Health care is falling apart. We all know it, we can feel it, but it’s hard to say why it’s happening or even what is happening, we just know that it is true. And as bad as it is for patients, it’s even worse for providers. We know that there is something wrong. We want to help people. We are busy all day long seeing patients. Why doesn’t it feel like we are helping people?
I’ve talked to the old physicians, the ones who had cash practices. They would charge $11 for an office visit that could take just a few minutes. They didn’t have an EMR; they didn’t have to worry about documenting 10/10 ROS just to get paid. They wrote a quick SOAP note and saw the next patient. Their patient’s loved and respected them, and because they could afford the $11, they paid every time that they came. The physicians were happy. They were busy, but at the end of the day, they knew they had helped their patients. The nice thing was that their overhead was so low that they were very comfortable even though they only charged $11 per visit.
We still like caring for patients, but we are not nearly as happy or satisfied as they used to be. Believe it or not, all of the things that we don’t like about our jobs are caused by insurance companies and government agencies.
Pre-approvals, denials, difficulties getting and staying credentialed, changing insurance requirements, documentation requirements and risk of prosecution for upcoding or insurance fraud are all artificial restrictions that only detract from actual patient care. I would make the case that even the current high no-show rate is a result of our third -party payer system.
Believe it or not, there is a simple solution for all of these problems: Cash! If we, as physicians and other providers, decided that we do not want to be beholden to other entities, we could just stop taking insurance. Instead, we would charge the patients for our time and skills. We would need to provide valuable services, and we would need to be able to explain to the patients why they were valuable, and why we were the best people to provide those services. Auto mechanics do it, why can’t we? Mechanics have even convinced people to do preventative maintenance, like changing their oil and getting alignments, because they know it will cost more in the future if they don’t do them. We should be able to convince them to get physicals and take their blood pressure medications to prevent bigger problems in the future, especially if they will be responsible for paying for their bad choices. Right now, people do not feel the financial effects of poor health habits. They smoke, eat bad food and don’t exercise; but when they have their heart attack, their insurance picks up the bill. We might see them change their habits if they had to pay for their future care themselves.
This would actually lead to more educated patients and true informed consent and refusal. They would come in with shoulder pain, and we could give them their options. An MRI? When it’s being paid for by a third party, they always want the MRI. But if they have to pay for it out of pocket, I bet they would try Ibuprofen first, then maybe some physical therapy. And the price of an MRI would come down if they were competing for cash payments. Lasik started off as a $3,000 per eye procedure. Since then, the cost has decreased to $250 to $500 per eye while the quality has increased because of the competition for patients. That happens in a capitalistic system, but not in a system of third-party payers and “benefits.”
Physicians would need to learn how to justify their tests and treatments in simple, easy to understand language so that they could convince their patients that their care was needed and appropriate. And people would learn to shop around for the quality and price that they desired for their care. Each hospital and provider would be competing for business. As a result, the prices would fall, and quality would improve as people were more careful with where they spent their health care dollars.
But I’m not heartless either. I think the university hospitals and government clinics should stay open and provide free care to those who cannot afford it on their own. This would include most trauma care, emergent cardiac catheterization and a lot of the cancer care. Patients would be triaged, and emergent care would be delivered immediately, but many of the non-emergent patients that we now see in our ERs would be referred to the free clinics for care at a later date. I also think that those institutions should be staffed with residents and students from all the healthcare fields, and they should be immune from litigation. Patients should not be able to sue for care that they receive for free. Patients who could not afford care in the private sector might have to wait weeks to months for appointments at these places, but I’m sure that the no-show rate would decrease substantially. It would correct one of the great injustices of our current system — that the people who contribute the least to our society, have the best health care benefits, at the lowest cost. I actually believe that we would see more people looking for jobs just so that they would not have to go through that system.
In the end, I believe that we, as health care providers, have the power to save our health care system, improve the quality of care, decrease the cost by 50 to 75 percent and improve our job satisfaction — all by going back to our roots and trusting in the capitalistic structure that made our country great in the first place. Why would we continue to allow the government and insurance companies to control us when everything they do seems to make it worse?
Timothy Barrett is an emergency physician who blogs at Healthcare The Way It Should Be!
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