The doctor’s customer has become the insurer

Next in a series.

You the patient are really not the customer of the physician. Since the insurer will determine whether and how much the physician will be paid for attending to your needs, you are largely a bystander in the relationship. The doctor’s customer has become the insurer.

Our system of care is definitely not customer-focused. Doctors truly believe that they have the patient’s best interests in mind and they do. But their work is not customer focused as it is in most other professional-client relationships. You wait long weeks and sometimes even months for an appointment (the national average is 20.5 days), spend long times in the waiting room and are frustrated that you get just 10-12 minutes with your doctor who interrupts you within less than a minute and who recommends you see a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. All of this because, in the case of primary care, the doctor must see 24-25 patients per day to meet overhead and achieve a personal income of about $170,000.

As for the insurers, you are not their customer either. Their customers are the ones who pay them — your employer or your government.  And it shows — by our long waits on the phone, by the complex, often hard to understand paperwork and by the frustration when the insurance you thought you had does not cover your latest tests, x-rays or specialist visit.

So you are not the insurer’s customer nor are you the doctor’s customer. You are a mere bystander. This is hardly the type of contractual relationship you have with your lawyer, architect or accountant. In those situations, you pay them directly. Want more time? No problem, but you pay for it. Want telephone consultation? No problem, but you pay for it. Not so in medicine. You the patient cannot decide and ask for more time or use of email or telephone. Because you are not paying for the time and your insurance will not. It is just not your choice.

Who is to blame for the current state of affairs? Each party looks to the other but perhaps each should hold up a mirror and take a close look. Nevertheless, here is what physicians think based on a recent survey. Ninety per cent say the medical system is on the wrong track; 83% are thinking about quitting; 85% think the patient-physician relationship is deteriorating; 72% do not think the individual mandate will lead to improved care; and 70% think that the single best fix would be reducing government intrusion. Further, 49% will no long accept Medicaid patients and 74% plan to stop accepting new Medicare patients. Finally, 80% believe doctors and other medical professionals are the most likely to help solve the mess.

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery of health care is truly dysfunctional. What is needed is fewer patients per PCP so that each gets the time and attention really needed. The PCP needs time to listen, to prevent, to coordinate chronic care and time to just think. This means increasing not decreasing the cost of primary care per person. An increase in costs, yes, but an increase that will dramatically lower the total cost of care. Fewer referrals to specialists, better coordination of the care of those with chronic illnesses, enhanced prevention such that many chronic illnesses don’t develop and by spending  the time to listen and become trusted as the healers that they could and should be will all lead to better care at much lower total cost.

A new vision for our system must make it a health care not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses to both improve the quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be. And, critically, to make it work effectively, America needs many more primary care physicians — they are and should be the backbone of the health care system — who are able to offer outstanding preventive care, care coordination for those with chronic illnesses and do it in a manner that is satisfying to doctor and patient alike — with true healing along with expert medical care. It’s doable but it means a rethinking of how our delivery system is structured.

My next post in this series will be about today’s impediments to good primary care.

The doctor’s customer has become the insurerStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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  • Martha55

    Part of the cost of our insurance plan is compensation for work and the other part we pay out of our pocket. The problem isn’t we don’t pay, it’s that we don’t have the choice to walk away because we have no other options. In fact we are trapped in unfulfilling jobs because we need health insurance.

    Our high deductible insurance plan also means we out of pocket for that primary care physician. As a customer, here I have a choice to walk away. And I have.

    • Patient Kit

      Yes, we are definitely paying — via taxes, premium co shares, copays and deductibles. Most of us with insurance don’t feel like our healthcare is free. And I agree about people being trapped in jobs because they need that insurance. That’s why I think the answer is a single payer system that is not attached to employment. I don’t think direct cash pay is the answer to all our problems.

  • Patient Kit

    When exactly when (what year?) did healthcare become dominated by health insurance? I’m in my fifties and my healthcare has been paid for by employee provided insurance for my whole adult life and by Medicaid for this last year. I’ve gotten excellent care when I needed it that I never would have been able to afford without insurance. I will say that I feel like, in general, I’ve gotten far better care from specialists than primary care. Therefore, I’m reluctant to move away from specialists and put more of my healthcare in the hands of primary care.

    It sounds great for primary care docs to charge more and only accept cash and treat patients for things that they now refer to specialists and get more cash from that too. But I have a hard time imagining how that would work well for me and most people I know. And if you’re no longer going to accept Medicare, you’ll be cutting a lot of the senior citizen population out.

    I’m not saying our current healthcare system isn’t a mess. It is. But it will take a lot to sell me and many people I know on the idea that direct pay is the solution. That may be great for primary care docs but I think it would be awful for huge chunks of the patient population. Maybe I’d feel differently if I had more cash. A lot more cash. Because I just don’t trust that healthcare would be more affordable if I paid cash. I think it would become more like I wouldn’t be able to see a doctor any more than I can afford a lawyer. And since I can’t afford layers, the last thing I want to see is doctors following lawyers’ financial model.

    • Deceased MD

      HC insurance or mangled care? HC insurance has been around tied to jobs since what the 40′s? Mangled care started in the late 80′s really the early 90′s it was going full blast with hmo’s

      • Patient Kit

        And Medicare and Medicaid, since 1965? So, basically, most doctors in the US have been accepting payment via some insurance for their entire careers? It’s nothing new. I realize that insurance has changed over that time in it’s rules, reimbursement rates and the number of insurance companies and plans. It’s just that sometimes, when reading here about how doctors want to go back to direct pay, they make it sound like that is a model they themselves used to use before insurance took over the healthcare industry. But aren’t most doctors currently in practice trying to make the switch from insurance to direct pay for the first time? I’m just trying to get the context of exactly when the good old days — before insurance — were.

        • Deceased MD

          I think the good old days were in teh 60′s and maybe 70′s. Private insurance as well as medicare and medicaid all from what I understand paid decently and more importantly paid without huge admin and bureaucracy. I think you are right when doctors talk about direct care I think what they are saying refers to a time where the care was between MD and patient and the insurance worked without such interference as it does now. The government and insurance were supporting not interfering with care and payment.

          • Patient Kit

            So then, if insurance used to work better for both doctors and patients, the big change has been in the way those insurance companies and government insurance now do business, not the very existence of insurance replacing direct pay. Because most of us don’t remember pre-insurance times in healthcare. But from what I understand, things were a lot worse for poor people and senior citizens before Medicaid and Medicare, imperfect as those programs may be.

            I think the heart of the problem is not just the insurance companies but the complete industrialization of medicine into a big business when healthcare really shouldn’t be, at heart, a business above all else. Couple this with the model for so many businesses today, not just healthcare — the relentless push for more and more productivity/efficiency, the exploitation and burnout and demoralization that comes with always trying to squeeze more out of less people and time, alll in the name of maximizing the bottom line and profits for a relative few on the backs of many.

            It seems to me that none of the problems we talk about here will be resolved until we stop treating healthcare like it’s a business that’s main reason for existence is to make money. Insurance is only one part of that.

          • buzzkillersmith

            Most of the heat having been turned up on us is due to HC inflation. That’s the main driver.

            Also insurance companies have a nose for money and they figured out they could get quite a slice of the pie by putting economic pressure on other components of the system. But HC inflation was the thing that came first.

          • drma

            Inflation is built into the insurance paradigm. I think that this did not show up at first but as time goes on it will worsen.
            For example picture a simple interaction between a doctor and a patient. The doctor charges $100 which pays his office staff and overhead with a certain amount left over.
            Now the patient gets insurance, Let’s say a group of people pool their money to pay the doctor bills. The patient pays $100 to the insurance company instead of to the doctor.
            The insurance company needs to take in more money than it pays the doctor.
            On a global scale, the cost of medical care has just increased even if the number of patient visits and doctor charges remain the same. This is because a portion of the money must go to the middle man-the insurance company.
            Now this generates other factors. The patients will try to minimize the money paid to insurance companies while maximizing their doctor visits to get the most for their money. The insurance company will try to increase premiums to maintain a profit and they will try to reduce payments. The doctors will respond to reduced payments by raising their bills so they can still cover overhead and maintain an income.
            This is what is going on today at an ever accelerating pace. It is not sustainable.

          • Deceased MD

            yes I think that is what everyone here means when they say direct care. That HC has turned into big business to say the least. I am not sure if back in the day the doc was actually paid directly by the patient and then insurance reimbursed the patient the remainder. But regardless I think you get the big pic.

    • buzzkillersmith

      The first cases were in the early to mid 90s, then HMOs were in remission for a while, then recurred even more viciously in the early 90s. Since that time it has worsened considerably.

      Re concierge: It would not work well for you. It would work very poorly for you. But to have a market, demand is not enough. You have to have supply. And med students don’t want to be on the supply curve of this lousy, lousy job.

      If lots of docs went concierge. Many if not most would end up at retail clinics, the urgent care, the ER, or the community heatlh centers. The last in particular would be an eye-opener for many middle-class folks. Quite a slice of humanity, if you get my drift. Of course many if not most will wind up in those places anyway. People can get used to seeing a different doc or nurse practitioner every time. People can get used to a lot.

      Primary care medicine is circling the drain and will likely not survive in its current form much longer. Concierge is one option for docs.

      Don’t blame us. Blame your country.

      • buzzkillersmith

        early 00s

      • Patient Kit

        First, thank you for acknowledging that concierge medicine would work very poorly for me (and I would add, many millions of Americans like me). I don’t blame doctors for the state of healthcare in this country. In general, I like and respect doctors. I’ve been very lucky to have some very good doctors and a few wonderful doctors treat me, both when I was covered by Blue Cross for many years and this past year when Medicaid picked up the pieces when I was diagnosed with cancer after a layoff. There are a lot of good docs here in NYC, even for Medicaid patients. I’m so thankful for academic medical centers/teaching hospitals.

        I had to lose my life’s savings and delay getting back to work in order to qualify for Medicaid. But I put my health first and did what I had to to survive. You can’t delay treatment for ovarian cancer until after every other part of your life stabilizes. Believe me, I value healthcare above almost everything else except love, family and friends.

        It’s been a surreal odyssey falling out of the middle class, through the working class and into the Medicaid class. I’d describe trying to navigate the healthcare system this year as a mix between The Wire, Catch 22, Barbara Ehrenreich, Kafka and Vaclav Haval’s The Memorandum. Our healthcare system was scarier than getting a cancer diagnosis.

        I’m almost a year past my diagnosis now and trying to claw my way back into the middle class. I will never forget this year though and the people I met along the way, both doctors and other patients. Hopefully, as of 1/1/14, my pre-existing condition won’t be such an issue from the insurance perspective. One of the best things about the ACA, from my POV, among many things that aren’t so good.

        To be clear, I think I hate insurance almost as much as you do. But I also need it. I know I can’t afford healthcare without it.

        One thing I don’t understand is why doctors as a group didn’t have more power to stop the health insurance industry from changing the way it did. Doctors are needed. It seems like you, collectively, should have had more power to keep healthcare from becoming a big business. People have collectively had the power to change whether insurance covers mammograms, for example. How did we let things get so bad?

        Sorry to be so wordy. I’ve been on highly stressed out, just trying to survive mode for over a year straight now. And I’m trying to shift into moving forward now in our daunting healthcare system without a net.

        • buzzkillerjsmith

          Sorry to hear about all the troubles you have been through and I hope things get better.

          Your personal story is a powerful argument in favor of universal health insurance. It is crazy that people should have to lose their life savings if they get sick.

          • Patient Kit

            Thank you. It’s been the hardest year of my life but I have things in perspective. I know that with an ovarian cancer dx, I’m very lucky to be alive and it looks like I have a very good chance of living long. I have skills and talents that will give me a shot at bouncing back financially. I tell my story because there are a lot of us out here living through stuff like this.

            There are a lot of sick people falling through the cracks solely for financial reasons. When I hear about people who can’t get the chemo treatment they need in this country, I literally start sobbing for people I don’t even know. And I get angry about it. And personally terrified. I’ve worked my whole life and it’s come to this. But the work I did for many years advocating for others prepared me a little to advocate for myself as I navigated new healthcare worlds that I didn’t know. Many people can’t do that.

            So, yes, I do think universal health insurance is the answer. I hope we get there. Sooner rather than later. I’m a hopeless optimist and a pretty good fighter for what I believe is right. And I don’t think people should get healthcare based on what we can afford. I don’t own a car or a home or have cable tv. But if I have cancer, I want doctors to help me, even if I don’t have lots of money. I have a lot of stuff to do still on my bucket list — like swim with whale sharks.

        • Deceased MD

          Sorry to hear that as well. That is a perfect example of the huge holes in our system prior to the recent change. But why did you not qualify for medicare if you were working?

          • Patient Kit

            I’m not old enough to qualify for Medicare yet. There are a lot of people in their fifties who got laid off in the recent bad economy years. Many of us have chronic conditions or serious illness that we are perfectly able to lead productive lives with. Thankfully, at least the pre-existing condition issue has been addressed by the ACA. I hope. Eventually, I will be covered by Medicare and will receive both Social Security and a decent private pension. The trick is how to survive between the ages of 50 and 65 when something like this happens. Hopefully, a new employer will provide health insurance. Or, if they don’t, I can try buying something on the exchange. That doesn’t look like a good option but, at least, it’s an option. In the meantime, while I was unemployed and uninsured, Medicaid is the only thing that would pay for the life-saving surgery I needed. Thankfully, I am in the hands of an excellent GYN oncological surgeon at one of NYC’s teaching hospitals. He has never treated me once like I am a second class citizen because I am on Medicaid. Alternatively, I might have been able to get someone to do the surgery, use my life savings to pay a small piece of the fees and then file for personal bankruptcy. Many do that. Either way, you end up in the same place — broke and starting over in your fifties because you got sick while uninsured. I’m not alone. There are tons of us out here going through this. I’ve been working since I was 18. So, I feel like I’ve paid plenty of taxes over the years and feel like I have every right to turn to my government for help for the first time. I’m sure my story is not news to most doctors.
            There are so many of us going through this.

          • Deceased MD

            Folks that have never worked and of course low income are eligible for medicaid. ANyone that has worked since they were 18 yo and now in their 50′s and is disabled according to their (medicare’s) erratic guidelines, is definitely eligible for medicare. I am sure of this as I have seen patients that have met this exact criteria.

          • Patient Kit

            I was told that, in order to qualify for Medicare under 65, I had to first be entitled to Social Security Disability benefits (SSD) for 24 months. The exceptions were for patients who have ALS or permanent kidney disease requiring dialysis or transplant. I couldn’t wait 2 years. And thankfully, I’m not permanently disabled and would not have been able to afford to live on SSD longterm anyway. I don’t know. Maybe I got bad advice about Medicare. Maybe there is a way to get around the “24 months of SSD first” rule. I was in shock and scrambling to figure out how to “find the money” for surgery.

            Those were actually my private practice GYN’s words: “You have to find the money for surgery.”. She’s the doc who first found my suspicious ovarian cyst and I wrote her a thank you note for that. But after she told me I needed surgery — and soon, she also told me, while I was in stirrups that, if I voted for Obama, I was going to get what I deserved. NOTE TO SELF: Never go to the doctor on Election Day again! She didn’t do my surgery and she is no longer my doctor. I ended up in the hands of a much better, much more compassionate doctor at a teaching hospital and I’ll stay with him now once I’m off Medicaid. If I somehow could have qualified for Medicare early, it’s too late for me. But it would be good for others to know.

          • Deceased MD

            OMG that is unbelievable. I know they (Gyn) do these exams all day but that is quite violating. What a thing to say!!

            Well I guess you have educated me about the gaping hole that is still in our system if one loses their job and insurance because you are right it takes a long while to get medicare from what I understand. That is really unsettling to hear about and still a real problem given the enormous lag time you describe.

          • Patient Kit

            One of the great things about KevinMD is that it is a place where doctors and patients can share and talk about ideas, perspectives and experiences that we don’t often have the chance to talk about with each other. I’ve learned a lot from both doctors and patients here.

            I decided to share my personal experience because sometimes I think even doctors don’t realize what some of us patients go through to get the medical care we need. I think my situation was going to be a financial disaster no matter what. I just went into life triage mode and decided the only thing that mattered was saving my life and, once accomplished, I would pick up the pieces and try to rebuild. My main point is that there are a lot of us in this situation out here. So, yeah, single payer for everyone advocate here.

            Re my political former GYN, I was truly shocked when she brought up politics while I was in stirrups. Believe me, I didn’t bring it up. She asked me who I was going to vote for while I was in that position (and full disclosure: I worked on Pres. Obama’s first campaign). She was clearly very angry about the ACA and in venting mode. But the exam room was not the place to do it, especially when she was telling me that I likely had cancer and needed surgery asap. She was also clearly frustrated when I told her I was about to lose my Blue Cross insurance (as was I). But her political rant was ironic given that she was making a new pre-existing condition official for me that day in Nov 2012 that I then had to find a way to deal with for all of 2013 until the ACA’s pre-existing condition clause kicked in on 1/1/2014.

            Thankfully, I had an angel on my shoulder, medically if not financially, that led me to excellent, compassionate, state-of-the-art care elsewhere, at the hospital away from my former private practice GYN. I don’t know. Maybe, after reading a lot at KevinMD since then, maybe my former doc was at some meltdown/breakdown point. In spite of everything she said to me, I eventually wrote her a note thanking her for being the one to find my cyst and impress upon me that I needed to take it seriously. I let her know that I found a way to have the surgery and my prognosis was good. I didn’t mention anything political in my TY note. ;-)

          • Deceased MD

            I am so delighted you got the help you required.It speaks a lot of your inner strength to deal with such adversity. Waiting in line for care is lethal in many cases as you have well described. I would guess there is not only increased morbidity but mortality for pts which is a crime because of these sorts of policies.

            As you said, you were hard working-what the party line says in the US is what America stands for. And yet i would guess like you said there are many more folks in that situation that don’t get the necessary help or in time. Truly a crime but not something that is particularly talked about. Thank you for bringing it to our attention. I think if you feel comfortable, you should write an article on here about this. I for one would be all ears.

          • Patient Kit

            Thank you for your kind words and for listening to my story and responding to it. I’d consider writing something for KevinMD but I’m brand new around here and still getting a lay of the land. Before I got laid off, I was a research analyst for a non profit where I mostly researched and wrote about social justice and political issues. So, I’m comfy expressing myself in writing. There is nothing I care more deeply about than good affordable healthcare for all.

            I actually would have thought my story would be all too familiar and widely known in the medical community, especially in the aftermath of the massive layoffs in recent years hitting peeps in their fifties especially hard. But I guess many don’t even make it to the doctor. And eventually you might finally see them when it’s “too late”. I’m probably more stubborn and hellbent than the average bear when I know I, or someone I love, really needs something. A lot of peeps just give up and with good reason.

            Thanks again for your words of encouragement and interest. I sincerely appreciate it.

          • Deceased MD

            It may depend where one practices. People don’t generally call if they don’t have insurance but may go to teaching hospitals. I have been aware that losing ones job and insurance meant they were eligible for cobra for 2 years and then i suppose medicare after that. Didn’t your job provide disability? i think that is how I have seen most pts in this situation. paying for tx. In any case please do write here!!

  • buzzkillersmith

    Medical care is a quasi-human right in this country, so most people get some care even if they don’t pay the full costs of it. Hence the propensity to overuse the system. If they did pay the full costs, there would be a propensity to underuse the system. Not so great either.

    Primary care gets paid less than proceduralists for reasons we have discussed over and over at this blog. This will not change. Also we get paid for office visits, not for fooling with the administrative sea anchor attached to our legs. The sea anchor is lighter for the proceduralists.

    Big demand, little supply-> wait for a few weeks for an appt and then get 10 minutes with a distracted and demoralized doc.

    This problem will not be solved. It will get worse as demand increases more than supply does. NPs and PAs will not solve this problem. Allowing in docs from other countries.

    There is no way out for patients. Patiens in the Latin for suffering. Fortunately, there is a way out for med students: don’t go into primary care.

    • buzzkillersmith

      Allowing in docs from other countries will not solve this problem. Sorry for the mistake. Not enough coffee yet.

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

      … but we are not really overusing the system. We are told that we are overusing the system. There is a big difference.

      This is like the Chinese finger trap thingy. The more bureaucracy we insert into the process to regulate use by patients and micromanage “efficiency” or “productivity” or “appropriateness” by doctors, the harder it becomes to break free from whatever it is we call a health care system. And it is so by design.

      • buzzkillersmith

        Some people are overusing–people who come in to the ER for colds of one-day duration, a rash of one day, people with back strains who want MRIs, people with minor head trauma who want CT scans, and so on.

        Sure these people don’t use much money, except for maybe the imaging, but they do clog up the system big-time. Since they can’t get an appt with me and my kind, they clog up the ERs.

        It will never change, people being people.

        I agree that micromanaging is a “cure” that is usually worse than the disease.

  • http://hautuconsulting.com/ Shane Irving

    Very true. It’s no wonder that more and more Primary Care Doctors are moving towards membership models to supplement the income so they can provider the care they want to (and patients desire). Others are opting out all together and going to the concierge model (direct pay).
    After all Doctors didn’t become Doctors to jump on a treadmill while not being able to provide the type of care that drew them to the profession in the first place.

    • uDRAKSh2L5

      Please pardon my digression to semantics, but it matters…
      Concierge medicine is not direct pay medicine. The concierge model is based on standard third party payers (insurers and Medicare), but patients also pay an additional annual fee directly to the physician practice which helps offsets the overhead costs borne by the physician due to the third party payers, and also offers the patient improved access to the physician. In effect, the patient is subsidizing the insurer’s bureaucracy in order to receive more attention from the physician.
      In direct pay medicine, the physician dumps the third party payers alltogether, charging the patients typically by time rather than on the basis of all the payer-mandated diagnostic and procedure codes, while the patient remains free (an admittedly perverse use of the word…) to seek reimbursement from the insurer – which, especially initially, can be a daunting task. Smart direct pays doctors offer patients some assistance with the process, but do not become engaged in it.
      Many patients are shocked by the demands insurers make prior to paying claims – they never realized just how much crap their physicians have to put up with at the hands of insurers. Conversely, insurers often reduce those demands when they are dealing with actual customers – the patient who is paying for the insurance – instead of a semi-captive doctor who they can force to practically beg for the money. Some really surprising transformations can occur once a patient takes the reins in driving the economics of these transactions – there really is such a thing as consumer power, but only if the consumer is willing to exercise it.

      • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

        I just want to underscore the truth of what uDRAKSh2L5 writes above. I’m a direct pay (not concierge) psychiatrist, with the exception that I see a limited number of patients on Medicare. I like to be available to the elderly or disabled on Medicare, but I do so at significant financial peril: Medicare pays 60-70% of what I can reasonably ask patients to pay directly, and then I risk having them take it all back if I fail to chart according to their truly arcane rules. As in other discussions on this blog about EMRs, it’s become virtually impossible to document everything to the satisfaction of insurers and administrators, and to do a good job at the same time. I’ve written about this in greater detail on my own blog: http://blog.stevenreidbordmd.com/?p=797
        http://blog.stevenreidbordmd.com/?p=812

      • Patient Kit

        Thank you for clarifying the difference between concierge and direct pay models. The discussion here about both of them has often been confusing to me since they sometimes seem to be referred to as if they are the same thing.

  • doc99

    The problem with Third Party Payor is that the patient is no longer the client.

  • clover

    We doctors let this happen. We refused to learn the law and business of medicine and now we are just employees. Doctors are too expensive for the present delivery system. We will soon be replaced by cheaper providers or three year med school fast track doctors. The only possible good part is that maybe we will have legal leg to unionize and start to be able to collective bargain. Or just step out of the system and not take any insurance.

  • uDRAKSh2L5

    I understand what you are saying, but the financial reality is that it simply isn’t true. The fee for a physician charges for an office visit is, for example, $200. Your co-pay is $25. The insurer does not pay $175 to make up the difference. Instead, they take some discount, determined by their (usually non-negotiable) contract with the physician, and the pay that arbitrary amount – say $85. So far, the physician has received $110 of the $200 he has billed. Shortly afterwards, you get a notice from the insurance company, and maybe the physician as well, saying that you owe the physician another chunk of dollars. This last chunk of dollars depends on 1) what percentage of the visit your insurer covers (typically 60-80%) and 2) whether the insurer is telling you to pay the remaining 20-40% based on the physician’s fee or their discounted price. Those terms vary among individual contracts.
    The bottom line (pun intended) is that the insurer is usually paying the majority of the money owed to the physician for the visit. Given that fact, the physician’s attention is more focused on complying with the insurer’s demands, and not pissing off the insurer, than on meeting your needs economically. The physician will still take care of you to the best of his/her ability, _unless_ the insurer (or his employer, if there is one) imposes some sort of condition which makes it uneconomical for him to do so. It’s not right when this happens, it is a violation of the hippocratic oath (probably unproveable), and it is the reality of the current state of the business of American health care. It sucks, no one is happy with it and, to a greater and greater extent, it’s the law, either mandated or protected by the government.
    As far as Visa goes, the bigger the transaction in question, the more likely it is that the retailer and Visa will get together to settle an issue, cutting you out of the process. Same general issues, but in a less brutal, and important, environment.

  • Resident MD

    I’d just like to point out that college summer interns at health insurance companies get paid more per hour than residents. Probably some attending physicians too.

  • katerinahurd

    How ethical is it to assign a monetary value to the doctor-patient relationship?