Primary care should be paid for directly by the patient

Part of a series.

Primary care need not be expensive and until the past few decades it was paid for out of pocket. Heretical perhaps, but it would be very useful to go back again to paying the PCP out of pocket directly by the patient, preferably with a tax-advantaged health savings account (HSA).

A County Doctor wrote on his blog:

I can freeze a couple of warts in less than a minute and send a bill to a patient’s commercial insurance for much more money than for a fifteen minute visit to change their blood pressure medication.

I can chat briefly with a patient who comes in for a dressing change done by my nurse, quickly make sure the wound and the dressing look okay and charge for an office visit. But I cannot bill anything for spending a half hour on the phone with a distraught patient who just developed terrible side effects from his new medication and whose X-ray results suggest he needs more testing.

In a later blog he wrote:

Health insurance is not like anything else we call insurance; all other insurance products cover the unexpected and not the expected. Most people never collect on their homeowners’ insurance, and most people never total their car. Health insurance, on the other hand, is expected by many to be like a bumper-to-bumper warranty that insulates us from every misfortune or inconvenience by covering everything from the smallest and most mundane to the most catastrophic or esoteric.

What would it look like if Johnny or Fido puts mud prints on the living room wallpaper and Dad makes a claim on his homeowner’s policy? Or if Sally spills chocolate ice cream on the beige upholstery of Mommy’s new car and the auto insurance has to pay to have the seats recovered?

How did we get here? Going back about a hundred years, there was limited call for health insurance. Medical care was relatively inexpensive; hospitalizations were uncommon and it was simply expected that the individual was responsible. Life insurance and especially disability insurance were considered much more valuable and important in the rapidly developing industrial world. Wage and price controls came into effect during World War II. This led unions to push for non-wage benefits such as health insurance and business reciprocated. It was an inexpensive way to be more competitive in the job market. The idea was to insure for the high cost, unexpected health event such as major surgery or hospitalization. The individual still paid for routine care, vaccination, family doctor visits and medications. He was still very much the customer of the primary care physician.

But over time employers (including government employers) — often at the urging of unions and legislators — began to expand coverage to include most of those elements previously paid for directly by the individual. Concurrently, state legislatures established mandates — requirements that had to be covered by any policy sold in that state. Slowly but surely, insurance has morphed from being “insurance” to essentially being pre-paid medical care. Of course premiums had to increase to pay for all for the added benefits. And now employers expect their employees to cover 25 to 33% of the premiums and pay significant deductibles and co-pays.

A decade or more ago, insurers instituted price controls on primary care physicians with the assumption that would help manage rising costs. Wrong.  Price controls meant the PCP had to see increasing numbers of patients to make ends meet as his or her office costs rose. So now the patient gets precious little face time with the PCP — the loss of relationship medicine. And many patients get referred to specialists when the PCP could have handled the issues if there was more time. This has driven up costs dramatically; just the opposite of what the insurer planned.

Think of health care as a one foot long ruler. 75% or the first nine inches represents primary care — which is the care of complex chronic illnesses just as it is care of acute issues and the common and anticipated needs of most of us. The other 25% or the last three inches represents the unexpected, very serious problems — what we might call “major medical” and in a minority of cases the “catastrophic.”

Today insurance purports to pay for all of this when in reality insurance should only be for the major medical and the catastrophic; the last three inches. That’s the whole point of insurance, to deal with the unexpected highly expensive events in life like a car crash or a house fire. Since today’s health insurance covers essentially everything, it is very expensive. A major medical/catastrophic policy on the other hand is not cheap but is much, much less expensive.

Consider a bronze plan with a $6,000 deductible. In Maryland it would cost a 55-year-old $3,660. The platinum plan with no deductible costs $7,728 — more than twice as much. What is the $4,060 difference paying for? Primary care. But primary care never needs to cost that much. It will cost even a lot, lot less than now if the system is turned upside down so that the PCP is paid to deliver high quality in a caring, relationship-based model.  When the PCP has enough time with each patient, he or she can give excellent care, avoid unnecessary referrals to specialists and unneeded prescriptions and do so at a reasonable cost.

Said somewhat differently, it is time to stop tinkering around the edges of the current payment system. It needs to change conceptually and completely to a new paradigm where that the PCP is paid directly by the patient. Direct primary care (membership, retainer, and concierge) is one such new paradigm. The cost is reasonable, the care is better, doctor frustrations come down, patient satisfaction goes up and total health care costs come down. It is time for a change.

Primary care should be paid for directly by the patientStephen 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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  • JPedersenB

    Amen! How do we implement this? (I, also, noticed that medical expenses starting rising dramatically around the time that insurance starting covering everything….)

  • lurking for answers

    “How did we get here?” How did we get to the point where the IRS has jurisdiction over whether my doc’s visit is an “allowable expense” for me to use my HSA?

    • Lisa

      An HSA is a tax preferred account.

      • lurking for answers

        Yes, I know it is pre-tax dollars spent for medical expenses. But the IRS, several health administrators and my accountant have differing opinions as to what the HSA can be used for legally. One says all the “concierge fee” can be paid for by the HSA, one says some of it, one says none of it and yet another says that it depends on each person’s medical needs as backed up by a physician’s letter.

        You can spend the HSA dollars for prescription drugs and condoms, but not OTC meds for treatment or prevention (antihistamines, nasal steroid, omeprazole, etc.) unless the doctor gives you a prescription for said OTC medication. The rules and regulations are so difficult, arbitrary and convoluted that few understand them and much of it depends entirely upon the wishes and whims of the auditor looking into every penny spent.

        • Lisa

          Does the IRS really audit every penny spent? I doubt it based on what I have read; they don’t have the staff to audit many tax returns. I suspect the opinion that really matters who ever administers your HSA.

          • lurking for answers

            The people I have known that have been audited had to account for every mile claimed, every purchase made, and every penny spent. The IRS holds the punitive power to take everything you own plus interest. If my accountant and three other professionals (including the IRS) can’t give me definite answers then mistakes WILL be made on both sides.

          • Lisa

            Quite frankly, I think you are overstating the power of the IRS. Take everything you own? They might disallow a deduction(s) and you would have to pay the additional tax plus interest. But in the case of an HSA account you really are talking about a limited amount of money. I have been audited and have had items on my tax returns questioned. I have prevailed in every instance.

            If those who promote DPC suggest that that they be combined with HSA accounts and high deductible insurance, I think that discriminates against those who are not employed. Also, if the rules for HSA accounts are not clear, then they need to be clarified.

          • lurking for answers

            I’m glad you had good experiences with the IRS. Yes, the rules for HSA accounts need to be clarified.

            There is much that “discriminates” against the unemployed, just as there is/was against the self-employed, but there are many factors involved in that as well as how much is “entitled.”

          • Lisa

            I didn’t even think about the ramifications of self employment.

  • lurking for answers

    Direct pay or “concierge” models seem ideal to manage chronic/complicated diseases. For a flat, yearly fee, I get all the time I need with the doc and I’m not afraid of a copay for a question or medication side effect. The doc gets to spend more time and actually use his education and his intellect to make the patient’s health better. The doctor gets compensation that they are happy with and I get care that satisfies me…win/win.

  • Patient Kit

    Would this version of healthcare — 75% of our care provided by primary care doctors who only accept direct pay from patients — be regulated (!!!) in any way to limit how much DPC doctors could charge for various services? Or would we patients be expected to just blindly trust all doctors when it comes to the financial side of healthcare? Because, news flash! I don’t think the blind trust in doctors that is required to make widespread DPC work is there in the general public.

    What we hear you saying constantly is something like this: Doctors need more money. We’re not making enough money. We have big debts to pay off and lifestyles to maintain. We need to put our kids through anything but med school. We had to work for a measly $50,000 a year (more than many Americans ever make per year) while we were in residency. It was like slave labor. Insurance, Medicare, Medicaid and exchange plans don’t pay us enough. It’s like we’re working for free. We need more money. We want more money. We want cash from patients or — to make it easy for patients who don’t have the cash flow — we’ll accept credit cards (and in some special cases, we might even accept chickens as payment). We want more money but you can trust us to charge you fairly and even to treat you when you can’t afford what we charge. You can trust us. We’re doctors. And we need more money.

    • lurking for answers

      Money is the currency that “modern nations” has agreed to exchange for labor, products and services. Everyone “needs” more money: the minimum wage is too small, they need more money. Teachers don’t get paid enough to teach our kids, they need more money. The playground at the end of the block is falling apart, it needs more money. Health threats like HIV, Ebola, Malaria and Breast Cancer should be cured by now, they need more money.
      People should be paid commensurate to their skills or value, I don’t want my doc to be paid like a cashier or a waiter. I don’t hear resounding complaints about how much plumbers, HVAC technicians or movie stars are paid, but if you look at government reimbursement rates to doctors, the hourly rate is at times far below the level of training and cost of liability that physicians incur.

      Every business has overhead and physicians have a much higher overhead than most businesses due to liability, staffing and malpractice insurance. If you want the best and brightest, you pay for it. If the doctors get to set their fees, you can negotiate with them and pay in chickens if that is agreed upon.

      Where does the “equality” stop? Who decides? Once everything is taken from those who have, and given to those who need, will utopia exist?

      • Patient Kit

        Most “modern nations” other than the US seem to be able to provide healthcare for all of their citizens via a variety of systems. Why can everyone else do it but the US cannot? I’ve never said anywhere that I don’t think doctors should be paid more and I certainly have never equated doctors with cashiers and waiters. I value doctors and what they do very much and think they deserve to be paid fairly. Doctors should be able to collectively bargain for what they agree is fair. The question is who should pay them and how?

        Bottom line for me: I believe very strongly that healthcare should not be a profit-driven business like any other business. I believe healthcare is a human right, not a business. That’s my starting point for discussing all the details of how our system should work. Our healthcare systems needs to stop being, first and foremost, a gigantic profit-driven big business.

        • lurking for answers

          “I value doctors and what they do very much and think they deserve to be paid fairly… healthcare should not be a profit-driven business like any other business.”
          Sooo, a doctor needs to be paid fairly, but not so much as to make a profit????

          • Patient Kit

            Doctors need to be paid either a good salary and benefits if they are employed or they need to be reimbursed fairly by the payer or payers — but not directly by individual patients by whatever the free market dictates. Far too many Americans will be left out of healthcare completely that way. If you persist in looking at healthcare as, first and foremost, a business — well then, you and I are not going to agree on anything. But that, I guess, is the general split in the US right now, between those who want healthcare to remain a business and those of us who don’t.

          • Lisa

            I think you have to differentiate between what a doctor earns as salary (or makes if they are in private practice) and the profits made by for profit hospitals, pharmaceutical companies and insurance companies.

        • Acountrydoctorwrites

          The big businesses here are not physicians, but insurance companies and large health care organizations. That’s where the money is going.

        • Ava Marie Wensko George

          Germany has provided a three fold single payer health system since the 1800s. The financial burden is shared between the German people, businesses, and the government….and it has worked for over 120 years – Even during the time of Hitler.

          • Patient Kit

            That’s what we need in the US.

          • Lisa

            And the people I know from Germany like their medical system.

    • Acountrydoctorwrites

      By letting your insurance company take your premium dollars and dole them out to your doctor according to their own more or less arbitrary rules, while ensuring a tidy profit for themselves, both you and your doctor become pawns in a game that seems rigged against both of you. If your employer gives you that money to pay the doctor, you will have more control over your own health care. Or if doctors didn’t have to carve out $80,000 each just for insurance billing expenses, their fees would be much lower.

  • JR DNR

    I don’t trust doctors. I need to be able to pick up and switch doctors on the fly if I don’t feel comfortable. Even though I’m pretty happy with my current care, there are situations where I might seek out care elsewhere if needed. That’s why I have a PPO. DPC wouldn’t work for me.

    I don’t think I’m an outlier on this at all, most people my age don’t have a relationship with a primary care physician because they are generally healthy so they don’t go for regular checkups.

    • buzzkillerjsmith

      Good for you. I don’t trust docs either and I am one.

      • querywoman

        Buzz, didn’t you imply once you were thinking of being a PA so you could make more money?

        • buzzkillerjsmith

          I don’t think so but I don’t remember what I had for breakfast, so maybe.

          • querywoman

            Well, perhaps you could make a small fortune by starting a janitorial business! One never knows!

          • Suzi Q 38

            The “grass is always greener on the other side.”
            It is difficult to may good money having a janitorial business. Between the Workman’s Compensation and regular liability insurance, plus wages and supplies, there is little for profit.
            Plus cleaning toilets and bathrooms all night long is not easy…..Add to that the people that don’t have insurance and they bid way too low because they have their underage kids on the job helping out…..

          • querywoman

            I read about a RN years ago who left nursing to sells worms off a farm!
            Perhaps Buzz could have a new career as a comedian. Robin Williams left a slot open. Buzz does have a wicked sense or humor.
            Or, maybe Buzz finally did enroll in PA school and is making preps to start in a few weeks.

      • Ava Marie Wensko George

        I suppose I’m lucky….I trust all my physicians.

        • buzzkillerjsmith

          Lucky? Well, maybe so far….

    • Suzi Q 38

      I don’t trust them at first, either.
      Even when I like a doctor and the care h/she gives me, I am still “on guard.”.

  • Patient Kit

    I TRUST the free market about as much as I TRUST profit-driven insurance and pharmaceutical companies. I think I TRUST the free market in healthcare even less than I TRUST government. I TRUST the docs I know personally who have earned my TRUST but I don’t blindly TRUST all doctors in general as a group. Obviously, TRUST is a huge issue to me and, I think, to many people. Doctors really need to address this huge issue of TRUST.
    But if I must choose between these untrustworthy evils (like we do every Election Day), I would place my bet-vote on government to provide healthcare for all Americans before I would bet on the free market to do that. It’s not that I don’t understand the free market. I fundamentally don’t TRUST the free market with healthcare.

    • lurking for answers

      Power corrupts. You would trust someone, elected by what has now become a popularity contest, to provide you with what they think you need as healthcare? What consequence do they have once they are out of office?

      • Patient Kit

        Power has the potential to corrupt anywhere there is power. Not just in government. I think we’ve all seen the wreckage that abuse of power in business has caused. I don’t see government through rose-colored glasses but the same goes for business.

  • Lisa

    My insurance company has not interfered with my primary care (or care from specialists for that matter). I have run calculations on what I would pay direct care practice care plus insurance versus maintaining my current insurance with known deductibles and co-pays under various scenarios. And the insurance is less expensive.

    No one has ever explained to my satisfaction how a direct care system can work for anyone who is not at least middle class, let alone poor. When you say that primary care should be paid for directly by the patient, you will wind up denying care to a lot of people who just can’t afford to pay cash for medical care.

    Finally, I will argue that free markets don’t work with goods such as health care as the demand is not all that elastic even though many people can’t afford to pay cash for medical care.

    • Kristy Sokoloski

      I agree with you Lisa. My insurance has never interfered with my getting care from my Primary Care Physician or my specialists. Also, you are spot on about the number of people that won’t be able to afford to pay cash for medical care. Very well said.

  • Lisa

    Every time I look at my paycheck stub, I see what my employer pays for my insurance, in addition to my contribution. When I receive an EOB from my insurance company, I see exactly what the insurance company paid the doctor and what my co-pay. This information is not just symbolic.

    • querywoman

      Ha! Ha! I hope it’s been fixed. Insurance has been known to show that they paid the provider more than they actually did.
      They don’t want you to know the truth.
      It’s called fraud. And since those forms are electronically submitted and sent out by postal mail, it’s wire and postal fraud.

      • Lisa

        I never said there was an error. When I said the information was not symbolic, it was in reference to the previous post.

        • querywoman

          I’m telling you that I have known insurance to lie on those Explanation of Benefits forms! Sometimes they state they paid more on those forms than they actually did! And that is fraud! I hope the gubbermint has cracked down on that bull stuff!

  • QQQ
  • HJ

    The difference between the cheaper high deductible and the expensive comprehensive insurance is not primary care…it’s being sick.

    Within the current system, having a high deductible plan means your either see a doctor in network so you can get credit towards your deductible…or you pay directly and hope you don’t have a catastrophe.

    • Lisa

      And this is one of the problems as I see it with DPC. You back it up with a high deductible plan, but you don’t get credit for the cost of associated with paying a monthly fee to a DPC practice. So it really doesn’t work financially.

      • querywoman

        It only works financially for the doctors. Do you really expect that kind to care what you think?

  • Acountrydoctorwrites

    Thanks for your post, Dr. Schimpff. Reading the comments it generated, I get the impression that some patients’ frustration and suspicion of today’s health care is unfortunately aimed at primary care physicians. It is sad and ironic that those who profit from the necessary interaction between doctors and patients are controlling us both through their financial power, which patients have relinquished, and by their ability to avoid attention to the fact that they have driven up the cost of doing business and created a hamster wheel mentality among doctors that has alienated patients to such a degree.

  • querywoman

    Medical tuition should also be paid cash, up front, no loans.

    • Suzi Q 38

      Why did you say this?

      There are student loans galore, at so many different universities.
      Lawyers, accountants, professors, nurses, dentists, etc. can take out loans, why not physicians?

      If your house has a huge water leak, and you do not have homeowners insurance, do you think that the plumbers will come out and fix it for free on regular basis?

      The reality is that the office rent has to be paid, as do other expenses, such as malpractice insurance, and staff wages…
      Also, their student loans have to be paid.

      Everyone has bills. If your family has money, they can assist, or there are the free clinics and medi-cal.

      • querywoman

        When I am sick, why should I have to cough up one hundred dollars to be seen? This has not been an issue for me in years, really! When my insurance first went to a PPO in 1989, and my copayment was only $5, I could pay. Then, when I was only paying $5, doctors ran every test they could!

        • Suzi Q 38

          Because you are the one that is sick and need to see a doctor.
          As far as how things used to be, insurances used to pay out more to the doctors.
          Now it has gotten to the point that $40.00 isn’t enough for private pay.

          • querywoman

            Not when I have been repeatedly sick and wiped out. Then the ER’s get to take up the slack.
            In Texas, an uninsured single childless person working full-time at fast food might have to take off work to go to a public clinic, and wait all day! And get fired. They can’t get Medicaid.
            FMLA can’t stop a lot of this.

          • Suzi Q 38

            If they have a non life threatening illness, they may have to wait 8 hours to be seen as well.
            I went to the ER on the weekend when my cousin slammed a sliding van door on my thumb.
            I waited 7-8 hours, and I had insurance.

          • querywoman

            Absolutely! It may be very difficult to blackmail an ER into getting seen sooner. They work by triage.
            I had my mother in a very large church affiliated ER once. Someone told us it’s the wealthy who want to be seen first. They offer to pay cash.
            A well-scrutinized ER cannot work that way.
            Yes, if people didn’t have to run to the ER with minor illnesses, it might help.
            But supposedly Britain has the same problem!

          • querywoman

            I get Medicare. My internist charged me a $21.26 deductible yesterday. I only paid half, which I have never done before. I have to move soon. Therefore, the total visit was probably $106.30.
            My endo and internist usually ask for payment of my copay up front, which can be $20 to $35.
            My derm and pulmonogist bill for the copay.
            I have steadily paid on a hospital bill from the internist. I have been in the hospital four times with here. Several years ago, she wrote a balance off though I did not request it. I’d been making small payments on the hospital balance.
            My endo and internist usually refer to an outside lab for labwork. There’s no copay on labwork. When doctors draw blood in their own offices, they really sock it to 3rd party payers.
            My endo team and internist, whom I have been seeing about 7 years, have always shared labwork.
            I estimate my docs normally get a total of $80 to $120 from Medicare and me.
            My derm usually only spends time with me. I get an occasional cortisone shot. Medicare doesn’t reiumburse him much for that.
            I saw on my last hospitalization that my internist’s pay was reduced due to budget cuts. I’m sure it is still profitable for her, but I don’t think it’s fair to target the GP’s. I hate the term PCP.
            My derm does a lot of research. He’s not greedy, but that’s where the real money is. My endo team has starting doing research. The endos are two very good guys, and I hope they make a mint off research.
            All of these docs have a mix of private insurance and government.
            They don’t take Medicaid normally. There is one doc in my derm’s office who takes Medicaid so I assume that doc would get the senior doctor as needed.

      • querywoman

        If someone gets something on buy now, pay later, I want the same. Why shouldn’t I?

        • Suzi Q 38

          I agree.

          Why not everyone?

          • querywoman

            I wonder if you have ever been as close to the financial edge as I have been. I have never been evicted or homeless.
            When people gripe about the poor getting food stamps and cash assistance, it’s often pointed out that people with higher incomes get more assistances like a mortgage.
            My income is not good enough for a mortgage.
            And, as one who could not get government aid for her bachelor’s degree, I really get irked at all the griping about student loans.
            Now I’m older and on disability. I could get a king’s ransom in financial aid now. I doubt that I would ever pay it back.
            Help when I was younger would have been more productive.
            I constantly give advice to middle middle class people or lower on how to get health care. I can give advice to the upper middle class to.

          • Suzi Q 38

            When I was younger and in college, the free student clinic took care of my basic needs when I paid the minimal 6 month fee. I got all my meds free from the school pharmacy.

            I left home at 18 and lived in a converted garage studio apartment.

            I have been on my own since I was 18, as my parents were not supportive and very abusive at the time. I walked to my part-time job at a bank, and took the bus or walked to a college about 3 miles away.
            At one time, I worked two jobs and went to college at the same time. I worked day and night.

            I am glad that you say that you wonder, because, you can’t assume that I or anyone else has had it all easy.

            As poor as I was, I at least got out of a bad situation at a very young age.

            No I didn’t have my own health care back then, either, but I was taking a risk. I guess people will risk a bad credit rating or bankruptcy when they don’t have the money to pay a hospital bill.

            Thank goodness I never got ill or in a car accident.

          • querywoman

            I was not fortunate enough to be able to get a job at 18 and move away from my parents. I could not get federal financial aid.
            I attended community college one year, down the street from home, then suddenly married an abusive man and moved away from my parents, where I eventually got a factory job.
            Then I went back to my parents, and struggled for years with them and various part and full time jobs while getting my degree.
            Whatever my difference with my parents, who could not understand why I could not get a job easily, they would have fixed stuff if they could have.
            While my parents were alive, I saw them reduced to needing me badly.
            I could not get meds free at a school clinic.
            We knew of the county hospital, but my family was blue collar. We paid our bills. There are things for which I do not blame family. Could I have gotten cheaper medical care, it would have helped us a lot.
            I don’t want to get eaten out for not being able to get a job when I was younger. It happens.
            I have spent a lot of time in social work, including in public welfare, helping others in lousy situations.
            If people think others are too lazy to work, you never know when the tables will be turned. I often sat across from people in public welfare who had always worked but suddenly bottomed out.
            Sometimes I felt like, oh, you got a job in a grocery store when you were young, and I couldn’t. But that did not effect the way I gave them benefits. I followed the law.
            And welfare law is only written to help the politically sympathetic, parents and minor children. I could not help everyone.

            There is plenty of food in this country. We need more affordable housing and medical care.

          • Suzi Q 38

            It is always tough to get a job.
            Sometimes being Asian in an anglo neighborhood was the reason for not getting a job during the early to mid 70′s. I had to visit a lot of businesses and follow up on a lot of leads to get any job. So many people said “no.”
            My first job was a maid at a motel.
            My second job was at a fast food restaurant.

            Eventually, I realized that if I kept trying, someone was going to say “yes.”

          • querywoman

            I was finally diagnosed with Asperger’s Syndrome in my mid 40s. Aspies have extreme difficulty getting jobs, in spite of our abilities.
            Once I got a job, I couldn’t get rid of it. I worked till I was half-dead.

          • querywoman

            Yes, we both went OT. But my topic is still that medical doctors aren’t the only who incur expense in life. Medical debt is not the only issue in our world.

          • querywoman

            Many times medical bills are disregarded for credit purposes. Bankruptcy is seldom necessary for medical bills. The medical bill industry revolves around scare.
            What I want you to realize about Texas is that free or low cost medical care, not too long ago, used to mean going to a county hospital and waiting all day. In poorer counties, a bus ticket to John Sealey in Galveston was what the uninsured got.
            Now we are getting more public and other charity clinics. George W. Bush was devoted to the community clinic concept, and many of these are from his efforts, nationally and state wide.

          • querywoman

            You have no idea how many 18 year olds, or anyone else, who couldn’t get a job committed suicide, ended up in a mental institution, turned to crime or prostitution, or shacked up with someone else to survive.
            Your tax dollars help support them some, but the damage of unemployability is unfathomable.
            I will never stop being a social worker!

          • Suzi Q 38

            Yes, that would be devastating.
            At first, I couldn’t get a decent job.
            I was Asian, and the only businesses that would hire me was a motel and a fast food restaurant.

            I was 16 and was a “B” student.
            I had to give any money made to may parents to help pay the bills.
            My point is that some people don’t want to clean motel rooms at the age of 16. I did because it was honest work and I needed the money.

            Of course a lot of kids at my school wouldn’t even consider it. At the time, my high school was largely Anglo.

            Eventually, I got a job at Disneyland. They liked it that I was Asian and spoke Spanish, LOL.

            I want to say that while it has always been difficult to get a job, there are jobs out there.

            Certain jobs people do not want to do, period.

            My sister was unemployed for 14 years.

            She kept saying that there were no jobs.

            Strange, I kept seeing ads on the internet, universities, schools, etc.

            She figured out that it was much easier to stay at home with no job. She said “her kids needed her.” That is true, but they were 10 and 12 at the time, and she could of least worked part time and brought some money in. Her husband was not making much, so money was scarce.

            They got by O.K. until he would lose his job from time to time. She still would not go out and get a job. I couldn’t believe it.

            She and her husband kept spending money, though. They lived in an upscale neighborhood and her kids went to private schools. Their friends were well off and had good careers.

            Anyway, her husband died unexpectantly and within a few years things got tough. She had to sell her house and move into a smaller one.
            That was fine. I told her that if she wanted to keep this smaller house, she should start looking for a job, if only for the insurance.

            Anyway, she found one for $15.00 an hour. While that is not much, at least it is a job.
            It is better than complaining and doing nothing when nothing is physically wrong.

            There are people in wheelchairs working at Walmart, and at call centers answering phones.

            Anyway, it is sad not to be able to get a job, but if you are determined and aggressive your chances improve.

          • querywoman

            Depression from unemployment will put a person in a mental institution, if they don’t successfully commit suicide first.
            Massive unemployment has high social costs in the United States. Most people can get free medical care at the ERs, but there are other problems, like housing!
            I am a lousy housekeeper and have never really bring strong enough to clean motels. An asthma inhaler after pneumonia 2 years ago has helped my endurance. I didn’t have very obvious asthma symptoms, but it’s really helped with bending and cleaning.
            Fast food wouldn’t hire me because I was too shy, probably.
            Hiring will always be a mystery to me. I have worked in two businesses closely associated with employment and/or unememployment: newspaper advertising and public welfare.
            Newspapers are almost dead now. I used to see people run the same job ads over and over again. I’d ask how they chose an applicant. Someone told me they gave them scores to try and help them remember each interviewee.
            In public welfare, I saw people who could lie, steal, and get fired and easily get other jobs, whereas a more honest person could not. Perhaps the cons were better bull stuffers.
            Asian and Spanish speaking does sound ilke an interesting combo for bull stuffers.
            I never thought of it at the time, but when I was young, I bet could have got a job at a day care center. Then, my mother would have screamed her head off at me that couldn’t I do better than work with kids?
            I have taught children’s Sunday school with doctors and lawyers.

          • Suzi Q 38

            Define “bull stuffer.”

            “…..Depression from unemployment will put a person in a mental institution, if they don’t successfully commit suicide first….”

            I don’t doubt that for a small percentage of people,
            but not the majority, thank goodness. Dression is understandable, but a mental institution because of a job loss? Not likely. If it did happen, the patient was not well mentally to start with.

            There are others who choose not to work, because it is difficult to do so. There are till others whose profession has changed and are not aggressive with reinventing themselves enough to get another decent paying job. Many times this means taking a lower paying job just because it puts food on the table and pays the rent. Some people have this attitude of I can’t take a lower paying job or do something menial or manual.

            Let’s face it. It is more enjoyable to stay home and not stress out everyday.

          • querywoman

            I edited this. I used bull stuffer for hustler or bull-
            sh!tter twice, when the 2nd time I meant Disney.

          • querywoman

            There are also state and federal laws that tell the govenment and insurance companies to pay up fast. You don’t see that discussed on kevinmd. Please don’t ask me how well the laws work; I don’t know!

          • querywoman

            A very important difference in the way you and I write is our states. California is a very generous welfare state. Texas is at the bottom of the barrel of social services, always!
            So what we have seen is very different.
            From what I see about what you have to pay with traditional insurance, you will be pleasantly surprised to have Medicare. Most docs accept your deductible, then 20% after that.

          • querywoman

            Many doctors and lawyers used to not pay back their student loans and then the guvmt cracked down on ‘em too.

  • querywoman

    Till the past few decades, doctors billed for services too. It was not cash in the office.

    • Suzi Q 38

      I remember that.
      It was in the 70′s and 80′s.
      I was told that I had to create an “account” with the doctor, and I was to pay cash or make a substantial downpayment to the bill and make regular payments. They would give me the paperwork to bill the insurance company for reimbursement.

      • querywoman

        When I first discovered KevinMD, I posted about how we lived in one town until I was seventeen. The doctor always billed my father for my office visits. When we came to where I am now, all the doctors wanted cash upfront and would not accept insurance assignment.
        Under the old $200 deductible, 80% reimbursement, I paid out a small fortune myself, roughly between ages 22 to 33, increasingly relying on credit cards, for my office visits. It adds up, and it led to massive debt.
        I could not believe the greed of the doctors.
        When I was using a minor emergency clinic for services, they agreed to accept insurance assignment finally. But, they diddled around paying the doctor directly by auditing claims, etc. I think insurance stalled on purpose. Then Texas passed some kind of clean claim law.

        • Suzi Q 38

          I remember I needed to find an OB in 1984 and 1986 when I was pregnant with our two children.

          A friend who was a nurse recommended this really nice doctor. I knew that I had to pay him the 20%, so I negotiated with him and asked his nurse to ask him if he would accept my insurance as payment.
          He agreed.

          If you are upfront with how the money needs to be paid, a deal can be worked out.

          Just like my plans for my medical care when I have medicare in about 6 years….If the doctors don’t accept Medicare, then I will offer cash for my office visits. I will also ask for a discount, since I am paying cash.

          I hope that I can make good on my plans, but who knows what medical care will be like in the next decade.

          • querywoman

            Here’s an OB story from hell….when I worked in welfare, and I’m now in my later 50s, another woman, who happened to be white and probably my age, told me a real horror story.
            The first time she was preggars, she was referred to an allegedly good OB. After she got there, some staff member pulled her aside and told her, “We don’t serve unwed mothers in here. Where did you get the cheap ring?” She never told her husband.

  • Lisa

    It disturbs me that your “poor” patients choose to opt out of buying insurance. What do they do if they are diagnosed with cancer or have a serious illness or injury that requires hospitalization?

    • Harry

      If they can’t afford insurance, they can’t afford insurance. That in and of itself should disturb you. What are people w/o insurance currently doing now for healthcare? I never said that DPC practices were a fix for every little thing wrong in our system today, but rather is an affordable way for a good number of people to get a good portion of healthcare that they actually need. Yes, there will always be people who unfortunately will require higher levels of complex care, including hospitalizations, surgeries, cancer treatments, etc. However, the vast majority of people in this country don’t require those services, yet still have health issues that require a physician’s attention on a regular basis. DPC is a Primary Care option that can deliver very cost-effective medical care for a number people who might otherwise not seek out medical care b/c of lack of insurance that is just flat out unaffordable. I wish all of my patients had the means to buy the best insurance that money could buy, but in the meantime, I can at least provide services at a very affordable rate that is much less cost prohibitive and still gets them a good majority of the care they need.

      • Lisa

        I disagree with you about the need for access to specialized treatment. Most people will need that access at some point in their lives.

        People can purchase subsidized insurance under through the federal exchanges. The people who are really screwed are the people with incomes under the federal poverty rates (so not eligible to purchase insurance through an exchange) and who live in a state that has not expanded medicaid.

        I just get irritated when DPC is hyped as the solution to medical care in this country as in this blog. It clearly isn’t as it doesn’t provide comprehensive insurance.

        • John C. Key MD

          Maybe the twain shall never meet. I don’t think most of us in DPC consider it to be the end-all of healthcare access, but it is a heck of a lot better than anything the ACA offers. Back to the drawing board.

          • Lisa

            As someone who has a history of cancer, I disagree with you about DPC being better than than the ACA. The one thing the ACA means, to me, is that I can buy insurance even if I loose my employer provided insurance. That is important to me. And I think it is also important to many other people.

          • querywoman

            You are talking from the patient’s view. I can’t afford the ACA, but I have Medicare anyway.

          • Kristy Sokoloski

            But you have healthcare coverage in order to insure that you get your healthcare. And yes, that’s right she is talking about the patient’s view. That’s the other big part of the equation here and when discussing this issue our concerns need to be addressed as well, just like the concerns of doctors and other healthcare providers.

          • Patient Kit

            I agree, Lisa. It’s certainly important to me to have the exchange options as a safety net. It beats all that tight-rope walking without a net. Only 8 months ago, it was impossible for me to buy insurance that would cover a cancer recurrence.

          • Lisa

            Yep. It is so important to have access to insurance and people who do not have pre-existing conditions do not realize that. May that term (pre-existing) disappear from our vocabulary….

          • Kristy Sokoloski

            I agree with Lisa. I have multiple health problems and it is important for me to be able to have access to my healthcare. Having insurance allows me to be able to do that. Same with my relative. Most of the people in this country will not be able to be part of a direct pay/concierge service practice/clinic. Also, nowadays a good majority of clinics whether it be specialty or Primary Care have gone corporate which also further allows people to have access to care. But yes, just like everything else it also has its down sides. Neither side is going to be completely happy because they won’t be able to get what they want. This is why there is no one simple solution.

        • Harry

          So, if “most people will need that access at some point in their lives”, does it make sense for people to be paying insurance premiums that they can’t afford if they’re otherwise not currently in need of those services? For those patients who require specialty and hospital care regularly, they would benefit from having a good insurance plan in place, w/ a lower deductible and better overall coverage, to cover some of the costs associated w/ this level of care. However, others who don’t require this level of service regularly, may not find the value in paying premiums for an insurance policy that doesn’t fit their needs.

          Again, DPC is an option for some people to obtain Primary Care services at an affordable rate. Health insurance exchanges or not, some people don’t want to pay for a product that they don’t feel works for them. It’s interesting that some people are so against DPC w/o truly understanding the value of it. After all, health insurance initially was only ever meant to cover people for catastrophic events, but has somehow morphed into the “comprehensive” payment plan that some believe it should be today. DPC is more of a throwback to medical practices of the past, where patients paid the doctor directly for services and had their insurance to fall back on in case of medical catastrophe. Maybe it’s just the designation “DPC” that bothers some, as historically, that’s exactly what most doctors’ businesses were before insurance advanced beyond catastrophic coverage.

          • Suzi Q 38

            “…….does it make sense for people to be paying insurance premiums that they can’t afford if they’re otherwise not currently in need of those services?…”

            It depends on what you mean by “can’t afford.”
            I would not have a nice car and have cheap or no insurance. Ditto for a house.

            If you have no income, that is another story.
            If you are disabled and unemployed, there is medi-cal.

            If you can make insurance payments, it is worthwhile to at least look into insurance with an HMO with a high deductible. This way, your payments will be affordable.

            If you are uninsured and you own property but don’t have insurance, the hospitalizations can cost a lot more than if you were insured and the insurance company negotiates a lower fee for services rendered.

          • Lisa

            And many people used to go without medical care because they couldn’t afford it. I think this country should be working towards tax financed universal coverage, not a system where you access to medical care is dependent on your ability to pay cash for it.

            The good old days won’t so good at all.

          • Ava Marie Wensko George

            I totally agree with you Lisa. I just don’t understand the arguments against health insurance. We are the only industrialized country in the world that cares more for businesses than people. Why don’t we have single payer? Why do some people argue against insuring the poor? I just don’t get it.

          • rbthe4th2

            Because if you look at the stats, the poor do not take it as a benefit and use it wisely. They abuse it. Always happens.

          • querywoman

            I envy those who never need a doctor. You have a point, but I don’t have an answer. Taxes spread the price of other services, like police and fire.

          • Suzi Q 38

            I am curious what happens when the healthy patients suddenly get diagnosed with a devastating illness or is involved in a car accident with a severe head injury, amongst other things.

            Who is there to negotiate a cheaper price with the hospitals? i was in the hospital a year and a half ago, and the hospital charged my insurance company about $70,000.00. The insurance paid only about 1/3 of the total bill and the hospital accepted that amount, as long as I paid my deductible.

            Do the uninsured but not poor just owe the huge balance forever, and relinquish their dream to someday own a home?

            I say even the healthy need some kind of basic, high deductible insurance to pay the hospital bill.

          • querywoman

            Your insurance company way overcharged the hospital. Yes, the uninsured may owe the debt forever, or until the state statute of limitations expire.
            Many mortgage companies and other creditors don’t count medical debt, and many people don’t know that.

          • Suzi Q 38

            “….Many mortgage companies and other creditors don’t count medical debt, and many people don’t know that….”

            I didn’t know that. Can you show some proof of such from a reputable source?
            That would be news to me.

          • querywoman

            I’ve seen it on apartment apps and mortgage apps before, and sometimes on the net. I’ll look for a net source.
            Medical debt revolves around scare! I have said that elsewhere.

          • querywoman

            Suzi Q, I will be in and out today. Looking for a good reference. Google, “mortgage, credit score, medical bills,” and you will some levity.
            In California, you might get a medical bill lien on your home. That’s not likely to happen in Texas, or Florida, the second best debtor’s paradise. Never forget that I write from Texas, which is very, lenient on debt. It’s not a welfare state, but there is an unofficial welfare system for debtors, but first you have to have had enough money to get in debt.
            I dated a lawyer (unemployed) once who said he learned in law school that a bunch of deadbeat debtors came to Texas and wrote the laws that way on purpose.
            There is levity in mortgage financing. If you have gobs of money and have not made medical payments willfully, it will probably effect your ability to finance a home.
            There are ways, and programs to assist lower income folks who do have medical bills, to be able to buy a home with enough saved up.
            I think I’m going to convince you that there is a lot of fear-mongering and paranoia in the medical debt collection business.

          • Suzi Q 38

            I was correct about medical bills in California.

            It isn’t a just walk in any ER and stiff the hospital routine here in California.

            If you have property, you still owe the money.
            Therefore, good luck on selling your house or buying any more property in the future with that outstanding bill.

            I am more concerned about California than any other state, as I live here.

            My point is that if you don’t have anything and don’t owe anything, going the medicaid route is fine. If you do own some property and/or have some money, it is better to have insurance to cover your medical bills for a couple of reasons.

            1. You are charged the price the insurance negotiates with the hospital.
            2. If you don’t have a bunch of cash lying around, the insurance will cover the medical costs, as you have paid for the service in your premiums.

            I am not setting off fear erroneously. The fear is real for those of us in California, and probably other states.

          • querywoman

            I always try to remind people that I am writing from Texas. I worked for the IRS 9 months, and I had people calling in talking about alimony income (very rare in Texas) and state welfare for single childless people.
            Also, Hawaiians, like Texans, talk about secession.
            Tons of people do get Medi-Cal in California, so they can’t be seizing everyone’s stuff.
            I have also heard that the California public health system is so overwhelmed by the undocumented aliens that the taxpaying California natives get very little of it.
            As for long-term Medicaid care, it’s still possible to hold onto a modest home in California.

          • Lisa

            Undocumented aliens don’t get Medi-cal. If the public health system is overwhelmed, it is due to poor Californians.

            People in California do get Medi-cal, but you have to be very low income to get it. Finally, if you are older and think it is possible you will need to get Medi-cal to pay for a nursing home, you should do some estate planning before hand. You do have to spend down you assets and if you own a house, it may be sole to recover costs after you die. I don’t know the exact rules, but there are rules.

          • querywoman

            I wasn’t talking about Medi-Cal. I was talking about the hospital, especially the public ones, which can’t turn people away in emergency situations.
            In Texas, the Harris County Hospital District has stricter eligibility guidelines for nonemergent undocumented alien care than does the Dallas County Hospital Care.
            By the way, there are lots of more people on Medi-Cal or Medicaid than you think. There are very generous federal income guidelines for minor children and pregnant women.
            In emergency situations, undocumented aliens in those groups can get Medicaid for a few days.
            This is a separate Medicaid issue than long-term care.
            Plus, the US citizen children of undocumented aliens get Medi-Cal or Medicaid. Also food stamps or SNAP, as it is called now.

          • Suzi Q 38

            “…..Tons of people do get Medi-Cal in California, so they can’t be seizing everyone’s stuff….”
            No, they can’t but I am not sure that people who own pricey properties get to receive Medical.
            Of course it is possible, but there are certain rules. Husband and wife O.K. Adult children, maybe, if they have lived with the parents in the same house for a specified period of time.

            Other than that, I would not want to qualify for medicare. Unless the facility I had to live in was a really decent place to live. Why should I, when I could stay off of Medicare and live in the comfort of my own home?

            What I am saying is that it is a choice as far as how a person chooses what to do with their own money. I am not giving it to the kids if I need it for my own care.

          • querywoman

            It’s easy to see how our state policies have caused us to misunderstand each other. Yes, if you are able to save up many thousands of dollars and have a nice house, you should be able to finance your long-term care.
            The Medicaid Estate Recovery laws are most aimed at the comfortable middle class. Supposedly, some people will keep caring for their loved ones at home to avoid Medicaid Estate Recovery, and that’s good.
            Some criticize that these laws hurt the lower income classes, and I don’t think that’s true. Most of them have exempt homes, and, if necessary, can get a hardship exemption.
            The laws affect the comfortable middle class. The really wealthy should be able to get care without hiding assets, though some of them may try it too.

          • Suzi Q 38

            The Hawaiians have been taking about secession since 1895. It is just “talk.” No one has been even mildly successful at attaining such.

          • querywoman

            I think we Texas legally maintained the right to secede. But, we tried to do that in the Civil War, and it didn’t stick.

          • Kristy Sokoloski

            Interesting because the medical debt collectors have not put any fear in to me. By the way, good to see you again. You have been missed.

          • querywoman

            That tells me you are strong and sensible. Thank you.

          • Kristy Sokoloski

            I can back up Querywoman on this one because when we tried to get our mortgage modified when they asked about the expenses we put out for they did not ask about medical expenses and things like that.

          • Suzi Q 38

            Yes, the thought of going about your business without a thought as to the money owed to a hospital is a good one.

            On the other hand, a loan modification on an existing loan and property may not be difficult.
            You are not selling, taking the proceeds (equity) and buying another house.

            I am just wondering what happens when you try to sell your house…does the hospital just “look the other way,” or do they file for the equity that is available when one sells their home?

            I know that they usually can not take anyone’s home, but you can’t live your life freely with savings accounts and such, or can you?

            I guess time will tell.

          • Kristy Sokoloski

            You are spot on.

          • querywoman

            Suzi Q, I know you are a smart lady. Methinks the lady Suzi Q doth protest too much here.
            Hospitals charge wildly divergent prices to different classes of people, a practice that would be illegal in any other business.
            They have been known to charge the uninsured more than the average contracted rate. Therefore, no one knows the true cost of health care.
            I doubt that the hospital was being generous in writing off 2/3rds of the bill. I’m sure they made plenty of profit off your insurance company. I’m sure they got more for whatever you had than the Medicare contracted rate.
            The question I always have was did they write off the 2/3rd as a business or tax loss?

            I call that, “phantom billing.”

          • Suzi Q 38

            Oh Lady Querywoman,

            Thinking differently is hardly new for me.
            I am sure I have some company as do you.

            “……Hospitals charge wildly divergent prices to different classes of people, a practice that would be illegal in any other business….”

            I agree with what you say about the hospital prices. I wonder how they get away with it.
            I don’t feel bad about them writing off 2/3 of my bill. I paid for the service in years of long term premiums. I just would like them to do the same for others, even those who do not have insurance.

          • querywoman

            I’d like the hospitals to charge everyone the same price. Did your hospital look like a nonprofit institution?

          • Suzi Q 38

            “…..Did your hospital look like a nonprofit institution?”

            No. What does a non-profit hospital look like?

          • querywoman

            Okay, I boo-bood. The nonprofits around here are always adding bright, shiny new buildings.
            My question should have been, “Does that hospital look like it’s not making a profit?”
            Nonprofit hospitals make lots of money, and bilk the gubbermint and insurance companies for every dime they can.

          • querywoman

            At the time of an accident or major illness, the hospital bill itself is not a worry. The bill is something to worry about later. As I implied elsewhere, medical debt does not trump other social issues.
            The US government is telling people it’s okay to go without insurance. If your gross income is under 300% of the Federal Poverty Level, you don’t have to enroll in the the Affordable Care Act programs.

          • Suzi Q 38

            “At the time of an accident or major illness, the hospital bill itself is not a worry. The bill is something to worry about later….”

            Definitely. Health trumps money.
            If you live in a rented home or apartment, there are no worries except for getting through the illness alive.
            If you have assets, you should have insurance.
            If you want to gamble, that is a personal decision.
            We are middle class, and I like keeping our assets. My income is not 300% below the federal poverty level (whatever that is).
            We are responsible people who hate to pay for good insurance but do because we think it is important and we work to pay for it.

            I would rather not worry about it later.
            There are people who don’t have insurance, and figure that the taxpayers can pay for them.

            If they need it, (Medicaid) that is fine.
            They are not losing anything because they don’t own property or other things. That is what Medicaid is there for.

            There are those of us who do not wish to lose what we have at this time to healthcare costs, so we pay for insurance.

            It is a choice. I know full well what i am doing.
            I have negotiated terms of payment and had the price of my husband and my colonoscopies reduced and discounted because we agreed to pay cash.

          • querywoman

            If you are a family of 2 adults in California, then 300% of the Federal Poverty Level is $47,190. Two people could live nicely on that in Texas, maybe not in California.
            Many people in the 48 continental states fall under that figure. The ones in approaching that level are not poor, but they are exempt from buying an ACA plan. If a state agreed to accept the new Medicaid provisions, I doubt it would cover people with incomes approaching 300% of the FPL.
            I would not have dealt with such people in the food stamp office.
            So, you can see, that the ACA still offers no real coverage for lots of people in this country. It helps the uninsured upper middle class, and those were the people most likely to get shafted w/o the new insurance plans.
            That should tell you how inadequate the ACA is.

          • Suzi Q 38

            How would they know if the uninsured middle class had money around, or not?
            Just because an employer decided to make them part-timers to avoid paying for insurance it doesn’t mean that they don’t have money to pay the reduced ACA premiums.

            I still do not know of a person in my travels whether it be family, friends, or business colleagues, who are covered with the new ACA and actually have received medical care as a result of the ACA.

            For me, it is all ‘lip service” right now.

          • querywoman

            Money in the bank help comprise, “resources.” Also a home. Resources are often disregarded for medical assistance to more comfortable folk. The drug companies don’t count resources for their assistance programs..
            Interest on bank accounts is income, and amounts over $10 get reported to the IRS.
            You can google, “Federal Poverty Level.” I think you can see that when we had conflicting views over the Medicaid Estate Recovery laws, we were talking about different economic groups. You were presenting home seizure as a done deal, when it’s not.
            If you are over three hundred per cent of the Federal Poverty Level, it’s easy to get an exemption. Just pay one of your utility bills late. Get a cutoff notice, and show that with your income tax return.
            I know one person who has benefited from the ACA. He is a mental therapist, not a nurse or doc who can prescribe drugs. He runs a talk clinic, and has made his money off third party payers for years. Apparently, he could afford the premiums and was thrilled to get it..

          • querywoman

            Here’s more, Suzi Q. I just googled, “United States median income 2013.” It’s a complicated issue, but it’s roughly around $50,000.
            So roll that one around in your head with the figure I gave you for 300% of the poverty level for two people.
            You are deeply concerned about hospitals harassing people about medical bills.
            You should see that people between 200% and 300% of the FPL are quite vulnerable to that harassment.
            They are over the limits for Medicaid, and state and local medical assistance.
            Church or other religious hospitals will often work with them.
            You can see that the ACA doesn’t help them.
            And they are a large segment of our population!
            The more compassionate doctors who read and post here will probably pay special attention to this. They need all the samples you can give them of expensive meds and may need help getting assistance from the drug company programs.

          • Suzi Q 38

            “……You are deeply concerned about hospitals harassing people about medical bills.
            You should see that people between 200% and 300% of the FPL are quite vulnerable to that harassment.
            They are over the limits for Medicaid, and state and local medical assistance….”

            Thank you.
            Although it took a few days, you finally realize what I have known for a long time.
            If you have money, or any other assets, the hospital and feds want it if you have run up hospital bills. It is not a “free picnic,” so it is better to have insurance if you can afford it if your interest is to conserve your property and other assets.

            Forget about the churches and/or religious hospitals….calling on them to assist is better than nothing, but no guarantee of debt forgiveness.

          • querywoman

            Yep! Especially in a nonemergency situation. Many times people with more money don’t pay any kind of bills. That’s why they have money!

          • Patient Kit

            DPC being a return to a model from the past is one of the things that bothers me about it. Back when DPC was common, people didn’t survive and live long with the conditions we live with now. Thanks to amazing medical advances, many people don’t die quickly now after a cancer, HIV, MS, diabetes, serious pulmonary or cardiac dx. We live with a lot. And all those people need regular specialist care that they didn’t need decades ago — because they died sooner back then. I think we can all agree that it is a generally good thing that people can survive and live with so much these days. I don’t see how we can go back to a model that worked in a much simpler time. And even then, it didn’t work for too many people.

            Another thing: Everybody who is healthy now and feels like they don’t need much healthcare is just as vulnerable as anyone else who lives inside a human body. Everybody wants to believe that “it” won’t happen to them or to anyone they love. But it does, everyday. My cancer dx was out of the blue, no warning, a total blindside. And it could happen to anyone. People need their illusions of safety and immunity though. And, as far as I know, the concept of insurance does not allow us to buy it after something happens to make us need it. So I’m not sold on the idea of so many people not needing much insurance. In the modern world, there is a huge medical territory between primary care and catastrophe. We all need to be covered for that.

          • Harry

            Differences in life expectancy have nothing to do w/ business models for PCP’s. It’s the advances in medicine and technology that can take credit for that. Most PCP’s I know are trained to handle more than just sore throats and common colds. We diagnose, treat, manage, and help others try to prevent chronic diseases that can predispose them to long term complications and more costly episodes of care.

            Also, health insurance companies are able to cover people for more complex care b/c of transference of risk. They need the premium dollars from those people who don’t use it to pay for those who do. If insurance companies only had sick patients paying premiums they would all be bankrupt. Hence, there have to be quite a few people w/ insurance that never ever use. But is it necessarily fair to make those who don’t use their insurance pay significant premiums just to have peace of mind in case of medical catastrophe? It’s that fear that insurance agents all across the country use to sell people on their products. The companies need that money to be able to transfer risk from one individual to another, thereby removing the risk from the insurance companies themselves, all the while allowing them to accumulate significant amounts of money along the way and then turn around and limit or deny care for their very customers who are paying premiums for coverage in the first place. Look at the general trend of insurance companies across this country that have been purchasing/acquiring hospitals and health systems over the past several years. They’re using billions of dollars to build their own brick and mortars, so they can now collect on both the premium side and the medical service provider side if the equation. Yet, as all of this has been happening, docs seem to be the ones who’ve been made out to be the villains. Some docs have decided to risk everything in an attempt to improve situations for both their patients and themselves. Unlike our government, we’re not forcing anyone to do anything they don’t want to. We’re simply presenting people w/ another option that may prove to be of greater overall value than what they currently have. And for some, it may be all that they can afford, period. Having insurance w/o true access to affordable care, in my opinion, does not seem like a better option than not having insurance but being able to receive affordable care through these DPC models.

          • Kristy Sokoloski

            In answer to your question at the start of this post the answer is yes.

        • Patient Kit

          I have a hard time getting past the claims by primary care doctors that most patients will never need specialists. That is so not true in the world I live in. Most people I know feel like their specialist care is far more necessary than their primary care. So, this whole DPC model loses me when nobody explains who pays for the specialists. Whenever I ask that question, the answer is a riff on how most people don’t need specialists.

          • Lisa

            Last calendar year, I saw my oncologist twice, my gyn once, my dermatologist once (I also have a history of skin cancer), my OD once, my dentist twice and my podiatrist twice. I saw my lymphedema therapist over 20 times. I also saw my pcp twice. So I agree – specialist care is very important to me.

            Where I have trouble with the DPC model is no one can give me a good explanation of how a high deductible insurance plan can coordinate with membership in a DPC plan. I strongly suspect that unless a DPC membership is credited against an insurance deductible, DPC membership and a high deductible insurance plan becomes quite expensive if you need to use the high deductible insurance plan.

        • Kristy Sokoloski

          Thank you Lisa. :)

  • buzzkillerjsmith

    DPC is a reaction to the current messed-up incentives in medicine and in HC in general. It is an attempt by primary care docs to survive, but, contrary to Dr. S., it won’t help the overall society much.

    System re-design is the only hope. Actually, that won’t happen, so there is no hope.

  • HJ

    RE: “Many of my “poor” patients have come to realize that they get actual healthcare services for much less than what they would be paying for a high deductible insurance plan that comes with a sizable first dollar cost. ”

    And when things go wrong, it’s my tax dollars that pay for their care.

  • querywoman

    In 1974, I paid ten dollars for a visit to my family practitioner. Now, I think direct pay FP visits are $80 to $100. Minimum wage was perhaps $2.35 back then. I thinks it’s $7.50 now.
    I know the FP I saw in 1974 didn’t work a day free per week.
    Yes, let’s go back to the old system, so the docs can bite me less percentage wise!

    • Suzi Q 38

      I never paid $10.00 in my lifetime.

      • querywoman

        I think you are one or two years older than I am. I am 58. The standard of living is much higher in California.

        • Suzi Q 38

          I am the same age, and I still never paid only $10.00, even as a child. You are right, the cost of living must be higher here in California.

          • querywoman

            The standard of living is much higher in California. I just saw a bit average apartment rents in the US. Throughout the country, the average is $1000 In Texas.
            I had a welfare supervisor who came from California. He said that it costs to much to live in California, that welfare recipients really don’t get any more than they do here, even though their checks are much bigger.

      • Kristy Sokoloski

        The last time I paid a $10 copay was like about 20 years ago.

  • Ava Marie Wensko George

    Only in America would your ideas be stated so openly.

    • Patient Kit

      I agree. And it’s especially disturbing coming from doctors (who want to change the world by helping people. Well, some people. The deserving people who can afford help.) There should be a lobbyist group called Doctors for an Inhumane System: You Get What You Pay For. If you can’t pay, get lost! or drop dead! Money talks.

  • Ava Marie Wensko George

    Then, it’s not the health care system that you really want to be fixed….It’s the way we educate physicians. Perhaps you should separate the two.

  • http://www.kevinmd.com kevinmd

    DPC = direct primary care.

    K

    • querywoman

      The moderator jumped in here in a very appropriate place for himself.

  • http://www.zdoggmd.com ZDoggMD

    WORD. The only things I would add:

    1. Employers can pitch in to help employees pay directly for primary care. It’s a great benefit and an efficient use of funds. Couple this with a catastrophic high deductible wrap-around insurance policy and BOOM. DIY healthcare reform.

    2. Certain progressive health insurance plans can carve out the primary care component (paying a bit more than standard to fund the personalized, relationship-based primary care described in the piece) and bundle it together with the true “insurance” piece in one package, on or off exchange and potentially eligible for federal subsidies if income warrants. Double BOOM.

    Full disclosure: we are using both of these approaches in our DPC practice (Turntable Health), along with a team-based model that leverages non-clinicians to allow clinicians to practice at the top of their licenses. Triple BOOM. Ok, I’ll stop with the BOOMs now.

    • Lisa

      I would love to see information (ie actual costs for employers and employees) of DPC and a catastrophic high dedctible wrap around insurance policy. From what I’ve read there are few insurance companies that offer such plans, in part becuase of their reluctance to change, but also because there aren’t enough providers to attract insurance companies.

      I would also love to see information about the second option you mention. To date, I have heard nothing about the actual nuts and bolts of such plans – how they pencil out as compared to traditional insurance plans. Key information.

      • http://www.zdoggmd.com ZDoggMD

        Check out http://nevadahealthcoop.org/ and see the Neighborhood VIP plans. Those are the ones that “wrap” our DPC clinic (Turntable). The premiums are competitive with other plans and the exchange plans are eligible for federal cost-sharing subsidies (like any exchange plan).

        • Lisa

          Thanks for the link.

        • Lisa

          ZDogg, I suspect if I lived in Las Vegas I’d be very interested in the plan. I find it very interesting that this plan is offered by a non-profit co-op.

  • rbthe4th2

    So how are my “poorer” brothers and sisters supposed to pay for care when they’re rationing at the end of the paychecks money for food and gas?

  • Patient Kit

    Is a public education through high school a right of all children? Taxes fund our public education system. And taxes fund many other countries’ healthcare systems. Whether we believe that healthcare is a basic human right in this country or a commodity like any other business is one of the big splits in the US. I, and many others, believe it is a right to receive medical care when we need it. And I believe it is inhumane to have a system that only provides needed medical care to those who can pay. Healthcare is not the same thing as buying a car or a TV (neither of which I own, btw).

    • Kristy Sokoloski

      Well said.

  • Kristy Sokoloski

    I get very good care from my doctors and that’s with my insurance. You are correct that DPC is not the ultimate fix for this but there are a number that are pushing this very hard and they don’t understand that not everyone is going to be able to afford to pay cash for medical care. This is exactly why so many people are not able to go to the dentist regularly as they ought to. The services are out of reach. Those that live in a situation where they are having to live from paycheck to paycheck end up having to make the decision of which is more important: to eat or to take medications and get regular check ups to make sure that they don’t get sicker. People in this situation are going to pick the being able to eat and keep a roof over their head. There has to be an option that works for those that live in this situation on a daily basis because otherwise, it’s going to be just like what is going on with dental. And if people don’t have access to healthcare then there are going to be even more deaths. And insurance even in spite of it’s problems at times allows those in this situation to get the care they need.

  • Suzi Q 38

    My cousin is a dentist and he donates some of his free time to free dental clinics and discounts his services to needy patients.
    No one forces him to do this.
    He just wants to do it.

    We get that you don’t want to give up any of your precious time.

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