Today’s high deductibles are tomorrow’s bad debt

I’m not sure if you’ve heard the parable of the tall man and the cat.

Maybe not, since I had to make it up in light of health care’s unending cost increase.

In this allegorical village, there was a group of citizens who were very upset with a man who lived there. This man was very, very tall, and he made all the villagers feel uneasy (they were insecure about the crowns of their heads, who knows why).

One night, a mob caravanned to the tall man’s house with tall, burning torches.

“Get out,” the mob cried.

The tall man peered at them from high up in a window, worried.

The scene was tense, until a woman ran up to the mob.

“My cat’s stuck in a tree,” she said. “The thing’s stubborn.”

“But we’re sick of this tall man,” said the mob.

“Yes, but he’s the only one who can save my cat.”

Moral of the story: Don’t run people out of town because they make you feel insecure; you might need their help one day.

I bring this up because of something I read lately. Hospitals are literally arranging loans for patients swamped by significant medical debt — debt that is increasingly attributed to high insurance deductibles and co-payments.

Since February 2013, Mount Carmel Health System has set up loans for as long as five years at an annual interest rate of 4% for patients with a minimum balance of $300.

Ohio State University’s Wexner Medical Center, whose bad debt swelled 31% to $118.6 million in the last fiscal year, also is considering a loan program, said Debra Lowe, the hospital’s administrative director of revenue cycle.

A recent report issued by Moody’s Investors Service warned that bad debt is becoming a hot spot for hospitals, partly because of the proliferation of high-deductible health plans that make consumers foot a greater portion of their health care bills.

In fiscal year 2013, local hospital systems reported $357 million in bad debt, a 14% increase from the previous year.

The Affordable Care Act is benefiting hospitals by expanding the number of people with health insurance; an estimated 5.4 million U.S. adults who had not been insured as of September now have health insurance, according to Urban Institute research released on Thursday.

But that windfall might be tempered by the fact that about 80% of people signing up for private health coverage through government-run marketplaces are choosing plans with high deductibles, Moody’s said.

“Today’s high deductibles are tomorrow’s bad debt,” the report states.

Yes, they definitely are when we waste money in the ER.

The reality is that 80% of what I see in the ER is “family medicine after hours.” I could just as safely see these patients in my own direct care practice, saving them time and money.

Ohio State is working to educate patients, many of whom previously have not had health insurance and might be experiencing sticker shock, Lowe said.

In other cases, patients aren’t fully aware of the particulars of their health plans, including the fact that they are responsible for a significant portion of the costs.

“Because of Medicaid expansion, we’re seeing fewer uninsured patients,” she said. But, she added, “We’re seeing people with $10,000 deductibles.”

Whoa, whoa, whoa. Ten thousand dollar deductibles?

Yes, Merry Christmas. You didn’t meet your deductible after an entire year of paying premiums.

Sure, for hospitals, there’s an incentive to work with patients upfront to resolve big bills. Lowe said less than 5% of Ohio State’s bad debt is recouped through the collection process. (Again, an example of cash’s negotiation power in paying for medical services.)

High-deductible plans have become far more common for those who have health coverage through their jobs, too. Overall, the number of people with health savings account/high-deductible health plans has grown at about 15% a year, reaching 15.5 million in 2013, according to America’s Health Insurance Plans.

Let me paint a rather controversial portrait of American health care. If I offend you, let’s talk about it. My goal is to heal you, not emotionally devastate you. However, we have one story told daily and that is that the ACA is insuring millions of people. That’s well and good.

Then we have another voice telling us that a substantial amount of these insured people are actually buying high-deductible insurance plans. In certain cases, patients aren’t aware of it.

And then we have people claiming that high-deductible plans are the reason patients are going broke.

I’ll let you stretch your legs after walking in that logical circle.

Then I hear a minority voice, strong, though, opposing my work as a cash-only clinic for exacerbating a two-tier health care system.

The thing about direct care is the math: For $600 per year, I promise you, I can handle about 80% of what you would ever need treatment for.

I can get you almost all of your medications, for dollars per year. Yes, dollars per year. And I’m here for you when you cut your finger in the middle of the night, when your child has a stomach flu.

And I will openly admit that I can’t treat every problem. I’m not an oncologist. I’m not a cardiologist.

However, if you’re seeing a specialist like that, you are in a rare and extremely serious circumstance.

However, when a direct care doc can reduce monthly costs for our patients, families especially, and keep them from incurring major debt, that’s a victory.

No, we’re not a one-size-fits all solution.

Insurance is important for the things we can’t predict.

However, if our government is going to swindle people into unwittingly buying high-deductible insurance, don’t mob the tall man who could at least save your cat.

Josh Umbehr is founder, Atlas.md.

Comments are moderated before they are published. Please read the comment policy.

  • Steven Reznick

    Well said. While the Affordable Care Act provides insurance and preventive care, many with high deductibles can not afford care when they are ill.

    • Dr. Josh, AtlasMD

      And thats why we’re working to expand direct primary care models where doctors offer unlimited visits, no copays, free procedures and wholesale medicine/labs for up to 95% savings. This in turn lets us decrease employers health insurance premiums by 30-60%

  • QQQ

    Monday, March 03, 2014 – One-in-three U.S. voters now says his or her health insurance coverage has changed as a result of Obamacare, and the same number say the new national health care law had a negative personal impact on them.

    A Rasmussen poll on Obamacare taken over the last three days has some startling facts:

    • 33% say they’ve been hurt.

    • 40% view it “favorably” (down from 45% two weeks ago).

    • 56% view it “unfavorably” (3/4 of these say it’s “very” unfavorable.)

    • 58% say free market competition would do more to lower costs

    • 14% say they’ve been helped.

    All of these numbers show an increase in negative opinions and a decrease in positive ones.

    • Dr. Josh, AtlasMD

      A key point in the argument is do patients need health “insurance” or health “care”. Regardless of political parties, lets embrace cost effective approaches to delivering care.

      • Patient Kit

        In our current system, many of us need both. I don’t think it’s an either/or question.

        • Dr. Josh, AtlasMD

          Which is why we still recommend that you have both if you can afford both. And DPC makes insurance more affordable. Win Win.

  • QQQ

    “Whoa, whoa, whoa. Ten thousand dollar deductibles?”

    If you can’t afford insurance, how can you afford a $10K deductable?

    • LeoHolmMD

      That is the point. It’s called “Uninsured Plus”.

      • Dr. Josh, AtlasMD

        Well, we think about it like car insurance. You don’t have auto insurance that pays for gasoline….why should we use health insurance for family medicine…assuming that we can/do make it much more affordable.

    • Dr. Josh, AtlasMD

      Actually, by raising the deductible like this, you can lower your premiums. Then use the savings to fund an HSA to pay for the 10k deductible.

      But in our #directcare model, we are able to offer unlimited visits, no copays, all office procedures free and wholesale meds and labs for up to 95% savings. A lot of other services like ultrasounds, CTs, and MRIs we get for 60-80% savings. So you’re just less likely to NEED your insurance.

    • Patient Kit

      High deductibles do make doctors inaccessible to many people. So, instead of moving toward people paying cash out of pocket for 80% of their medical care via a direct pay family practice doc and all the discounts a solo private practice doc can somehow magically negotiate from drug companies etc, why not go after the insurance companies and force them to lower their deductibles to a point where people can afford to use their insurance to access uncatastrophic medical care? A credible threat of moving to a single payer system that eliminates the need for insurance would be a good start toward forcing health insurance reforms on such things as outrageous deductibles and accountability.

      • Dr. Josh, AtlasMD

        Force and Threat huh? is the compassionate lexicon of a single payer supporter? Scarry. What else are you going to force people to do?

        • Patient Kit

          I’m not proposing literally holding guns to insurance companies’ heads.. But in order to effect change in greedy businesses, some kind of leverage is usually needed. What do you propose — that we just ask insurance companies nicely to be more accountable for the medical decisions they make and to sell a product that people can actually use? No, of course not. Your proposal is that we just give the money directly to you instead.

          So, yes, I do think insurance companies might be more open to change if they faced the possibility of their entire industry becoming obsolete if they don’t rein in their greed. In your mind this makes me a thug?

          • Dr. Josh, AtlasMD

            Yes, if you say things like forcing them to change or threatening them with extinction, then yes it makes you a thug.

            The only legal option is to find ways to encourage people to cooperate willingly with you.

            I’m not asking the gov’t to force you to purchase an iphone, or a car or my DPC membership.

            The goal is to prove to the consumer that product a is better than product b. They have the right to make those decisions for themselves.

            We’re working with insurance companies to show them that there is a better way and they are changing b/c they see the mutual benefit. Not b/c someone is threatening them.

          • Patient Kit

            It’s not illegal or immoral or unethical for citizens in this country to build a political movement and public support for change. Whether you believe it or not, I care passionately about access to good, affordable for ALL Americans. I consider myself to be a very compassionate person. The insurance companies, on the other hand, often act like thugs. And if we’re going to push back against their greed, we’ll need some tactics and strategy. And some of it will not be nice.

          • Dr. Josh, AtlasMD

            There’s a big difference b/w mobilizing political change and forcing people to see it your way.

          • Patient Kit

            I don’t have the power to force anyone to do anything. But we can’t fight things as overwhelmingly powerful as health insurance companies and Big Pharma without any ammunition.

          • Dr. Josh, AtlasMD

            There is only one boss. The customer. And he can fire everybody in the company from the chairman on down, simply by spending his money somewhere else. — Sam Walton

            You have the best ammunition available, your dollars. Vote with your feet.

            I don’t accept the view that they are too big to compete against.

            The role of good business IS to innovate better solutions even if that means going over around under or through the big companies.

          • Patient Kit

            You’re quoting Sam Walton, founder of Walmart, as inspiration as we grapple with how to reform healthcare in this country to make it better for everybody? OK. That tells me a lot about how different our values and beliefs are.

            Sure, there is some consumer power in how and where we spend our dollars. But some people have a lot more dollar/power than others. For the majority, who have less dollar/power, it takes an organized effort to pool our resources to have any influence with business powers like Aetna — or Walmart. You really do believe that the free market will solve all problems. Do you also believe if the wealthiest — like Sam Walton — keep getting wealthier that it will trickle down?

            And how is it that you, a [solo?] private practice primary care doctor, can go “under around, over and through” big pharmaceutical companies to negotiate drug prices for pennies that the rest of us have to pay so much more for? How does one doctor manage to get that kind of power over Big Pharma?

          • Arby

            Unless you can out think those who do organizations well and would freely use your well-meaning compassion for their own ends, I say don’t meet them head on. Create a different system that is better and people will gravitate towards it.
            Also, Sam Walton was not like his spawn running the companyt now…at least not that I have read.

          • Dr. Josh, AtlasMD

            yeah i don’t think Sam would be really happy with whats happened at walmart since he passed.

          • Dr. Josh, AtlasMD
          • Arby

            I honestly think this is one of the smaller things that would bother him. He might even approve of it because it is a safely issue; too many greeters were getting into altercations with “customers”.

            Nope, I was thinking of other things such as how the “Buy American” idea was canned or that they schedule all of the cashiers in AK not at the store level.

          • Dr. Josh, AtlasMD

            just an example, but i agree

          • Dr. Josh, AtlasMD

            Build a better mousetrap, and the world will beat a path to your door – Emerson.

            And a small company can’t win in a head to head match up with Walmart. Thats why we didn’t go head to head :) We took a david v goliath tactic.

            B/c we are able to sell our time as physicians, i don’t need to make profit off of the medicines like walmart does, or is currently doing. We’ll make them compete on our terms.

            We can’t purchase wholesale meds on our own and we’re the “gatekeeper” if you will for patients to get medicines. So walmart needs me more than I need walmart when it comes to medications.

            So if i’m going to see the patient first, i might as well be the one helping save $$ on the medicine before they ever get to walmart.

          • Dr. Josh, AtlasMD

            Now if walmart wants to out compete me, they’ll have to give the medicine away!! How great would that be for patients ;-)

            And there’s precedent for it too: http://www.publix.com/pharmacy/Free-Medications.do

          • Arby

            Wegman’s does this with an antibiotic too.

            Careful for what you wish for though. Walmart is well known for undercutting the competition when they first move into an area or with a new line that they carry, and then raising the prices or decimating the line of products after the competition fades. And if you are interested in the pay, I found a balanced article (esp. balanced if you read the comments) at Motley Fool. The URL is too long to post, so if interested, please google the title “Does Wal-Mart Really Underpay Its Employees?”

          • Dr. Josh, AtlasMD

            Thats the best part, how do they undercut me from 1 penny a pill to free? I already don’t make profit on the medicines. So it doesnt’ hurt me at all. And if they go back up, i’ll just out compete them again…..its BRILLIANT :)

  • Lisa

    Yes, you maybe able to handle 80% of what most people see a doctor for, but people still need insurance for the other 20%. The thing is, I don’t think it is all that unusual for people to need to see specialists. I can afford a deductible (even $10K , which is higher than the deuctibles allowed under the ACA), but I couldn’t afford to pay for cancer treatment out of pocket. I probably wouldn’t even qualify for a loan in the amount needed. Sigh…

    • Dr. Josh, AtlasMD

      Lisa, Yes we do recommend that people have insurance for the catastrophes of live, but we can also make it more affordable.

      Interestingly, the total cost of call cancer care in 2010 was only 158 billion http://costprojections.cancer.gov/expenditures.html For a 2.8 trillion dollar system, thats only 5.6% of total spending.

      The cost of all medications was 263 billion. If we can decrease the cost of medications, labs, copays, procedures, insurance premiums and decrease ER/Urgent Care visits, specialist referrals and hospitalizations….we could save enough to PAY for cancer care! :) exciting

      • Lisa

        And how do you propose that the savings actually get funneled to pay for the care of the cancer patient? How is DPC going to make insurance more affordable? True high deductible plans, purchased on the private market, aren’t cheap.

  • TC

    High deductibles don’t necessarily make people foot more of the bill. The other half of the term (which opponents of such things often fail to mention) is ‘low premium.’ The problem is some people with these plans don’t plan for the future and rather view the extra money in their paychecks as, well, extra when in fact they need to be saving it for health care. If course, if they end up not spending it they get to keep it, which is more than can be said for high premium (low deductible) plans.

    • guest

      Actually, I moved to a high-deductible plan this year. Premiums are actually higher than my premiums were last year. Coverage, especially for medications, has gotten worse, too. The fact that I am coming out behind on this has exactly zero to do with me “failing to plan.”

      • Dr. Josh, AtlasMD

        Unfortunately that may be the result of a poorly designed plan and/or the ACA.

        The ACA bronze plan is basically a catastrophic plan but now it covers less and costs more than similar plans 1-2 years ago did

    • Jess

      My old “catastrophic” policy (that I liked) was cancelled because it was not Obamacare compliant, and I ended up with a new Obamacare compliant policy where both the deductible/OOP and the premiums are higher. Among healthy under-40s in my circle, this is not a rare occurrence.

      • Dr. Josh, AtlasMD

        You’re correct, its not a rare occurrence and i’d say its the experience for the majority of patients we talk to.

    • Dr. Josh, AtlasMD

      Exactly! The goal would be to take the savings from more affordable premiums and put them in an HSA until you have enough to pay for the higher deductible. Then either use the extra to enrich your life or continue to save/invest.

  • HJ

    For someone my age it’s not $600 but $900. Of course I don’t live in Kansas…my local concierge cost $2040 a year.

    If I lived in Kansas you wouldn’t see my child in the middle of the night unless we paid an additional $120…and you wouldn’t provide vaccines.

    I went to the doctor once last year. A hefty price tag for a single visit, even in Kansas. I take medication that costs $3000 a year…I would guess that medication isn’t included in the price.

    While Prilosec at Walmart may cost $225 for a months supply, over the counter omeprazole is only about $10 a month. I could take care of my own GERD without paying the $900…if I was in Kansas. If my GERD was so severe, I am sure my $900 wouldn’t include the EGD to check for Barrett’s Esophagus.

    My main medical expense is for a condition that a primary care doctor is not qualified to treat. I am not rare or extremely serious circumstance.

    Giving a doctor x dollars for a bunch of maybes feels a lot like insurance.

    • Dr. Josh, AtlasMD

      yes, we charge $10-100/pt per month based on age only.

      Yes we do see children in the middle of the night (stitches, fever etc) for no extra fees.

      We don’t provide vaccines as part of the membership b/c that would require that we raise the membership fees to cover the added cost. Plus, insurance covers most vaccines.

      Our wholesale price for omeprazole is $1.55 wholesale to our patients. So about 20% of your membership is saved each month on one benefit.

      an EGD is not included b/c we’d have to raise the cost to everyone to cover EGDs. Instead, pts who need EGDs can pay about $700 which is about a 75% savings.

      Family physicians are highly qualified to manage GERD.

      • HJ

        I am not in Kansas, but if I was in Kansas, instead of paying $75 for direct pay, I could upgrade my insurance to a gold plan for $95 a month. I would only pay $5 for an office visit and be better covered for that catastrophic event. And my brand name medication I have to take is also covered.

        • Dr. Josh, AtlasMD

          I find that unlikely that you’d be able to increase your insurance to a gold plan so affordably….if that was true, people across the country would not be complaining about a broken health care system.

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Risk is that use of high deductible won’t be used or be used for other options which may or may not be as helpful medically – http://www.kevinmd.com/blog/2013/10/obamacare-risk-american-public-worse.html

    Either way, high deductible plans will not go away.
    The risk to patients both physically and financially will simply increase.

    Davis Liu, MD
    The
    Thrifty Patient – Vital Insider Tips to Staying Healthy and Saving
    Money (2012) & also Stay Healthy, Live Longer, Spend Wisely: Making
    Intelligent Choices in America’s Healthcare System

  • DeceasedMD1

    “Hospitals are literally arranging loans for patients swamped by significant medical debt”

    Sounds like a good time to have Wallstreet start credit default swaps and derivatives to help these pts with their medical loans, as they will likely become more unaffordable than housing was.

    • Jess

      We saw the result of the Federal Government stepping in to “fix” the problem of not enough low-income people owning their own homes; now we’re going to see the result of the Federal Government stepping in to “fix” the problem of not enough low-income people having health insurance. No doubt that the Medical Industrial Complex (including its Wall Street profiteers) is going to be in for a taxpayer-funded bailout. “Too big to fail” and all that. Crony Capitalism for the win!

      • DeceasedMD1

        interesting. A lot of people think the MIC will fail and then we will go to the single payer system. But as you pointed out, if it is anything like the bank, bailouts are all the rage these days.

        • Dr. Josh, AtlasMD

          It’ll be hard to go to a single payer system in America for a variety of reasons.

      • Dr. Josh, AtlasMD

        I agree that crony capitalism is wrong and really not even capitalism in the first place.

    • Dr. Josh, AtlasMD

      Unaffordable indeed! So step one should be making care more affordable so that a) fewer people need loans for medical care and b) those loans are much smaller and more manageable.

      • DeceasedMD1

        unfortunately good will does not prevail I am afraid. Look at the VA. The MIC (medical Industrial Complex) would love to continue to create more and more income for themselves with disregard to what pts actually need.

        • Dr. Josh, AtlasMD

          And thats why a free market that can introduce disruptive innovation or even creative destruction http://en.wikipedia.org/wiki/Creative_destruction to compete with the interests of the MIC

          • DeceasedMD1

            I agree with your many of your premises about the current problems.. But The fundamental flaw IMHO is the pt doc rel’n is being assaulted. Getting back to the way things were before the MIC took over seems more like a revolt which not sure is possible but if you look back HC was not broken or in crisis at that point in time. Things seemed to change when MIC took over.As far as creative destruction, not sure how destroying the system further can be constructive or creative but maybe i am not understanding exactly what that infers.

          • Dr. Josh, AtlasMD

            Those are terms common in economics for how the free market innovates solutions. Apple is an example of disruptive innovation b/c they are able to shake up the market by making better products.

            So we don’t want to “destroy” healthcare, rather out compete the broken system to create a better one….

            out of the ashes…. :)

          • DeceasedMD1

            Call it what you may, there are too many costs that don’t add value. Get rid of it. We need to get back to basic fundamentals that are being eroded. How are new inventions going to solve the fact that many people with treatable medical problems are not even being followed by a PCP and are lost? Not sure how Apple’s philosophy translates to good patient care unless you think technology can solve all of medicine’s woes.

          • Patient Kit

            I am painfully aware of the flaws of the ACA and the flaws of our healthcare system before the ACA. But I trust the free market to create affordable, accessible, good healthcare for ALL Americans about as much as you trust the government. I trust the free market to create a good healthcare system about as much as I trust The Heritage Foundation, The Cato Institute and The Ayn Rand Institute — which is to say, I don’t trust the free market to do that at all.

            What is your position on healthcare for the poor and the elderly? Would you abolish Medicare and Medicaid and let the free market prevail for those populations? Or would you keep those two programs?

          • Dr. Josh, AtlasMD

            Then we can agree to disagree.

            My position is that we should continue to utilize the free market to make healthcare affordable for everyone.

          • Patient Kit

            You didn’t answer my specific question: Would you keep or eliminate the Medicaid and Medicare programs?

          • Dr. Josh, AtlasMD

            I would work to decrease the need for these programs by making more care more affordable to more people. Especially since medicare will be bankrupt soon.

            http://www.forbes.com/sites/aroy/2012/04/23/trustees-medicare-will-go-broke-in-2016-if-you-exclude-obamacares-double-counting/

            Did you know that there’s plenty of research to show/suggest/document that patients with medicaid have worse health outcomes than the uninsured?!

            http://thehealthcareblog.com/blog/2013/12/31/how-can-patients-on-medicaid-possibly-be-worse-off-than-those-who-dont-have-insurance/

            http://www.forbes.com/sites/scottgottlieb/2014/01/02/new-study-shows-how-medicaid-fails-the-poor-and-why-obamacare-will-fail-the-middle-class/

            So no, i don’t think we’ll ever eliminate these safety net programs, but in the same breath I can say that i don’t think they work well for the majority of recipients.

            I want everyone to be able to get great care.

    • LeoHolmMD

      It really is the housing crisis all over again. I would tell the next generation to get ready for the next bailout…but they haven’t been born yet.

      • Dr. Josh, AtlasMD

        I agree. But it also means plenty of opportunity for those who can fix problems in healthcare.

    • Dr. Josh, AtlasMD

      Its never a good time for bad debt….but at least maybe the ridiculousness of the system will drive patients to demand improvements.

  • Lisa

    Our goverment is running a plan based on the ideas of conservatives, who do not want any one to get a benefit without paying for it.

    The maximum out of pocket expenses for someone who purchased an insurance plan through an exchange this year is $6,350 for an invidual and $12,700 for a family.. Affordable for some, not affordable for others. But the ACA does allow people, depending on family size and income to receive assistance not only with the premiums but with out or pocket costs (if they chose a “silver plan”).

    But what I said above still holds true and I think it is true for most people. Even the maxium out of pocket amount are small compared to the treatment costs for a major illness or injury and I don’t think that many hospitals are going bankrupt. I also think hospitals have long set up payment plans with patients and had heavy handed collections departments.

    • Jess

      “Our goverment [sic] is running a plan based on the ideas of conservatives,”

      That simply isn’t true, no matter how often the Democrats and their cheerleaders repeat it. Not one single Republican voted for the ACA, not one. This was supposed to be Obama’s proudest moment, his signature legislation, and it was only because he had a super-majority in Congress that he could push it through only a purely 100% partisan Democrat basis.

      Trying to disown it and pawn it off on conservatives now that it’s turning out to be every bit the disaster Republicans predicted it would be, is just plain ridiculous.

      • Lisa

        The ideas in the ACA are conservative – it is based on ideas from conservative think tanks and on Romney Care in MA. The Republicans in congress would have voted for it if the bill was sponsored by a Republican. Furthermore, it is not a disaster and the Republicans, despite their efforts to repeal it haven’t offered a single workable alternative.

        I am not disowning the law, although I won’t deny it has some problems, which should and can be fixed.

        • Dr. Josh, AtlasMD

          Just b/c Romney is a conservative, doesn’t mean he speaks for all conservatives.

          Many people from both sides of the political isle aren’t comfortable with the gov’t forcing people to buy something. Where does it stop?

      • Dr. Josh, AtlasMD

        That is a fair point, the republicans did not vote for the ACA.

    • Barry Lowe

      I disagree entirely. I recently called a doctor that I owed money for. It was something related to my eye and I had overlooked my bill. It’s been about 6 months now, but I called, saying, I owe you money. The receptionist said, literally, “Oh my god, that’s so sweet of you.” (Referring of course, to the fact I was OFFERING to pay.) I’d suggest that the reality is that many, many, many people don’t ever pay for the medical service they are provided.

      Really, we’re in a convoluted clusterf*** (pardon my French) of IOUs. And it’s lobbyists and the elite who benefit most from these invisible transactions.

      I’m a fan of any doc or hospital who wants to bring a little cash transaction back into medicine. The more two parties can regulate their transaction directly, with cash, the less power that abstract, corporate organizations can benefit from the transaction.

      Even if Josh isn’t perfect, I don’t understand why anyone would attack him outright. That’s like saying, I want to live the rest of my life being robbed in daylight.

      I mean, maybe that’s easier on all of you. If so, why come to this site? Why participate at all? Your voice is a weak whimper against an unfazed power elite.

      • Lisa

        1) I didn’t attack Josh directly in any way. I have been questioning the economics of DPC, which is legitimate. I don’t think DPC is going to be affordable for many given the fact that people still need to carry insurance.

        2) Most people pay for their medical care. They pay for insurance, they pay their deductibles and co-pays. If they are on medicare they have paid through taxes while they were working and they pay in monthly payments for the different parts of medicare. They usually pay for supplemental insurance. Some people even pay cash for medical care. But if you don’t have the cash, how the heck do you pay for medical care? Do you have the cash to pay for a major illness?

        • Dr. Josh, AtlasMD

          Lisa, i’m sorry that you can’t see the value of DPC, despite how clearly we explain it.

          It cost more to pay for insurance premiums that cover the cost of your medication (most of the time) than it does to pay for your medicines directly. This means people get their meds and their insurance cheaper.

          Repeat the above for labs, office visits, imaging, procedures etc.

          • Lisa

            You explain the value of DPC; the problem as I see it is is that you still need insurance to cover catastrophic illness or injury. Therefore, you are paying for both insurance and the monthly fee to belong to a DPC practice. For some people, it may work out, but it won’t work out for all people.

            I figure that it would cost me approximately $1,200 a year to belong to a DPC. That would be on top of my employer provided insurance, for which my share is approximately $90 a month. As long as I see providers within the network, my co-pays are $20, with no deductible. Generic medications are generally $10 or under. I would have to see my PCP very many times and take a lot of medication for a DPC to make sense financially. I generally see my pcp once or twice a year; however, I also see my oncologist and a lymphedema therapist on a regular basis. Belonging to a DCP practice would not do away with my need to see the specialists I do nor would it do away my need to maintain insurance.

          • Mike Henderson

            The hard part to explain, is how all of this works together. First, as in my post above, to me DPC is about practicing medicine the way I have been trained and not for insurance companies.

            Another point is that the word insurance isn’t being well defined. Insurance is something that is paid for over a period of time. If an event occurs that is covered by the contract, the insurance company will reimburse you to prevent financial catastrophe.

            In the health care world, “insurance” is being used very loosely. Yes, you need insurance for the big stuff – cancer diagnosis, heart attack, major surgery, hospitalization etc. – things that would cause financial catastrophe. DPC isn’t going to replace that. But why is “insurance” needed to cover medications that cost pennies? Insurance companies make money providing patients services and products (like pills that cost pennies) they could buy themselves and so are very happy to “cover” those things

            If we were to treat homeowner’s or auto insurance like we do health “insurance”, we would be expecting our wiper blades, tires, gas, housecleaning supplies, landscape maintenance and utilities to be “covered by insurance,” in addition to the car being totaled or the house burning down. Every time you go to fill up your tank with gas, the gas station would have to have hire multiple staff to make an appointment, document useless information, pre-approve the visit and then the gas station attendant would come out, document inspecting the gas cap, filling with fuel from which pump on what side of the car, putting the gas cap back on and that the car ran normally afterwards. Then the billing department would take over, send off a claim. The insurance company would reject a third of the claims and then the billing department would resubmit, with some of them never being reimbursed anyway. In this bizarre scenario, some drivers would try to bring in extra gas cans and want premium ethanol as well and blame the gas attendant for not filling them. As bizarre as it is, it isn’t too far off from how primary care is experienced by your physician.

          • Dr. Josh, AtlasMD

            Well said Dr. Mike, thats exactly the point we try to make when discussing the benefits of DPC with people.

          • Dr. Josh, AtlasMD

            As I’ve said before, given your history of cancer, which is a smaller % of the population. We are trying to fix what we can and you’re ignoring that fact.

            You’re also not seeing the “true cost” of care. Just b/c you pay $10 for a generic, that doesn’t include the cost to your employer.

      • Patient Kit

        I don’t think anyone here is attacking Dr Umbehr — just questioning him and disagreeing with him and trying to understand him. Is disagreement on a major issue such as DPC considered (a) an attack and (b) a reason not to participate here on KMD?

        I can’t speak for Lisa, but as someone who is skeptical myself about DPC but who sincerely wants to try to understand it, I will say this about Dr Umbehr’s posts: I find the almost evangelical uber enthusiastic tone of his posts about DPC a bit offputting. He presents that model as if it is THE big magic answer to all of our problems in the US healthcare system. Initially, he enthusiastically responded to my questions with what sounded like hard sell sales pitch talking points. Once he realized I wouldn’t be an easy convert, he stopped responding to my comments and answering my questions about DPC completely. I guess I was considered a waste of his time.

        All of the comments to Dr Umbehr’s posts here about the DPC model have been respectful even when they are disagreeing with him. In general, preaching to the choir sometimes feels good but accomplishes little. The better discussions include tough questions and different points of view. From Dr Umbehr’s perspective, if he wants his model to spread more widely in the US, I would think it would be useful to him to get a good grip on the reasons that some people are resistant.

      • Dr. Josh, AtlasMD

        I’m not perfect? Have you been talking to Mrs Josh? :)

        We work with our patients all of the time and have many scholarship patients that we either don’t charge or we allow to receive care despite their overdue balance.

    • Dr. Josh, AtlasMD

      The problem is that the gov’t rarely makes thing more affordable b/c they don’t “innovate” the same way the market does.

      The Massachusetts healthcare system is also called their 2nd “big dig” http://costprojections.cancer.gov/expenditures.html b/c of the extreme costs and problems.

      Where as the market allows for a greater number of trials/experiments to find more effective systems.

  • ninguem

    Maybe one advantage of the high-deductible insurance is to re-price the grossly overpriced “cash” rates of the hospitals and big box places, to the insurance fee schedule (assuming participating), which is at least a step in the right direction.

    There may be some advantage to the independent docs, who charge “X” for their services.

    The big box places tack on facilities fees, and all too often charge “2X” for the same service.

    People may pay attention…….finally.

    • Dr. Josh, AtlasMD

      We are able to be much more transparent with our prices b/c we are not a giant system with numerous competing contracted prices with gov’t and private insurance.

      Its exciting to be able to help patients get great care that is affordable but without the restrictions of red tape.

      • ninguem

        rock on josh

        That “2X” thing really does seem to be a constant.

        I’ve seen that 2 – 1 ratio (price of hospital-owned clinics vs price of independent clinics, for the exact same service)….that same ratio reported in newspapers on the East and West Coasts, in the Wall Street Journal, and on NPR. And in my local papers on the left coast.

        And…….maybe more relevant, at least to me, I have seen the same thing with my own healthcare, when one of my kids needed healthcare from a pediatrician who USED TO BE independent, now is a hospital-owned practice.

        Same office, same carpets, same furniture, same personnel, same doctors, the only thing that changed with the sign, stationery, and business structure.

        Sure enough, the fee doubled. Even with insurance repricing, it was reflected in higher out-of-pocket cost for my insurance, the same plan I’ve had for about five years.

        In fact, I wonder if the independent clinics, yours, mine, even with different business structures, the common link is INDEPENDENT…….maybe we should be advertising this somehow.

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

          Yes, you should, because that’s exactly the keyword that needs to be stressed, and not all cash practices are INDEPENDENT…
          I just saw a website of an organization like that in NYC http://www.idny.org/ I didn’t research it fully, but I absolutely love the concept.

          • Dr. Josh, AtlasMD

            I’d say the majority of cash prices are independent except for MDVIP

        • Dr. Josh, AtlasMD

          We are trying to help independent direct care doctors advertise by launching a website http://www.iwantdirectcare.com to help connect doctors and pateints.

      • Patient Kit

        What would you say the dominant demographics of your current patient panel are? For example, is it mostly relatively healthy young families? Or have a lot of older former Medicare patients switched from using their Medicare insurance to paying you directly instead? Have you kept many patients who do have serious medical conditions? If so, are they in a high enough economic class to afford both good insurance and DPC? What do you do when one of your previously healthy patients suddenly has cancer and they don’t have insurance to cover specialists because all they thought they needed was one good family doc for almost everything?

        I’m trying to understand who the DPC model works best for.

    • Patient Kit

      Did you see the article on MedPage Today today (June 19, link in today’s Top News in Health and Medicine above) about Pennsylvania’s biggest health insurance plan challenging the higher cost of care at hospitals vs private practice?. Chemo went from $5,000 to $16,000 when the private oncology practice was bought out by a hospital . For the exact same treatment. Same doctor, same drug. And the insurance co is balking. I see it as a power struggle between greedy insurance co and greedy corp hospital system with the suffering cancer patient caught in the middle. I see it as a good example of just how obscene our profit-driven big business model healthcare system is. But it will be interesting to see whether more insurance companies start refusing to pay so much more for the exact same treatment, just because it is hospital-owned/based treatment.

    • Patient Kit

      Did you see the article on MedPage Today today (June 19, link in today’s Top News in Health and Medicine above) about Pennsylvania’s biggest health insurance plan challenging the higher cost of care at hospitals vs private practice?. Chemo went from $5,000 to $16,000 when the private oncology practice was bought out by a hospital . For the exact same treatment. Same doctor, same drug. And the insurance co is balking. I see it as a power struggle between greedy insurance co and greedy corp hospital system with the suffering cancer patient caught in the middle. I see it as a good example of just how obscene our profit-driven big business model healthcare system is. But it will be interesting to see whether more insurance companies start refusing to pay so much more for the exact same treatment, just because it is hospital-owned/based treatment.

      • Dr. Josh, AtlasMD

        and i’ll be the first to say that’s ridiculous if its flagrant.

        The problem is that we don’t know the math…was the $5k losing money? then maybe they had to move the price up to sustain the hospital. Fine.

        If the $16k was a reckless attempt to increase profit over a profitable $5k fee…then people should leave that hospital and find a better provider.

        • Dr. Josh, AtlasMD

          Did you know medicare often reimburses LESS than the cost to provide care for hip replacement and cancer?

          • Dr. Josh, AtlasMD
          • Patient Kit

            If that is true — and I do not doubt you on this — then I would say we should increase the reimbursement rates from Medicare (and Medicaid) rather than eliminate those programs.

            I don’t know how true this is but I know I read somewhere (reputable) that many insurance plans reimburse at the exact same rate for a hysterectomy regardless of how it is done (open, laproscopic or DaVinci robot-assisted). Mine was done roboticlly and paid for by Medicaid. If I still had the Blue Cross plan I had for 20 years before this hellish year down the rabbit hole, I would have received many trees worth of statements containing clues about the math of the transaction. But because this surgery was covered by Medicaid, I get zero info. But I can only imagine. But I credit Medicaid for saving my life along with a great teaching hospital and my awesome GYN ONC.

            The good news is that I’ve survived this cancer catastrophe and am about to jump back into being a productive member of society again, as I have always been before this little one-year break. Look for further reports from me from the patient front as I get back to work with no clue about how or if I will be able to access medical care going forward. But as you may be able to tell, I have a lot of fight in me. I don’t fall through cracks quietly.

          • Dr. Josh, AtlasMD

            Yes, the article i referenced would agree with you. Private insurance would be 10% cheaper if they din’t have to cover the cost shifting from medicare/medicaid.

            I’m not familiar with medicare reimbursement for surgery to answer with any authority on payment like that. Sorry.

        • Patient Kit

          Agreed that there is more to find out about this. And I’m a big believer in knowledge is power. That’s why we all need to pay attention to — and try to understand — what is going on. But by anyone’s POV, a jump from $5,000 to $16,000 for the same thing seems excessive. I just keep hearing so much here about hospitals tacking facility fees onto everything that I imagine that has to be part of this..I understand that hospitals severely inflate the price of many things to offset their losses from other things. But they’ve also been getting away with charging so much more for a long time and it has escalated. In my experience, people sometimes do things because they can get away with it. And the lack of transparency in healthcare pricing has been fertile ground for creative accounting. It can only help to shine a light on it and ask questions. $5,000 one week and $16,000 the next for the exact same thing, at the very least, needs to be somehow justified. If they can justify it.

          • Dr. Josh, AtlasMD

            I suspect that the fee increase has more to do with profit margins than corrected cost shifting, but i don’t want to jump to conclusions.

          • Dr. Josh, AtlasMD

            I also don’t think they are happy inflating these prices….they lose a lot of money all over the system b/c of these inefficiencies so they up charge in other areas. Its a giant shell game!! ugh!

            But you don’t see this kind of cost shifting in markets that are free and open.

            I’d be on your side here, i want to see a stop to unnecessary confusion, pricing secrecy, etc.

  • Anne-Marie

    High-deductible health plans were introduced long before the ACA, and they have proved very popular with employers, i.e., the much-vaunted private sector, looking to save $$ on the cost of providing health insurance to their workforce. I don’t think this is really about politics; it’s much more about economics.

    • Dr. Josh, AtlasMD

      Agreed, and we’re able to work with employers to provide better care, more access, lower prices for heatlhcare, lower prices on insurance premiums AND often a raise for the employees.

      The economics of such is a win win for all.

  • Patient Kit

    I agree that the ER is the worst place to go for unemergent primary care. I also agree that high-deductible insurance keeps healthcare unaffordable and inaccessible for many people. I just don’t agree that direct pay primary care is the magic answer.

    For starters, I think you seriously underestimate how many people are living long lives with serious conditions. Thanks to the wonders of modern medicine, many people are surviving and living with cancer, heart disease, stroke, major injuries, serious pulmonary conditions, HIV, MS, Parkinson’s, diabetes and it’s many complications and other serious chronic conditions that are best treated and monitored by specialists.

    You say we are very rare. I respectfully disagree. I don’t think we are rare at all. I think we are actually pretty common. And, for us, DPC is an extra expense on top of the expense of absolutely necessary insurance — and not just catastrophic insurance. We need insurance that will, for example, cover seeing an oncologist 4x a year along with lab tests and imaging even if we, for now, don’t need further surgery or chemo. Is the specialist monitoring considered to be catastrophic care? Or only surgery and chemo?

    I just don’t agree that a family practice doc can handle 80% of what many people need treatment for. The little stuff like colds, flus, sore throats, earaches, minor injuries — I usually don’t need a doctor for those kind of things. Those things are easily self-treatable unless they go on too long.

    Most people do not need to see a doctor if they have a cold or flu. We could save a lot of money in the healthcare budget if people would just stop going to doctors for unnecessary antibiotics.

    My biggest issue with your proposal that DPC can be a big solution for most people is your serious underestimation of how many people are surviving and living with serious medical conditions.

    • Barry Lowe

      Patient Kit, even if you’re right about these points, which you might be, you gotta source some data to back up your claims. Otherwise your opinions are like armpits: everyone has a couple, and they both stink.

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

        Below are some sources for numbers. The point I think is that if you need specialty care on a regular basis, and if furthermore you are forced by your plan to obtain a referral from your assigned PCP, and if you cannot pay for all your care out of pocket without it even counting towards your deductible, so if you need surgery or some other expensive procedure, you still have to run out your high-deductible, then DPC is not the best financial choice for you.
        And if I may add, neither is high-deductible, bare bones junk insurance sold on the exchanges. Medicare, and even Medicaid in some locales, are better for people with serious chronic conditions.

        DPC is a good solution for some people some of the time. Maybe lots of people, but certainly not all people. There is nothing wrong with that. It’s actually refreshing to have any kind of solution in health care today….

        1) “Approximately 7 of 10 (and 95% of the elderly) people in US health plans see one or more specialists in a year.”
        Starfield, B., Chang, H. Y., Lemke, K. W., & Weiner, J. P. (2009). Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences. The Journal of ambulatory care management, 32(3), 216-225.

        2) “…51% of physician office visits in 2013 were with specialists”
        Lowes, R., “Specialist Office Visits Outpaced Primary Care in 2013″, Medscape Multispecialty, May 7 2014.

        3) “In 2012, among civilian, noninstitutionalized US adults, approximately half (49.8%, 117 million) had at least 1 of 10 selected chronic conditions. More specifically, 24.3% had 1 chronic condition, 13.8% had 2 conditions, and 11.7% had 3 or more conditions”
        Ward BW, Schiller JS, Goodman RA. Multiple Chronic Conditions Among US Adults: A 2012 Update. Prev Chronic Dis 2014;11:130389

        • Patient Kit

          Margalit, thanks very much for the back up data on the prevalence of Americans surviving and/or living with serious/chronic conditions who need access to specialists for medical care. I’m frequently posting here from my phone while on mass transit or in a waiting room. My phone is smart but there is only so much I can do on it in the subway.

          I didn’t think there was much dispute in the medical community that many people are now living long with disease that, in the past, killed people quickly. I think that reality has to be seriously considered when suggesting healthcare delivery solutions. It was definitely cheaper when people died quickly of diseases like cancer — cheaper but not preferable.

        • Mike Henderson

          The numbers of visits provided by specialists seems to be correct, and for the sake of my arguments, will assume they are. What the numbers don’t show is why there are so many referrals. Anything that takes slightly more time is referred to a specialist to keep the PCP’s volume up. PCP’s are practicing production line medicine and are not practicing to the full extent of our training. The current insurance model rewards mediocre, expensive care – not providing effective, coordinated care that patients need. Patients need time, which is very difficult to provide.

          When in residency in a specialist rotation, would see many patients that the PCP could have handled, but referred to the specialist for what I considered to be trivial reasons. Now that I am out, I realize the necessity of not doing anything for patients that takes extra time.

          In my current work performing consultative exams, I just saw a person who had a stroke, with comorbid conditions of diabetes and hyperlipidemia. Even though it has been several months since the stroke, the diabetes and blood pressure are still not controlled. The blood pressure today wasn’t even close to being controlled, which I did inform them. This example is par for the course. The PCP is being hampered/overloaded by the current system – there simply aren’t enough PCP’s in this area. I see this frequently – patients aren’t getting the care they need due to the adverse environment we practice in. This is why those of us that support DPC are so supportive.

          Perhaps where we are off is the focus on the business aspect of DPC. To me that is the tail wagging the dog. The current system is personally unethical, and I will do whatever I can to avoid it. DPC allows me to work for the patient and do what I am trained to do. That is why I went into medicine. Working in the best interest of insurance companies or Medicare/Medicaid simply isn’t that interesting and not worth the ever increasing unrealistic demands from those who don’t understand the actual delivery of healthcare.

    • Mike Henderson

      Here is my opinion on DPC. DPC is about restoring a healthy patient doctor relationship. It is about physicians being able to provide patients the healthcare services they need – not inappropriate care, under care or overutilization the current system promotes. It is about getting rid of the perverse influences of the insurance industry. It is about making insurance actually function like insurance, not pre-paid medical services/insurance.

      Most health service people need can be provided by family practice or internal medicine physicians. Whether it’s 80%, who knows. Currently, specialists are providing primary care and are also practicing below their training. Many countries have 70% PCP’s, whereas we have 70% specialists – I am unaware of any country that has as many specialists as we do. This gives the public the misperception that they need a specialist when they really don’t.

      I think the biggest difficulty patients have is seeing how things could be different. Working and seeing how the system operates from behind the scenes gives physicians a very different perspective than what patients see. This is difficult to overcome. If you could see what we see, you would understand how much more streamlined and effective healthcare could be. From your current perspective, DPC costs would be additional to your current high expenses and therefore unaffordable. From my perspective, change would be iterative and in the future, your costs would go down and quality go up.

      To demonstrate here is an example about exercise. Lets say you are deconditioned and want to start exercising. The risk of a heart attack goes up many times compared to when at rest during exercise. However, if exercising appropriately OVER TIME, your overall risk goes down significantly – its worth the cost. We are currently painted into a corner and the solution isn’t going to be instantaneous – it will have to be a back and forth process, which I see DPC being a central mechanism. There is a difference between your acute risk and long term risk. The understanding I am trying to get across is that by paying a little more for primary care, overall healthcare costs go down significantly in the future. What you are correctly concerned about is the change process – how do we avoid harming people in the meantime.

      • Dr. Josh, AtlasMD

        Very well said, you definitely have a firm grasp of the DPC model. Thanks

      • Patient Kit

        As a gym rat who is addicted to lap swimming, I appreciate your exercise analogy. It does help me see how gradual change can add up to something good in the future. I think most of us here agree that our healthcare system needs to be changed, although I’m still not convinced about widespread DPC or that primary care can do most of what specialists do now just as well. But whatever change our system is headed toward — and I think both single payer and DPC will be equally hard to sell to the American people — I am very very concerned about how people with serious illness now may get hurt during the change process. Nevertheless, even though I am one of those patients, I agree that we do need change. It’s a very scary time to be seriously ill in this country. Terrified or not, that doesn’t mean we should hang onto the devil we know. But as we change, we all need to be questioning agendas and anticipating unintended consequences. After this thread, I might have to swim an extra mile today. I love the YMCA and ocean parts of my personal health plan. When I’m this stressed out, there is nothing better than a good swim in the ocean for me.

        • Dr. Josh, AtlasMD

          I am a fan of the gym analogy. Do you pay to swim by the lap? do you pay more to exercise on weekends? Is there another price if you chose to use machines? Typically a gym is a flat price for service or levels of service.

          I think a key problem with the ACA is that it tries to do too much at once. A one size fits all for the whole health care industry.

          It would be much easier for the gov’t to take smaller, focused approaches. Create high risk pools, develop incentives and tax breaks.

          But for the majority of care that most people need, DPC will be able to help.

          • Patient Kit

            That’s a fair question. And no, thankfully, I don’t pay my Y membership by the lap. Since I swim 36+ laps a day, at least 5 days a week, that would get expensive. I do pay a flat $60 a month for unlimited pool, equipment and classes. And I use it a lot for swimming, weight room, cardio and some yoga classes. There are a few classes that cost extra like synchronized swimming or swimming lessons. At my rate of use, that translates to about $3 a visit and well worth it. Gyms make a lot of their money signing up a lot of members who have good intentions but end up using the facility rarely. I do feel like a gym membership is well worth it. This is the first year ever that I literally couldn’t afford it since my layoff and ovarian cancer dx. So, a good friend paid for my membership this year because she knows it is a lifeline for me. Good friends are priceless and I will do the same for someone else once I’m back on my feet financially.

            If I got as much from my primary care doc as I get from my gym, I might be able to see the value better. Maybe part of the problem in imagining your vision is that many of us have never experienced really good primary care, while we have experienced excellent specialist care.

            I do agree that the same thing is not going to work for everyone.

          • Dr. Josh, AtlasMD

            so maybe we’re getting closer?

            Not everyone goes to gym like you do, and thats ok. And not everyone needs as much from a DPC doc, and thats ok.

            But if some one saved $300 per year in the cost of normal labs (CBC, CMP, Lipids, TSH, Vitamin D), and never had another copay, and had unlimited visits, and saved $15/mo on medicines…then it they would pay $600/yr and save $600 year, effectively costing them $0. Any additional savings continue to improve the value.

            But if you’re willing to pay $2/day for your gym, then its a reasonable statement that paying $1.65/day for a DPC provider.

            Wouldn’t you agree that is fair?

          • Patient Kit

            LOL! If by “getting closer” you mean me getting closer to agreeing with you, maybe we should just settle for the minor miracle that we are actually still talking to each other.

            I couldn’t quite follow your math on what a DPC membership would cost or not cost me. ($600 – $600 = 0?) But it still would represent an extra expense on top of the cost of insurance because I am definitely not interested in catastrophic insurance that only covers events like a car crash or the house burning down (not that I own either a car or a house).

            I want insurance to continue to cover much more than medical catastrophes, not only because I know I already need to see specialists and have more complex labs done and a certain amount of imaging, all of which, as I understand it, would not be covered by low premium/high deductible insurance, but I would want to be covered that way even if I didn’t already have cancer — in case I developed cancer or another serious illness in the future. I’ve just seen to many people believe they didn’t need much coverage because they were young and healthy until suddenly they were unexpectedly seriously ill or injured — and not covered.

            Nobody wants to believe it could happen to them. But it can and does. One thing we all have in common as humans with vulnerable bodies is that any one of us can suddenly be very sick. To me,insurance should cover that possibility. I’m not comfortable with insurance that defines catastrophe narrowly as surgery or hospitalization. Where do all the outpatient procedures fall in the language of catastrophe? Is it still a catastrophe if you weren’t admitted to the hospital?

            And that kind of more inclusive insurance would also already cover primary care. Insurance companies tend to want us to have primary care docs. So DPC would be an additional cost. (Ironiclly, I don’t like all-inclusive resorts for vacations, back when I could afford vacations, once upon a time a few years ago.)

            The only thing that appeals to me about DPC is more time with my doc and a better primary care doctor patient relationship. That part I get and if I had the money to do both, I would. But given a choice, I’d rather have insurance that covers more than the house burning down. Because there is a lot between surgery and basic primary care that I don’t want to have to pay for out of pocket.

            If you feel like I’m not getting it, I feel like you’re not understanding me either. But at least we’re not calling each other names. That’s something.

          • Dr. Josh, AtlasMD

            $600 may be an additional cost, but then we can save you $600 or more.

            Your gym is an additional cost, but you’re ok with that.

            A DPC doc is less than the cost of your gym per day.

            If a DPC model saves you by making medicines, labs, office visits, consults, imaging, procedures cheaper, then its reasonably worth it.

            If you have migraines and need imitrex, then the generic is $83-256 depending on the pharmacy. My price is $7 by going wholesale. $7 for medicines + $50 for membership and you’re still saving money.

            so its no longer an addtional expense?

            fair enough?

          • Patient Kit

            You don’t give up easily, I’ll give you that. Sorry to say that I still have some issues:

            (1) I don’t understand how you can effect the price and scope of insurance that people get via their employers. Wouldn’t you have to have all of an employer’s employees signed on as members to do that? Or, at least, the vast majority? I know that I would be mighty pissed off if you somehow talked my employer into switching my plan to catastrophic unless that’s what I wanted. How do you go about negotiating a change of insurance plans for a whole workforce? Do employees have a vote? Or is it a top down decision made unilaterally by the employer after being sold on the idea by you with no input from their employees?

            (2). I also don’t really understand the inexpensive prescription drug thing Do all doctors have access to buying hundreds of different drugs wholesale cheaply enough that they can sell them to their patients for $7 instead of the retail pharmacy price of $250? If all doctors do have access to buying drugs that way, why don’t more do that?

            (3) I think I might have an easier time considering this kind of DPC arrangement if I already knew, loved & trusted the doctor. Signing up for this kind of thing with a doctor I was meeting for the first time, I’m not so sure about. Is there any longterm commitment involved in signing on? Or is it a month-to-month deal that patients can get out of at any point if they don’t, um, like you?

            I swear that I have lots of spontaneous bones in my body and I’ve done some pretty crazy things on a whim. But healthcare I take very seriously.

          • Dr. Josh, AtlasMD

            i’ve been accused of being stubborn once or twice ;-)

          • Dr. Josh, AtlasMD

            well i’m happy to go through each question you have. even if we don’t have the same vision for the healthcare system, at least i can help to answer your questions, concerns.

          • Patient Kit

            Sorry for the delay in getting back to you. I got sidetracked by Dr Grumet’s post and it’s comments thread, drawn in by the raised fist illustration. ;-)

            I think it’s apparent that you and I will never see eye-to-eye on many things, including DPC. I simply do not worship or trust the free market the way you do. And you think my activist approach to working for change is thuggish.

            While you haven’t convinced me that DPC is the way to go in any widespread way, I can see how it could work as a niche model. I do think it’s amazing that you are trying this straight out of residency with all new patients. If it works for you and your particular patients, I hope you succeed.

            I hope you don’t feel like you’ve wasted your time answering my questions just because you haven’t converted me. Many people read this blog who don’t participate. I hope my questions and your answers are useful to the many readers who don’t comment. I’m sorry if I’ve been a little tough on you, grilling you with my detailed questions. My journalist/researcher mind has to explore all the angles, ask the tough questions and attempt to get the full picture. I’ve never been able to re-write the press release and call it news. I always want to hear both sides of the story and ferret out what’s not being said (on both sides). I may be tough in my questions but I always strive to be fair and keep an open mind. I hope you know that the goal of my questions was to sincerely get a better understanding of DPC, not to hassle you for fun. ;-)

            I t

          • Dr. Josh, AtlasMD

            1) we never require any employees to change their doctors. We don’t require a “minimum participation” like an insurance company does.

            Your insurance premiums change each year based on your experience rating. http://www.ehow.com/info_8048695_experience-rating-health-insurance.html

            the more claims you make by seeing the doctor, getting labs, getting medicines, all means more filing, billing, claims etc. That causes the insurance to increase. Bc they assume the risk is going up if more people are dx with hypertension. right or wrong thats how it works.

            b/c we don’t file with the insurance, they don’t see every visit as affecting your experience rating…

            but also we manage their risk better b/c they aren’t paying for visits, labs, meds and the paperwork.

            Pts and their employers are paying for the care, directly, which cuts out the middle man and saves money.

            If an employee wants to stay with their current doctor, they can. It just might mean they have more of an experience rating.

          • Dr. Josh, AtlasMD

            2) wholesale medication. Its legal in 44 states for physicians to dispense medications out of their office, most just don’t do it b/c they have too many patients and would go through insurance, so that would mean they’d have to do all of the paperwork, prior authorizations, etc etc etc. painful.

            http://aaucm.org/Professionals/MedicalClinicalNews/DispensingRegulations/default.aspx

            And there’s a number of wholesale providers.

            an example of our medication prices can be seen on our blog. http://atlas.md/blog/2013/06/you-cant-beat-our-prices-at-atlasmd/

            why don’t all docs do this? EXACTLY! ;-)

            i may be a business man but i’m a physician first and i take pride in both. Which means as a good physician, i want a run a good business that helps people be healthy and save money, a perfect combo.

            shouldn’t every doctor be working that hard to help their patients?

          • Dr. Josh, AtlasMD

            3) Trust – you nailed it, its all about trust. a great book, the speed of trust, is all about that.

            http://www.myspeedoftrust.com/

            which is why it was so hard to start a practice like this straight out of residency with zero patients to start with :)

            So we’ve had to work very hard to educate patients about how this can work for them.

            One way we help gain that trust is by being 100% transparent. Flat fee, based on age, always predictable, no hidden costs, no mark ups on labs or meds. Under promise and over deliver.

            we even do free visits from patients who need to meet us first and see if its a fit. I dont’ know other docs who do that.

            No contracts at all. month to month. I hate contracts.

            its all designed around building trust ;-)

          • Dr. Josh, AtlasMD

            i hope that helps some

    • Dr. Josh, AtlasMD

      Here is a list of the 100 most common diagnosis:

      http://sagemb.com/info-resources/medical-billing-reference/95-100-most-common-diagnosis

      The cost of all cancer care is only 5.6% of our systems healthcare spending.

      Your logical fallacy is know as “hasty generalization”

  • HJ

    He trying to change the landscape of medicine by using exaggerated claims to make his point.

    • Dr. Josh, AtlasMD

      Which is?

  • Arby

    My debt is called high deductible + COBRA, and I’ll be paying it off for a long time.

    • Dr. Josh, AtlasMD

      Sorry to hear that. We’re trying to make it all more affordable.

  • Dr. Josh, AtlasMD

    Judging from his medications, he’s talking about GERD and/or Barretts Esophageal Cancer….both of which I treat regularly.

    • HJ

      “In Barrett’s esophagus, the tissue lining the lower esophagus changes. These changes are associated with an increased risk of esophageal cancer. The risk of cancer is low, but your doctor will likely recommend regular endoscopy exams to look for early warning signs of esophageal cancer.”

      If you don’t do the EGD, you don’t fully treat Barrett’s esophagus.

      I have very mild GERD and do not feel that spending $900 to save a few dollars on medication is worth it, especially since I can get “free” advice from my doctor because my insurance pays for an annual physical.

      • Dr. Josh, AtlasMD

        Sorry Sir, but that is a straw man argument.

        EGD is a test, it is not the treatment and management of an illness. Just like i might order repeat xrays, ultrasounds, CTs, MRIs, or labs to follow a patients illness…I can order an EGD.

        And then with that information, I manage the course of their care.

        You don’t get “free” care b/c you’re paying for that through your insurance. And paying too much for insurance in most cases.

        Save a few dollars? We decrease the costs of medicine and labs by up to 95%. We also are able to decrease the cost of insurance premiums by 30-60%.

        • HJ

          I assumed that treatment includes gathering information and making recommendations.

          You recommend your patients use their insurance for vaccines.

          Preventive care is a requirement for all health care plans. Are you recommending people pay the penalty and forgo insurance to participate in your health care plan? I can’t get a plan without a “free” physical.

          • Dr. Josh, AtlasMD

            yes we recommend that patients use their insurance to pay for vaccines when appropriate. Since that is a benefit of their insurance and vaccines are very expensive.

          • HJ

            So I use my “free” physical and this is a bad thing because it makes my insurance more expensive but it is OK that I use my insurance for vaccines?

    • Patient Kit

      You feel that family practice docs are qualified to treat esophageal cancer? I wouldn’t be comfortable with that. By the same token, I want my GYN oncologist monitoring me for recurrence of ovarian cancer — not my primary care doc. When would you feel like you need to refer your patients to an oncologist?

      • Dr. Josh, AtlasMD

        I’m sorry that you’re ignorant to the training that Family Physicians have and what we are capable of.

        • EmilyAnon

          Both Patient Kit and I have ovarian cancer. I think what is confusing to us in this conversation is that every cancer site such as ACS, NCI and others emphatically state that ovarian cancer requires a gynecological oncologist for best results. Not a general surgeon, not an ob/gyn, and presumably not a PCP. I don’t have to tell you that this is a deadly cancer with recurrence for late stage almost a certainty. Do you really not understand why we take this concensus from the medical community of specialist care so seriously.

          • Dr. Josh, AtlasMD

            You both continue to use a strawman argument that b/c a FP isn’t a gyn onc surgeon, that its not a viable solution to the care that most people need.

            No one is suggesting that specialists are necessary in some cases. But the primary care specialties of IM, FP, Peds etc are the most numerous physicians and thus care for the msot patients. We are trying to fix as much of what we see in our office as we can.

            https://www.aamc.org/download/313228/data/2012physicianspecialtydatabook.pdf

            Approximately 22,000 women will get ovarian cancer in 2014, http://www.ovariancancer.org/about/statistics/

            Not an insignificant # but small relative to the 55% of nearly 1 billion office visits per year.
            http://www.cdc.gov/nchs/fastats/physician_visits.htm

            Do you really not see the difference b/w working on 550 million office visits to make care affordable?

            I can only hope that a gyn onc physician would work as hard as we do to make onc care as affordable. But thats up to them.

          • Patient Kit

            Hi Emily. I agree with you. As you said, after being told that, for best outcomes, we need a GYN oncologist, not a general surgeon and not a regular OB/GYN, it’s hard for me to believe that family med docs should do most of what specialists are currently doing. And I would feel the same way if I had a different serious illness.

            Are we supposed to suddenly believe that years of specialty residency training and the experience of treating many patients with a specific serious disease means nothing? And that primary care docs, who do not have that extra training and who have treated that disease rarely would be just as good at it?

            Whether this is a territory fight between primary care and specialist docs or a way to make the system overall less expensive, it doesn’t sound like it’s in the best interest of patients who are dealing with serious illness like cancer (or numerous other serious
            conditions).

            Also, if we are so rare, why do some primary care
            docs want to take us back from specialists so much?

          • EmilyAnon

            Interestingly, I didn’t meet my gyn/onc until after my surgery. In fact I had never even heard of the specialty, let alone the importance that they do the initial debulking. Short story: I discovered I had a problem after a rush visit to the ER due to severe abdominal pain. A scan showed a ‘mass’ on one of my ovaries. I asked what do I do now, and was directed to see my gyn. After viewing the scans, and concerned by the CA 125 results, the gyn suggested a biopsy, and if the pathlogy was cancer, a complete hysterectomy. I agreed. At that time I thought the gyn was going to do the surgery. Laparoscopy if benign, open if cancer. When I awoke after surgery, and saw the 9 inch incision down my belly, I knew I had cancer. It was on that day that I learned a gyn/onc had been brought in to do the surgery, with my gyn assisting.

            I saw my PCP just before my surgery date to fill him in on what was happening. I never got the feeling he was disappointed not to see me first, but don’t know for sure. I’m still with the same PCP and trust him completely. I didn’t deliberately choose my path in deaing with this cancer. In my naiveté and panic I didn’t know what else to do so I just followed the guidance from ER docs to gyn to surgeon. All in 9 days time. Now that I’m sort of healthcare ‘savvy’, I think I can be more emotionally calm should another health crisis come my way, and hopefully be included in any choices and plans for recovery, with all my doctors involved.

          • Dr. Josh, AtlasMD

            I’m sure your doctor didn’t mind that he didn’t see you first.

            Often the case with ovarian cancer is that there is not a lot of symptoms until it is progressed. So rapid action by the surgical team makes sense. But having follow up with a doctor who has time to answer questions (a DPC FP) is valuable too.

            Similar to the book Think Fast Think Slow, i view medicine as a happy balance of act fast and act slow. Benefits to both strategies at times.

          • Dr. Josh, AtlasMD

            “panic” — That might be one reason where a DPC doc who’s available as you’re driving home from the ER with questions.

            The best doctor in the world still can’t help you if you can’t reach them. But a FP you trust that is available can help you navigate the waters.

          • EmilyAnon

            I agree with you there. I will have a better handle with my next health crisis. Just curious, are you ever grilled by your own patients like here? I think you’re a good sport for sparring with us.

          • Dr. Josh, AtlasMD

            :) never! but then again, i can see how there would be an element of selection bias b/c people who like the idea are more likely to sign up.

            But more so, we’re able to help people with a specific problem; like paying too much for medicine, then they see our price/savings, and they can apply it directly to their needs.

            I can’t directly help you guys the same way, so i respect that its harder to see the value….if that makes sense…

          • Dr. Josh, AtlasMD

            thanks for sticking it out with me too :)

          • Dr. Josh, AtlasMD

            If i’m not communicating well, then let me try again.

            I’m not saying your FP/DPC will replace your gyn onc. I’m saying that your FP (DPC or otherwise) is a helpful part of any medical team.

            Typically, the more specific the specialty, the less time they have to focus on questions, concerns not directly related to their field.

            So your gyn onc will be ideal for questions about surgery, radiation, chemo, etc. But they may not have time to discuss depression, anxiety, labs, nausea from chemo, or cholesterol.

            Does that help?

        • Patient Kit

          If I’m so ignorant, please do enlighten me. How many years of residency did you spend in oncology that makes you a better choice doctor than an oncologist and gastroenterologist for a patient suffering with esophogeal cancer?

          I agree that primary care docs can do more than many are currently doing. But you seem to be saying that you can do most of what many specialists do even though you don’t have their further specialized training and experience.

  • Dr. Josh, AtlasMD

    Hi Gina, there’s a new website, http://www.DPCunited.org that is compiling a list, and so is http://conciergemedicinenews.wordpress.com/

    We have a website, http://www.iwantdirectcare.com to help doctors and patients find each other.

  • Dr. Josh, AtlasMD

    btw a direct care practice that has cash discounts in combination with a co-op like Samaritans is an excellent solution

  • Patient Kit

    This thread has been a bit of a wake up call for me. I now realize that I have a real tendency to trust doctors too easily and to assume doctors are on my side. I now realize that doctors are not necessarily on my side. Thank you Dr Umbehr for that wake up call.

    • Dr. Josh, AtlasMD

      That seems pretty unreasonable since all my articles are about how to improve patient care. We can agree to disagree with out name calling.

      • Patient Kit

        You’ve called me ignorant and a thug in this thread. I haven’t called you any names, not even in the deleted comment above. All I said in that comment is that I now realize that I have been trusting doctors and assuming they are on my side too easily.

  • Dr. Josh, AtlasMD

    I disagree with that. Often we’re able to help patients save hundreds per month by going to a major medical plan. We’ve saved some families as much as $1000 per month on their insurance. So they can use that money to fund an HSA account.

    The rules of an HSA account are that you can’t raise your deductible over $5k unless you have at least 5k in your HSA. This prevents people from taking on too much risk.

    But since a small % of patients reach their deductible each year, that means they have an opportunity to save money year after year.

  • Dr. Josh, AtlasMD

    Another point to consider is that the ACA plans are in fact, high deductible plans.

    here’s a great video showing the average costs https://www.youtube.com/watch?v=1TwksBrTun8&feature=youtu.be

    But for a bronze plan, you’re looking at $6800 OOP for an individual and $12,700 OOP for a family and then most ACA plans have a co-insurance of 60/40 after your deductible, meaning they only pay 40%….. http://www.cigna.com/individuals-families/understanding-health-care-reform-metal-levels

  • Dr. Josh, AtlasMD

    Regardless of the deductible though, we need to make every day care as affordable as possible.

  • Dr. Josh, AtlasMD

    if you consider DPC to be “bundled rates” which I can see how that would be a good description, then yes.

    Your $10-100 membership per month includes unlimited visits, no copays, all office procedures for free and wholesale prices on meds/labs for up to 95% savings. All bundled in one payment.

  • Dr. Josh, AtlasMD

    Will that value, we’re able to help businesses lower their premiums by 30-60%

  • Dr. Josh, AtlasMD

    I agree that the lower the cost, the lower the barrier to care. But cost is only one barrier. Having providers who are available to care for you when you need them is important too.

    We feel that the direct care model helps solve both of those problems.

    For as little as $10/mo for kids, you can have unlimited 24/7 access, no copays, free procedures and wholesale meds/labs that are up to 95% off.

  • dontdoitagain

    We used to be able to get a good deal with buying a high deductable plan. Now we pay enormous premiums for what is a high deductable plan. It’s a win for insurance agencies. That and the idea that if patients don’t pay those enormous deductables “up-front” like drug dealers demand, the insurance company doesn’t have to pay a dime.

    I notice that another business model has sprung up around medical treatment centers. Those would be for the “loans” that you speak of. Financial outlets to loan you money for your deductable, probably at enormous interest, but less than a credit card, so that you can get your insurance company to pay the bill, which is what you give them thousands of dollars per year (or maybe monthly) for. These entities would be considered a “win” for the government as these places need part time, low paid employees to sign up patients. Unemployment goes down. Yet another layer of industry surrounding health care that needs to be paid for. Unbelievable.