One of our goals at Access Direct Care is to provide excellent health care at a reasonable price. In practice management literature, it is reported that the average office visit with a primary care doctor (like myself) is around 6-8 minutes. The question is: how can a doctor take a good history, do a thorough examination, reach a diagnostic conclusion or plan of action, and explain it to the patient all in the space of 6 minutes? The answer is: it’s impossible. So, instead, what we can get is an abbreviated visit, lots of unnecessary testing (it’s easier to order a CT scan than to do a thorough history and physical examination), and substandard depersonalized care.
But, let’s go back to the root cause of this. Why is the average office visit only 6 minutes long? When we are honest with ourselves and cast aside all of the excuses, it all comes down to money and survival. And the reason money has become such a big part of the problem is the involvement of third-party payors like Medicare, Medicaid, and commercial insurance companies. These big companies and government entities call the shots when it comes to how much a doctor gets paid for a given service, test, or procedure. Over the last 20 years, those payments have been squeezed down lower and lower to the point that there is just barely enough payment coming in to cover the expenses of doing business, let alone having anything left over to put food on the table. The natural outcome of this dilemma is to increase volume to maintain a sufficient level of income. Two important things happen when patient volume increases: 1) the doctor has to hire more staff. The more patients a doctor sees, the more staff it takes to see them. There are more phone calls, more refills on medications, more tests to order and keep track of, more insurance claims to file, etc. You get the drift. 2) patient care suffers. Let’s just take it to extremes to make a point. Which doctor would you rather go to? The doctor who sees 40 patients a day, spending 5-8 minutes with each one, or the doctor who sees 10 people a day and spends 30 minutes with each one?
So, let me get back to the point behind insurance companies (aka “third party payors”). Third party payors have corrupted the medical system by: 1) dictating what care is given, how often, how much, etc. They are like the big brother in every examination room across the country. And you thought you’re going to see your doctor…..no, you’re seeing your doctor under the auspices of big brother 2) increasing the cost of medical care by adding another layer of expenses (the extra staff, computers, postage, phone time, paperwork filled out by the doctor, etc, etc that I mentioned earlier). The third party payors add expense without any added value. 3) by ratcheting down their payments to doctors, they have encouraged a culture of increased “productivity” amongst doctors which has led to shorter appointments.
As a result, I am slowly weaning myself from the insurance trough. I’m trying to get off of the insurance merry-go-round for a number of reasons. The most important reason is that I’m tired of having my care and interaction with my patients dictated by an ever-present third party in the mix. The way things are when we deal with insurance is that there are three parties in the exam room: the doctor, the patient, and the insurance company. And unfortunately, the insurance company decides which medicine you will receive, which test you will have, which consultant you will see. There’s something wrong with this picture, isn’t there? Healthcare should be between a doctor and a patient. PERIOD! In addition, all your private, personal health information gets forwarded to the insurance company. They know your diagnosis. They know what medicines you are taking. Sometimes, they ask for a copy of my office notes that document your visit with me (ostensibly to justify payment at a given level of service). This information can be highly personal…but they have a right to it. After all, you and I both had to agree to it in order for them to agree to pay the bills. So, patient privacy is a huge reason to be free of insurance. Your notes stay in my office and no one ever has to see them.
So, how does ridding my medical practice of insurance companies help you, the patient? Number one, it costs less. Since I don’t have to have the extra staff to process the payments, the extra nurses I would need to see lots of patients, the computer software costs, the postage costs, etc., my overhead is much lower, and therefore, I am able to charge considerably less and still make a living. Instead of charging $89 for a 15 minute visit, I can charge $49. Instead of charging $400 for the labs that I do with a complete physical exam (CBC, comprehensive metabolic panel, lipid panel, urinalysis, and PSA), I can charge $80. Those are just two examples. Last year, I had a complete physical examination with my doctor, who is a fine doctor with excellent credentials and excellent clinical skills. I have a high deductible insurance plan, so the entire cost of the visit was out of pocket for me. For the examination alone, the charge was $220. For the same exam, plus all the blood tests I mentioned a couple sentences ago, plus an EKG, I charge $199 total. Number two, my appointments are longer. Instead of an 8 minute appointment, my appointments are more like 20 minutes, and often longer. More time means a more thorough, reasoned approach. Number three, my schedule tends to be a little more open, so I usually see people that call with acute problems on the day that they call. I send very few of my patients to walkin clinics. Walkin clinics serve their purpose, but who wants to go to one when you already have a doctor of your own?
You might ask “OK, that’s great for people with no insurance or for those with high deductibles, but what about those of us with regular health insurance. Why should I pay $49 for an office visit when I would only pay a $20 copay if I went to a doctor in my network?” That’s a great question. There are a couple possible answers. Number one: many people that have stayed with me even though I am no longer in their network end up ahead financially even if they pay for their visits out of pocket. Here’s how: they pay for the visit out of pocket (let’s say $49 for a 15 minute visit). They then submit the paperwork to their insurance company and ask for reimbursement at out-of-network rates. The insurance company, in turn, sends them a check for $30. Total out-of-pocket cost: $19. I’ve had some people that were reimbursed 100%. One patient, who used to have a $25 copay for her visits got reimbursed $40 for a $49 visit resulting in a $9 out-of-pocket cost. She ended up $16 ahead by seeing me out of network………again, because my fees are so low. The second reason to stay goes to the issue of value. If you value your relationship with me, if you have come to trust me as a physician, how much is that worth to you? For people that see me once a year for their hypertension or arthritis, and leave me because they have to pay $49 instead of the usual $20 copay once a year, I guess I wasn’t much of a doctor to them. It wasn’t even worth an extra $29 a year to stay with me. But I would hope that my care is worth something more than that. It’s ultimately up to you.
A couple of excellent websites that review the effects of third party payors on the health care system are www.aaps.org, the website of the Association of American Physicians and Surgeons, and www.medibid.com.