met. Unfortunately, for the majority of the population like my friends and family or even myself we can’t afford direct pay.

      • Guest

        “Beggars can’t be choosers”. If you want someone else to pay your way, you have to accept what they’re willing to give you.

        • LIS92

          Another horse to beat…that the insured get “free” healthcare.

        • Kristy Sokoloski

          Actually, yes, up to a point beggars can be choosers. And that includes even when it comes to the issue of making sure that everyone has access to healthcare. Because if not, then instead of having people worrying about the number of people not being able to manage chronic conditions as they should. And then in that case those people who can’t manage chronic conditions as they should such as Diabetes there will be many more deaths to count.

        • T H

          Beggars get off more easily: they don’t have anything for a collections agent to grab.

      • Suzi Q 38

        I understand how this would be a hardship for many.
        Also, the insurance company has negotiated a price that I may or may not be able to negotiate.
        My hospital bill for my cervical discection, is an example.
        Maybe the full price is $100K, but the insurance company pays and the hospital accepts $40K.
        If I don’t have insurance for this negotiating purpose, I may lose a lot of cash in one day.

    • adh1729

      Patients can go the “direct pay” route if they have the money.
      People can go to an expensive private school if they have the money.
      But everyone will be mandated by law to support Medicare, Medicaid, Obamacare, public school, federal aid for education, etc, whether they use such services or not. See the glory of socialism? You support the government whether you like it or not. The government wins whether you like it or not. There is no choice. (Sorry liberals, but all the “pro-choice” stuff is cr*p. There is no choice, and no liberty, in socialism. And “voting the bums out” has never worked; democracy is a sham.)
      “Direct pay” will quickly become healthcare for the rich, and only for the rich, same as what has already happened in education.

  • drgn

    This blog reminds me of the one i just got an answer from the AMA. Brian’s post on Why the Accuracy In Medicare Physician Payment Act should pass. Anyone reading this should seriously take a look at their response. It is eye opening!

  • buzzkillerjsmith

    Interesting article, especially the first part about the admin hassles that are similar to those in the US.

    Charging a little but not exorbitant co-pay is a good idea. I once worked with a doc who volunteered in Liberia and they made pts pay a little something at the time of the visit. Maybe not money, but something.

    Co-pays can reduce visits by folks who don’t treally need a doc’s attention, especially in these times of worsening doctor shortages. They also signal that the service being provided does have value.

    • mmer

      There is some good empirical evidence as to what nominally increasing co-pays does, see: “Japan’s Health Care System: Containing Costs And Attempting Reform”

      • buzzkillerjsmith

        Gimme the Cliff’s Notes version.

        • Guest

          Naoki Ikagami and John Campbell, “Japan’s
          Health Care System: Containing Costs and Attempting Reform,” Health Affairs 23 (2004): 29–34.
          ——————-

          Part of the problem: “We Japanese have a tendency to go to the hospital even when we have only minor ailments such as the flu, headaches, or stomach aches. If medical expenses are not high and we do not feel well, then why not go see a doctor and get some medication. . . . The result, of course, is that waiting rooms of clinics and hospitals are full of people. Everyone is welcome and there are, in fact, regular customers. Sometimes elderly people come to see a friend and the hospital waiting room becomes a sort of salon.”

          This problem is aggravated by the demographics of a rapidly aging society. By some estimates, the elderly are responsible for 90 percent of the aggregate increase in Japan’s health care costs. If current trends continue, Japan will almost triple its government spending on health care in the next 20 years.

          And the situation will only grow less stable with time. Japan is expected to lose 35 million workers by 2050, with 35 percent of its population in retirement.

          This raises questions of how a system that relies on payroll taxes for funding can continue to fund rising costs even as its payroll base shrinks.

          ——————–

          Something that can’t go on forever, won’t. Japan will have to make going to the doctor much more expensive to disincentivize over-use… and to avoid running out of money.

          • T H

            It comes down to “If you don’t have skin in the game, you don’t appreciate it.”

          • Guest

            Sounds familiar!!!

  • Anthony D

    “In an environment of increasing regulation, government mandated red
    tape, and shrinking reimbursement, health care practitioners find
    themselves caught between a rock and a hard place.”

    If the ObamaCare exchanges are good enough for the hardworking Americans
    and small businesses the law claims to help, then they should be good
    enough for the president, vice president, congress and federal
    employees?!

    • mmer

      False – the ACA does the opposite of what you claim:

      In the Health Affairs blog (Implementing Health Reform: A Proposed Rule On Congressional Exchange Participation), health care expert Timothy Jost noted that “the requirement that members of Congress purchase coverage through the
      exchange was included in the law because of a political gambit offered by an opponent of the law, Charles Grassley. Reportedly, Senator Grassley, intending to embarrass Democratic supporters of the law, offered an amendment requiring members of Congress to purchase coverage through the exchanges through which many of their constituents would be purchasing coverage. Democrats, however, embraced the idea and added it to the ACA. Far from exempting Congress from ACA requirements, as some have reported, the amendment subjects members to a legal requirement that will apply to no other Americans..”

      Also:

      “Members of Congress and their staff must go into the exchange,” said an administration official. “No ands, ifs, or buts. They will not be eligible in any way for subsidies or tax credits…”

      The rule itself:

      Subparagraph 1312(d)(3)(D) of the Affordable Care Act states that, “Notwithstanding any other provision of law . . . the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are– (I) created under this Act (or an
      amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act).” The Act defines “Member of Congress” as
      any member of the House of Representatives or the Senate and “congressional staff” as all full-time and part-time employees employed by the official office of a Member of Congress, whether in Washington, DC or outside of Washington, DC.

      • M. O’r.

        As a point of clarification, it is not law yet. It is open for comment until Sept. 9, 2013.
        Grassley use to be a practicing doc in Iowa.

  • Guest

    Kim, I looked at your FB page and read your feelings about your article being posted and your reaction to the negative comments.

    I was very impressed by how you took the high road and appreciated ALL of the comments, not just the positive ones. Also, I think it’s wonderful how you serve your area and found away around the nonsense that is the ACA. Keep fighting the good fight!

    You are a wonderful representation of your field.

  • buzzkillerjsmith

    I’m conflicted about direct pay. On the one hand, as a guy who has been in the ballgame for 24 years. I am very, very angry about the deterioration of my profession, a profession that I happen to believe in. I think doctoring is important, indeed noble, and I am disgusted by how this society has reduced it to a business, and I am disgusted by all the impediments placed in our way by ignorant and greedy businessmen.

    So, #$%& it, let’s do what everyone else does: pay to play. If you have lots of money, I’ll take care of you. If not, go to hell.

    On the other hand, I also happen to believe that sick people, and sick children are the ones that really get to me, should be taken care of in this wealthy society. Make no mistake about it: Many of the sick people out there have abused themselves to the utmost. Many are lying in the bed they themselves have made. I certainly do not believe that the poor and oppressed are necessarily superior in virtue.

    When I’m feeling optimistic, I think we can wait it out. Our profession has existed in all societies for thousands of years, perhaps tens or hundreds of thousands of years. Over the last century, we have arguably benefited our species more than any other group of humans.

    As of now I still favor universal care over direct pay.

    • https://www.facebook.com/arobert6 Alice Robertson

      So doctors are a “species”? LOL I love it! But Buzz you simply don’t look old enough to have been in the ballgame for 24 years!: Please tell us your secret to your youthful good looks!:)

      Okay, but seriously….universal care? Oh please, please say it isn’t so. I have shared that I lived in the UK (married a Brit who is absolutely terrified of needing medical care when he visits there, and I refuse to go back…I am doubly terrified. I could get free cancer care for our daughter. Oh good God no!:)…and I live near Canada. How about you come and sit with me at the Cleveland Clinic and hear the overload of Canadians there tell you about their system. And then I will tell you all about the reality of care in the UK. I promise not to reveal your identity and I am slowly finding a strange addiction to blue, bald posters online! ha!

      • buzzkillerjsmith

        There are no perfect solutions here, Alice, but I happen to believe that basic health care should be a human right. The details of providing such health care are wickedly difficult, and reasonable people can and do differ on whether it is even a worthy goal.

        • https://www.facebook.com/arobert6 Alice Robertson

          Fair enough but it’s not truly a human rights issue, it’s a human responsibility issue and that means more doctors volunteering their time if they feel this way. I do volunteer my time in the ghetto (driving people and buying them food out of my own money because with all my heart I believe we need to help those who are hurting, but it is not a rights issue).

          • M. O’r.

            And w/ all due respect to the nurse. It is a human rights issue. You go live in a country where the mortality rate is 50% by 5 years of age. I saw the dead babies in the garbage. And I saw the dead collected every morning – starved, most likely, or cod secondary to starvation. Rigor has set in, usually and the bodies can be stacked in the cart like cord wood.
            I had mothers beg me to take their babies so that the child in their arms wouldn’t die. Every day. As I worked through the adoption process. I got to know the doctors there. My daughter was almost dead when I got her. Visa needed an xray. Everyone rushes into the “xray” room to hold the baby down and I walk out. No lead aprons, gloves, anything. took 5 shots and it was an old machine. They will all be dead of something else before the radiation will get most of them . I worry for the radiologist though. That is why there are no or few public health programs in those countries – they worry about meeting basic needs. Maslow – remember him? Why bother with a car seat for the baby?

            1 more thing. There are more countries like that than there are like ours, or Canada or universal health care countries. More countries where people die of starvation, or easy to treat nutritional deficiencies.
            And the USA spends over 3 BILLION Dollars per year on weight loss products. (old number there – a figure from the early 2000′s. ) So yes, we spend 3 billion dollars a year to eat less calories.
            I never bought another diet anything in my life. I spend extra money on the foods that do not contain the crap that is used in industrialized countries. Because my nutrition class was taught by a nutritionist w/ a PhD in biochemistry. And she made sense of things.

            So with the money we spend on food, or need to direct at the lower SES, let’s make the nutritional options available to them that my kids had. There are many cultural misunderstandings about what is best for a child re fats, sugars, juice, etc.
            Or the only store is the one that sells chips and pop.

            I could go on. I’ll stop.
            I hope you realize it is a human right to have access to healthcare. And I know a lot of good people who work in this country and in others to provide the best we can for everyone who needs it.

            Give the MPH a little credit – we are not the same as a home health nurse. We have a high level of training that docs, admin and nurses do not know about. And a lot of us are on this career by choice of 2 or 3 career.

          • https://www.facebook.com/arobert6 Alice Robertson

            You left out too many vital details to even understand the comparision.

          • Margaret Houlehan

            Many of us beg to differ. For every story you have heard from disgruntled Canadians or Brits, I have at least one about a catastrophe in an American health institution. We need Single Payer. Those who can pay for and want concierge care, more power to them, they are already doing this in countries with universal health care. We will never have a perfect system, but we can sure do a hell of a lot better than we are now. Only in the US does one pay 2k/month for crappy insurance, and go bankrupt if they have the audacity to get sick.
            And Cleveland Clinic? I live in Cleveland. That place is great if you are the Sheik of Saudi Arabia and need heart surgery, otherwise very much overrated.

          • https://www.facebook.com/arobert6 Alice Robertson

            Margaret I live in Cleveland…in Berea. I completely disagree with you. I don’t like a waiting lists.

          • https://www.facebook.com/arobert6 Alice Robertson

            Sorry I was rushed earlier and when I post from a Mobile device it’s a right mess. Margaret (that’s a nice British name:) think about it. I have a daughter with cancer. If I was rich and could choose anywhere in the whole world to get care I know it would be right here in the good ole’ USA. Why do you think Sheiks and others (like Canadians and Brits) who can afford it come here ? It’s because that bloody system in the UK and elsewhere stinks. It’s decent care but don’t get cancer (you may die waiting for care and don’t think dying is the same there either). Look at Canada and their waiting lists. Last week I got an MRI two days after the doctor ordered it. In the UK and Canada I would have waited a year. I have an extremely painful cyst on my spine (I couldn’t figure out why I was in such extreme pain). The difference between an MRI in Canada and here is big too. Some of the older MRI machines in those countries are really scary and that’s if you can get in one (my sister in law was too scared to get in and they refused her a sedative. So it takes another year of waiting to get back and get the sedative). And look at their XRay equipment that is often older than 10 years old in both countries. Which can mean leakage. Why do I bring that up? That’s how my daughter got cancer…radiation leaked.

            I am literally terrified of the UK healthcare, not that it’s not spectacular at treating the mundane.

            So single payer is costly on the really sick who end up dying on a waiting list (and my cousin just died without the pain meds he needed and he couldn’t get Zofran to help with the nausea because it’s not on the approved list. Tons of meds aren’t on the approved list unless like about 60% of the physicians you have private pay. But private pay there is different and builds upon the government system. But at least you can get the drugs you need if you are private).

            The media has glamorized single payer/socialized healthcare and I fear it’s usually the naive who desire it, not the actual ones who experienced it and have something to compare it to.

          • Margaret Houlehan

            Alice, I have worked in oncology. Some of us are going to die no matter what system we are in. I am not discounting what you are saying, but no system is perfect. I’ll take the one where I don’t go bankrupt when I get cancer. I know lots of Brits and Canadians who wouldn’t have our system on a bet. Why are our outcomes here in the US 37th in many parameters? I am sorry, we are NOT the best. Please Google Josie King and the Duke transplant mishap. And sorry, I have dealt with Cleveland Clinic and am NOT impressed with them.

          • Kristy Sokoloski

            In some areas of the country when it comes to the getting access to some specialists there are already waiting lists. Those waiting lists are like 3 months long. Why is there a waiting list that long for some specialists? Because there aren’t enough of those specialists in the community to take care of the people that need them. This has been going on for several years now.

          • https://www.facebook.com/arobert6 Alice Robertson

            Three months? That’s fantastic compared to Canada the UK and other countries. Do you realize the additional nine months will kill people? And if you are actually very sick at least here you can jump the line.

          • Kristy Sokoloski

            Three months is not fantastic for let’s say someone who is Diabetic and needs to get in to an endocrinologist to get their sugars under control. The waiting the 3 months could kill them just like what people say about the wait times in the UK and Canada.
            I have friends in Canada and in the UK and I have heard very good things from them, just like I hear about the bad. There is good and bad in every system in every country around the world.

          • Margaret Houlehan

            I have plenty of horror stories on the US system, both as patient and practitioner.

          • https://www.facebook.com/arobert6 Alice Robertson

            Of course you do. It’s medicine, but nothing like the waiting lists and old equipment of socialized medicine. I have a horror story of my own. A doctor at the Strongsville Cleveland Clinic satelite center refused to read the lab notes on my daughter and let cancer spread all through her lymphs from a delay in treatment. I call that a horror story. No country has perfect medicine. But if you get sick I can bet you want to be cared for in the United States even with their horror stories. And socialized medicine means worse care for the truly needy. Socialized medicine has killed so many of my relatives (one died begging us to bring a gun in so she could blow her brains out because the hospice care was told to limit pain meds. She couldn’t even get morphine…another died vomiting from chemo without the anti-nausea drug because it’s not on the approved list….I could fill this page with stories where the suffering could have been alleviated)

            You know Christopher Hitchens wouldn’t listen to stories about other countries unless the person had lived there a few months. Living there is an eye opener.

          • Margaret Houlehan

            I am so sorry for what happened to your daughter. I hops she is doing ok. Again, I do not believe that any system is perfect. But one thing I do know is that no one should have to go bankrupt if they get cancer. There are many jobs which do not provide hc insurance, and getting it on your own can be horrifically expensive. This is wrong.
            As for your hospice story, my mother’s friend experienced the exact same situation right here in Cleveland. Her poor husband had to raise holy hell to get her pain med regimen changed. That should NEVER happen to anyone anywhere.

          • Jonathan

            No one waits a year for an MRI in Canada. If you are going to use a country in your argument, make sure your claims are accurate.

          • https://www.facebook.com/arobert6 Alice Robertson

            They are accurate. My husband lived there. Keep playing the fairy tale medicinal game until you get sick, then you will appreciate medical care here. Or like I said come and sit with me at Cleveland Clinic and hear the truth. What’s bothersome is the people wanting single payer rarely know what they are talking about.

          • Margaret Houlehan

            I know many Canadians who are happy with their system. Tommy Douglas is considered a national hero because Single Payer was his idea. I honestly think that, overall, you are going to hear pros and cons on ANY health care system, ours included.

          • Margaret Houlehan

            Have you tried to get in with a primary care or specialist around here lately? Month minimum. The US has waiting lists as well, sorry. We are not number one, not in any way shape or form.

          • lissmth

            Margaret, are you aware of cancer survival rates in the U.S. vs. socialized countries? I dare you to go get breast cancer in the UK. And I’m so done with your homosexual slurs.

          • Margaret Houlehan

            Lissmth,
            ? Homosexual slurs. That is quite a leap. And as for your (undocumented) assertion: If I do have a choice, I will “get cancer” in a nation which will not punish me for getting sick, and losing my home and life’s savings in the process. Also, I will let you in on a little secret. We are all going to die some day, it is just a matter of when.

          • Kristy Sokoloski

            I have to disagree with you about healthcare not truly being a human right. It is both a human right and a human responsibility issue. Children and infants as one example have the right to be protected from diseases like measles that can kill. How do we protect them? Vaccines. But yet you have people that want to insist that vaccines do more harm than good and as a result of that thought the number of those not vaccinating has risen. This in turn has caused outbreaks of diseases such as measles to occur throughout this country.
            The human responsibility (if one chooses to carry through on that responsibility) is to do the best one can to live life in a healthy way such as eating right, and exercising. However, if someone doesn’t want to make those changes that is also their right.

          • https://www.facebook.com/arobert6 Alice Robertson

            But Kristy that misses several points. Have you studied what the word “human rights” entails? Although, your last paragraph is true are you saying it’s a “right” for the government to take those who are careless in their lifestyle choices and remove their “human right” to healthcare?

            Can I ask if you have studied the ingredients in vaccines? How they are made? Is it my right to say I don’t want them?

            It simply isn’t as easy as the passionate “human rights” people insist.

            You see I would have to ask you, Margaret and Buzz what you are doing to help people obtain that “right”. Is Buzz donating his time? Maybe two hours a week in free care a week at the Clinics that offer free care? Are you transporting people to doctor appointments?

            You see I find that most people who proclaim it’s a human right actually means they want others to pay for it and basically do nothing but lip service to the rights argument.

            I don’t think it’s a human right but I am willing to use my car and time (as the mother of six I don’t have a lot of time or money but I have a desire to help others) to help those that I can.

          • Kristy Sokoloski

            I have read about the ingredients in vaccines. However, the risks that occur from them as far as adverse side effects are low. Of course, I am aware that not all cases are reported because not everyone chooses to report them.
            As for your statement that you feel that most people who claim about health care being a human right actually want someone else to pay for it and basically do nothing but lip service to the rights of the argument that is not necessarily so. What the others like me are saying and feel about healthcare being a basic human right is making it so that everyone has access to that healthcare whether they choose to use it or not.

            As for you not wanting to have a vaccine, that is your choice but you are an adult so you get to have the right to make that choice. Children such as infants do not get to have the choice on whether they get sick and possibly die from something like measles.

          • https://www.facebook.com/arobert6 Alice Robertson

            But again you are missing what a true right is. It is a parental right to choose for a child. Do they not choose a child’s clothing, what school they go to, what that child eats.

            The rights argument is actually a preference for those who proclaim it because they are usually wanting others to pay. Reminds me a lot of the “I don’t mind paying more taxes” proclamations from those who are usually paying no federal taxes and gaining from it.

            I guess I am dismayed that so many proclaiming haven’t studied other countries and truly understand what it entails. They lack constitutional understanding of what rights actually means, and more dismaying is their lack of motivation to help the truly needy while sitting around declaring they care.

            How can they care if they are doing nothing to help people accomplish the care they so desperately need (the government rarely does anything well)? Who is the real humanitarian? The one who gets their fingers dirty or the ones who do nothing but sit and talk about it?

            See where this goes? It’s an appeal from me to get people up off their seats and do something. I think volunteering should be mandatory in the school systems as a credited program because students will learn far more getting their hands dirty than simply reading about it.

          • Margaret Houlehan

            Alice, I apologize. I looked at your profile and see that you are a conservative. (I hope you are a true conservative in the William F. Buckley tradition and not a Teabagger). Anyway, I am an unabashed liberal, or, as I prefer, progressive, so I doubt that we will agree on much, although I suspect we both want many of the same things for our families. Let us just agree to disagree. I do believe that one of the few good things about Obamacare is that you and I will both have our wishes met. Progressive states like Vermont will develop individual Single Payer plans. Those that have a jones for BC, Aetna, et all, can continue to worship at the altar of Big In$urance (and take it in the ass) I know I will not be in Ohio much longer with Kasich at the helm.

          • Margaret Houlehan

            Alice, dear…..I have worked in free clinics my entire 26 year career as a PA. Your attitude truly dismays me. I hope one of your six kids does not find themselves without insurance during their time on this earth. You are on the wrong side of history and humanity.

          • https://www.facebook.com/arobert6 Alice Robertson

            Well I have had two children with cancer and I am grateful that right now any child with cancer can get treatment. Under Obamacare that won’t happen. You are supporting a plan that is booting people like my neighbor off her insurance. If her child gets cancer her only option will be buying mandatory insurance she can’t afford (even if she qualifies for the 90% government gift the 10% she will have to pay and the deductible of $3000 will kill her. She could afford nothing above the Metallic plan which means she pays 40%.

            I don’t see how in the world you can support that type of plan. Nor socialized medicine where the mundane care is fantastic and catastrophic care is terrible.

            So are you saying if you get sick you wouldn’t mind being in a ward in the UK? And in Canada you still pay for many things if you are hospitalized.

            Now all that said Margaret I have many friends who are liberals, but I do volunteer in a think tank when I am well. But I would still love to meet you for coffee.

          • Margaret Houlehan

            Oh, I don’t really like the ACA either. It is a gift to the insurance industry. And maybe SP isn’t the answer. But I do know one thing. Our “system” now is running on fumes and will inevitably collapse, especially as Baby Boomers age.
            To answer your question, my opinion is, if one is dying, they are dying, whether in the UK or here. I would prefer to be in hospice if I were terminal, rather than undergoing expensive, wasteful treatment that lines the pockets of hospitals and Pharma. But that is just me. I find we Americans as a whole do not deal well with end-of-life.
            Anyway, sorry for being so snarky. I think that at the end of the day, we all want the same things for our families. It’s getting there that is the issue.
            Coffee would be great! I have many conservative friends as well. I have respect for Traditional Cosnervatives. Alas, theys eem to be a dying breed.

          • Margaret Houlehan

            Alice, I say this with all sincerity: I hope none of your six kids ever finds themselves very sick without insurance. Or inadequate insurance. By the way, I have volunteered at free clinics throughout my career.

          • Margaret Houlehan

            Perhaps Alice has a different value system than we do?

          • Margaret Houlehan

            Alice, are you a teabagger? No offense, just curious.

          • lissmth

            Margaret, why the homosexual slur?

        • M. O’r.

          I agree. Raised working in my dad’s clinic. Low SES but no fed/state $ back then. Never turned anyone away that needed help provided they paid something. I saw accounts that 1/mo on bills of over 10K…but as long as that was paid, he provided care. And some people bartered. And I grew up believing that is how we practice medicine, dentistry, mental health.
          He still managed to put 8 kids through college, tho we all worked, from 14 on…

          I went into med and switched to public health after living in a 3rd world country to adopt my child. The medical and nursing professions in this country need to acknowledge that an MPH is highly educated in addressing the health issues of populations. And we know which programs work with which disease type, age group, etc., based on scientific data. If it is still a problem (ie suicide in some cultures) it is still being studied. Find someone like me who has working in medicine, done medical missions, spent 20 years in the medical and pharmaceutical research industry before the MPH… come on, folks….
          Public health? Yep… how do you define it?

  • https://www.facebook.com/arobert6 Alice Robertson

    We can learn a lot from England and what not to do.

  • Save On Medical

    More power to you Kim! We love to see care providers thinking outside of the box like this to transform care delivery.

  • Stephen Sutherland

    I have heard so much about these cash or concierge systems. If someone could provide a little education on what exactly it covers, that would be great.

    What happens if the patient needs an expensive blood test who pays? Some of those test can cost 800 dollars like anti-phospholipid antibody.
    what happens if a person needs a CT scan, who pays ?
    Who pays for prescriptions? what does that direct pay thing really cover ?

  • Kim Byars

    As the author of this post and owner of Byars Family QuikCare I am grateful to see that so many of you have taken the time to read and comment on my post!

    Mine is NOT a concierge practice. I charge a flat fee for each visit. A sick visit is $45 including in-office testing such as Rapid Strep, Mono, Urine Dip, Flu, and HCG. The cost also covers any injections indicated at the time of service. For example, someone being seen for a sore throat might receive, not only a 30 min office visit, but a Strep test and/or Mono Spot, and an antibiotic shot (if indicated.) All inclusive! Our check-ups are $50. DOT physicals are $60. Because we do not send bills our patients do not have to worry about surprises appearing in their mailboxes and our administrative savings can be reflected in our fees.

    We contract with an outside laboratory service for send out blood work and we provide a price list upfront. If a patient has medical insurance, they may use it for this service! We are proud to be able to provide affordable convenient care to our community!

  • http://www.mightycasey.com/ MightyCasey

    Shifting the public’s perception of direct-care practices away from the “Royal Pains” rich’n'famous idea is critical before this idea can really take off. Posts like this help immeasurably. I’ve got an audience that looks to me for ideas in healthcare cost-transparency, with whom I will now share this =)

  • N. Cognito

    I would go to a NP in a hearbeat over most MDs and PAs (aka the “let’s pretend physician”) concept. I was having right upper quadrant pain. I went to my PCP (Friday) and stated I think it’s gallbladder though I’ve never had any problems before. My PCP was retiring that day, ordered an ultrasound, and said the PA would review the result and get back with me. The US result came back the following Tuesday afternoon and it was a horrendous result, showing a possible mass and severe gallbladder congestion. The idiot PA called me and told me I had a stone, but one wasn’t a big deal. On the following Friday I was having extremely severe pain. I called the damn PA and she said “it’s spasms”–I told her I was going to the ER–this wasn’t just spasms. Good thing–I would have died had I listened to her (three hours more per the surgeon). I had a GANGRENOUS GALLBLADDER–why? Because the boulder within its structure blocked the cystic duct. The gallbladder was dead and I was rapidly becoming septic. After a most phenomenal surgeon whom I requested completed a lap chole, I was released from the hospital, returned to the PA and told her what happened. She didn’t now what sepsis is or how a gallbladder could turn into a gangrenous situation. I explained it to her. The education PAs receive can be great or pathetic–as little as an associate’s degree from one school if you have a bachelor’s degree on admission (doesn’t matter what in). If this idiot PA would have known what she was doing, I would have received the URGENT referral I needed and would have done the surgery on an outpatient basis at a much-reduced cost. Because of her stupidity, I paid a much higher cost AND came damn close to paying the ultimate cost. NEVER will I trust a PA again. Putting on a lab coat and touting yourself as a doctor is a scam. NPs have at least a master’s degree and by far are much more knowledgeable than PAs and most PCPs and other MDs.