The insurance industry’s increasing intrusion into my practice so I could provide them with data to “prove” that I am providing quality care continued to decrease patient face time and increase my paperwork time. (Actually, this “report card” was developed so insurers & IPA’s could benefit from additional payments they received for higher acuity that was never passed on to me – nor in the form of reduced rates for their clients – my patients).

I’ve been in office based medicine since completing residency, teach clinical medicine at a major medical school, work for a MLB team and cover sports & entertainment events. I provide basically “free” healthcare at those venues for the countless ushers & security who don’t have insurance. Over the past 4 years, the “extracurricular” work I’ve done has financially carried my practice, which I kept because I felt it was important to provide continuity of care to all of the patients in my office.

Unfortunately, what it lead to was alienation from family and friends because of the long hours spent in the office, spending LESS time with patients so I could do their paperwork, and seeing patient care actually suffer because I had to work “other jobs” to keep the practice afloat.

In the end, it was cut the practice loose, alienate the hundred upon hundreds of patients I had in my practice, but be able to cut back on the “extracurricular” work, so I can devote the proper amount of time to the patients I do have.

Providing better quality of care is “elite-ist”? Providing medicine for the masses at 40-60 patients a day & giving myself an MI stressing over how to make payroll is not what we trained to do.

One of the “there-is-no-answer” questions I ask med school applicants is “if health care is a right & everyone should have free access to it, how do you justify charging the $250,000 per year it will cost you to maintain your practice, pay your loans & feed your staff – before you make cent one so YOU can eat?”

In reading the above exchange, I am not sure I have any better ideas. I CAN relate to the concept that when I raise my fees for service that my customers expect better service. That’s kind of a no-brainer. The higher the fee, the greater their expectation for the quality of my service and ability. They actually don’t care how long it took for me to acquire the ability to do what I do, they only care that I can do what I claim to be able to do.

I suppose it is all about expectation, and whether what the customer is asking for is reasonable for the price they are willing or able to pay.

I also have clients that want a discount on every service I offer, and even some that refuse to pay (they are one-time customers, obviously). I can’t bill my clients before service is rendered and sign off on the project (expectations, expectations delivered). In good times, I can usually ask for a deposit on the work, but that is also no guarantee that I will get 100% paid of the total bill in the end.

I have a few “types” of clients: those that keep coming back because of the quality and return on investment of my work; some that want that quality, could afford it, but try to get it for nothing; and finally, some that need it, but can’t afford it at all.

Now, lives are not being saved by what I do, although, if what I do results in more income for them, especially if the return is greater than their investment on my services, I am affecting them differently, than if I were a simple vending machine, $1.00 in for a candy bar, candy bar out.

So, when it comes to looking at this problem of delivering medicine, I can only scratch my head.Dang. I do think that the price to see a doctor is too high for a few minutes of a physician’s time, when he/she is more likely trying to do the paperwork/notes of the patient who just walked out ahead of me. But isn’t that the outcome of insurance being in the picture?

I also think it costs too much to have health insurance, and that is where my cash flow goes first for health care now ($1100. monthly for health insurance for a family of 4, PPO). Why do I do this? Out of fear. Fear that something completely catastrophic will come along and wipe us out financially. Since we have an utter fear of insurance companies, and the tactics that they use to decline coverage, we maintain MORE coverage, not less. Now, you can argue that is stupid, but when you are middle class, you are not that far away from the bottom, quite frankly.

With the cost of procedures, hospitalizations, etc… one needed surgery could wipe us out on copays alone.

Now, that wasn’t always a fear and we didn’t always spend more on health insurance. What happened that we would have one spouse take a lower wage/position (despite years of education/cost/actual experience) just to keep portable health insurance? Health problems.

Both myself and my spouse are not insurable. Not because we led un-healthy lifestyles, didn’t floss, didn’t care. We put more cash into upfront preventive care, just because it made sense, we didn’t need someone telling us to do it…just common sense.

So, what happened? We are human? We both ended up with chronic “states” that doctors don’t want to deal with, didn’t care about when we first sought medical opinion/care, were, sadly, mis-guided about cause (time?), and the end result? Health problems that, while not terminal, not life-threatening, have completely depleted us financially, from getting expert opinion, to affecting our efficiency to generate an income…

Why did this happen? If I had to point fingers…our health problems developed at that point in time when Insurance companies began denying claims big time, claiming that doctors (and their patients) were over-utilizing expensive testing/diagnostics, etc. and that, in order to remain profitable, doctors began altering their diagnoses, whether they realized it or not, depending on a patients’ health coverage.

What to do now? We are plain out of cash. In order to fully understand what was wrong, we paid cash to specialists in the hope that if they weren’t “worried” about the bottom line that we could remove that poor reimbursement element. Then we found that when doctors had us by our credit cards, seriously, the outcome still wasn’t that much better, for the amount we were spending.

We thought, money would solve our problems, and it didn’t. Now, we don’t have that option of throwing more cash at the problem. We are down to maintaining status quo, and having a simple vote when it comes to legislation.

Even after paying into the overall system, over 30 years (x2), paying our way (taxes, insurance, all our copays and remaining fees), and playing by the rules, we not only don’t have access to “incredible medical”, we are the “type” of patients, none of you guys would “want” on your waiting list.

What is my gut telling me? Doctors are not the problem, this “need” to carry insurance, at any cost, even if the return isn’t there, IS. The insurance companies are for-profit, but expect doctors to work in the red, and the patients to be able to fill in the rest.

There are plenty of patients who could pay (higher than middle class) who work the system, and find a way weazel out of their medical debts. I know of many that don’t carry health insurance, have the means to do so, and when big medical expenses come up, lay claim to being indigent (magically).

The problem is just too complex. I do appreciate that you guys are at least talking about it without making the patient the absolute problem. Good luck!

My husband has been recently diagnosed with MS and I have had radical surgery for cervical cancer. We are both uninsurable if we lose his group insurance.
I would welcome paying a concierge fee to our fabulous primary care physician because he deserves it. Unfortunately he does not have that type of practice.

Why does anyone feel is out of line for a Physician to earn in excess of $300K
per year? I don’t.

Prior to Medicare, physicians set their own prices for their services. Prior to Medicare, the American public as a whole, paid for their primary care. There is nothing wrong with asking someone to pay for their primary care. I’ve found that those who pay nothing for their care are less likely to be an active participant in keeping themselves healthy. If you give someone something, they are less likely to appreciate it than if they contribute something themselves. That is what is wrong with the logic that some in healthcare espouse today. They have the “let’s just give everyone healthcare for free attitude.” Some do need help in attaining healthcare, but out of those 50 or so million who don’t have coverage, over half don’t have it because they choose not to and could afford it if they wanted.

I am in Primary care, and I am practicing in a model not too different that these concierge practices. I do not accept any insurance. My patients pay my fee at the time of service, and I provide them the documentation that they need to file a claim with their insurance company. I spend more than 10 minutes with my patients, and am actually able to build a relationship with each one because I’m not as rushed as the doc who runs a medicare factory and has to see 50 people/day.

And for the little ninny who has been on her high horse, bashing concierge medicine as yet another tool to deny the poor care, I would tell her that I actually provide more indigent care now than before I went to this type of practice. Before I converted my practice to one that doesn’t accept insurance, I provided minimal indigent care (maybe 2-3 patients per week) because I did not have time. Now I see at least 10 patients/week that have NO way to pay me, and I do not ask for payment. So, grow up, and practice a little before you start pretending like you know what goes on in the real world.