Business model woes traps doctors and impedes health care

If you are a physician, therapist or any other helping professional whose business model relies on third party manged care reimbursement you are engaged in the world’s worst business model.

Let me start with a story to set the stage.

Imagine you are a bright, idealistic college student. You’re good at academics, want to make a difference in the world and have hundreds of career options in front of you.

After lots of thought and planning you invest $100,000 in a graduate education. After all is said and done, you are in school anywhere between 2-12 years past your college graduation. You train to change people’s lives, heal what pains them. You make a difference and you sacrifice your life goals to prioritize your career. You may delay getting married, having children, taking vacations.

You do good work, finish school and training proving yourself and set out to make a living practicing in your area of expertise.

The first order of business is to figure out how you will get paid for all of your good work. The standard business model is accepting payment from a third party.

This third party decides how much your work is worth.

The third party sets limits on how much work you can do with each customer.

The third party can reject your invoices at any time for any reason.

The third party prohibits you from discussing your fees with other providers of the same service.

There are many of these third party payers and they all pay different, seemingly arbitrary rates.

The third party can change what they pay you at any time.

If you don’t follow all of the rules of the third party they don’t have to pay you at all.

The business model requires you to rely on an outside source to determine what you work is worth, set your rates and reimburse you on their terms. They can change the rules at any time. Outside forces constantly and consistently determine your bottom line. You have no choice, no chance to test price points. If you want to add a new service that isn’t recognized by the third party, they don’t pay you. The third party tells your customers that you are responsible for accessing their funding on their behalf, so no one knows what they really pay you or what your services are worth.

If you have any entrepreneurial spirit at all, please re-read the above paragraphs and tell me if you would sign up for this business model. Honestly, it’s ridiculous, don’t you think? Who in their right mind would invest $100,000 and years of their life in education, training and business and then turn over all hope of a profit to an outside entity?

Why don’t health care providers do anything about the model?
Doctors, therapists and other health care providers are not business people. We are not trained to pay any attention to how we get paid or who pays us. Many of us work in organizations that take care of all the administrative silliness so are have no idea how broken the system is. We are trained to do work that “insurance will pay for,” or to “find something that the insurance will reimburse.”

Nice, huh? Your doctors are trying to find things wrong with you so they can get paid. It’s not their fault. It’s the business model and no one questions it.

Those who understand that business model, CEOs of insurance companies think it is a great business model. They call the shots, they are in charge, they have the power and they make lots of money managing your business and our health care. Those in power never want to give it up.

As providers we are also brainwashed that if we don’t accept this crazy business model our patients will be harmed. “How will they afford care? Who will take care of them?” But, in the USA, we don’t want to provide a public health plan to help out those who are less able to afford care, so providers are put in a bind: take the lousy capitalist model that puts you in a subservient position to third party payers, or be a guilt ridden, selfish person for not buying into the model and getting the respect and pay you deserve.

What can we do about it?
Create different business models. Take ownership of our careers. Declare, “We’re not going to take it anymore!”

Imagine what would happen if doctors, therapists, dentists, and all other helping professionals declared this at once? What if we only worked with third party payers who treated us with respect? What if we only accepted insurance that had a real person answer our calls and handle our questions? What if we dropped insurers who pay us insulting rates and make us fill out 5 pages of busy work to access that cash?

And what if we informed patients that it is their insurance company that restricts their care, pays low rates, makes us wait on hold for hours? Or how about we put the onus on the patient to submit all insurance claims, understand how complex and time consuming it all is? It’s their care after all. [And don’t tell me the public ‘can’t figure it out.’ They figure out auto insurance, life insurance, home insurance. They can figure it out. Now we just enable ignorance].

Do you think the public would speak up? Complain to their insurance company, employers, government officials, congresspeople and senators? Well, yeah, they would. Would health care policy need to change if the providers of care stood up and demanded respect, a fair system and lower overhead costs?

Let’s not agree to business models imposed upon us. Let’s educate ourselves about business and empower both the medical profession and consumers to be proactive in how health care is accessed and paid for. If we are told that health care is a business, and entrepreneurs run the system, let’s even the playing field so that the competition is fair.

We have a choice.

Susan Giurleo is a psychologist who blogs at the BizSaavy Therapist.

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