Comments on: Pulling primary care out of insurance

By: Anand Vayuvegula

Anand Vayuvegula — Mon, 19 Oct 2009 02:07:17 +0000

A great article. But am intrigued by your comment that the current system doesn’t encourages the use of internet and online communication mediums to increase the time spent with a patient and focus on the quality of care rather.

Are there any legal implications? I am working on a startup (www.ezdia.com) where we are using features like live chat with billing (for the actual time of the transaction) wherein physicians can advise patients (especially cases where face to face presence is not necessary) and charge for only the time spent on the case.

Will appreciate yours and other physicians feedback?

By: Outrider

Outrider — Wed, 14 Oct 2009 18:28:45 +0000

Solo Dr:

Based on my experiences with clients, I don’t think patients would have any problem at all paying $60/15 minute office visit. I think that’s quite fair and reasonable, actually. If the physician can pay the fixed costs of running the office (rent, utilities, staff), a fair salary for him/herself, and fixed costs of being a physician (licensure, CE, DEA), AND the patient is paying the physician directly so there’s no cost associated with insurance paperwork or billing, everyone wins. Especially if the patient is able to purchase catastrophic/chronic illness insurance “just in case” (hoping it will be used only rarely).

This also brings a degree of reality into the discussion of health care costs. Consider: I have car insurance, but I expect to pay for oil changes, tire rotation, and the occasional timing belt out-of-pocket. The insurance is just in case a drunk driver sideswipes my car and rips off the door, for example. I hope I’ll never need to use it. Health insurance should be more like car insurance, in my opinion.

By: solo dr

solo dr — Wed, 14 Oct 2009 01:29:08 +0000

I think most primary care doctors would be agreeable to seeing patients for $60 for a routine office viist and then in increments of 15 minutes at $60 each. This would be in the middle of insurance and Medicare reimbursement. Without insurance primary care doctors, to address the earlier comments, could bill for phone calls, prior authorizations for medications, email, and other paperwork. As a solo doctor on Columbus Day I tracked my calls and received 103 calls into the office from 8 am until 6 pm. Some are simply appointment requests, but others are free med refills by phone.
Most patients with chronic illnesses, such as T2DM, HTN, and cholesterol see a primary care physiciian 3-4 times a year for the $60 office visit. Since copayments are hitting $35 for 2009 and since deductibles are often $1,000 or more, patietns may be agreeable to a $60 office visit without insurance.

By: Weekend Roundup « See First Blog

Weekend Roundup « See First Blog — Tue, 13 Oct 2009 14:17:03 +0000

[...] Robert Centor continues to share his terrific insights on how medical quality being wrecked by how insurers deal with primary [...]

By: Outrider

Outrider — Tue, 13 Oct 2009 13:36:56 +0000

I’m a veterinarian and I work with horses. A number of my clients have purchased medical/surgical insurance for their horses. The most common insurance policies for horses cover catastrophic injuries/illness or expensive care for chronic conditions (with many exclusions for pre-existing conditions, cutoffs for age, and the option to drop the patient or exclude the condition in the future, which obviously wouldn’t be okay for human insurance).

Routine care – annual physical exam, vaccinations, routine laboratory tests, dentistry – is not covered by these plans. Clients pay out of pocket. Average care for an average horse on an annual basis is quite affordable for the average owner and probably isn’t much less than it would be for the average human minus administrative costs.

It’s a model worth examining for human health care. My clients who want more routine care (examples: two physical exams/year, Lyme titer in asymptomatic horse) pay for this out of pocket, free choice. I’m paid COD for my work as a primary care veterinarian. Clients of modest means who have purchased insurance don’t worry about having to euthanize their horse in the event of a catastrophic illness. The one educational point my clients have difficulty grasping (likely based on their experiences with human health care) is: buy insurance, and hope you’ll never have to use it.

By: Brian

Brian — Sun, 11 Oct 2009 15:32:51 +0000

MY experience has been that people would use primary care a LOT more and justifiably so. if they had better access to the physician. Most people “only” go for a physical and maybe “one” other visit just because it is “to much of a hassle.” In reality, people often have questions and concerns about their health(especially in their 50s) that warrant a doctor visit (or at least a phone conversation) with their doctor. Not to mention this increased regular interaction massively improves the patient doctor relationship and the doctors understanding of their patient and their health concerns and needs.

I personally would like to see Family Medicine (and Internal Medicine) change th concept of what Primary Medicine is. We are not just for colds, basic prevention and to refill meds (all though that is important.) Primary care doctors serve the best roles and improve health the MOST when we are advocates for our patients to the healthcare system as a whole.

A True health professional and advisor.

To Anonymous, as a lawyer you should understand. people come and call upon you for your legal advice. if you were forced to “ration” your time with each client and paid in such a way that “volume of clients” was more important than the quality of your legal advise, do you not think that people would complain and see you “less often?”

If a Lawyer, Accountant, or even a plumber are not there and easily accessible when you need them… you would fire them a get another professional.
but in healthcare…. the system has trapped doctors and patients both i a bad situation.

Without giving primary care doctors more time, then there is NO reform. Whether you pay them better or simply do away with the TONS of useless and extremely time consuming and expensive bureaucracy forced upon doctors by the government and private insurance. It does not matter. you just have to give primary care doctors more time.

By: Anonymous

Anonymous — Sun, 11 Oct 2009 01:46:54 +0000

Since I am a patient – and a retired lawyer – I wonder if any doctor here could give me a handle on how much primary care an average person – say a 50 year old – uses? A once a year check-up with perhaps another trip for “something wrong between visits” – or once a month or more? I – at the age of 62 – am in the former category. My father – 91 – has to go to his primary care doc every 3 months because he needs an Rx for narcotics for back pain. He is otherwise in excellent health – especially for his age – and might need only one trip a year except for state requirements regardings presciptions. Anyway – can any of you doctors generalize about your experiences? Robyn

By: Dr. Bob (FP)

Dr. Bob (FP) — Sat, 10 Oct 2009 17:20:47 +0000

Unfortunately, the ability of those going into primary care is a mixed bag. Some of the best doctors I know are family docs, but unfortunately some of the worst docs I know are also family docs. I’m not sure which blog I read the comment from, but one of the more astute observations was from an ER doc asking “So, did you go into family medicine becuase your’re really smart or because you’re really stupid?”

As an FP married to an FP who teaches at an FP residency, I’ve seen this over and over. I’ve had residents on both sides of the coin. Given the payment disparities, we can’t always attract the cream of the crop. We’ve got some the brightest most dedicated docs you could want. On the other some of them make me want to go back into private practice after a night of backing them up on call (one of the reasons my wife did).

As db points out, the system doesn’t allow the better docs to get paid more for doing a better job. In fact, it does just the opposite. Those great docs who went into primary care for the right reasons make much less than the worst ones. That’s becuase the dedicated docs won’t drop their patients when they loose their job and end up on Medicaid or quit seeing them when there illnesses have forced them into bankruptcy and they can no longer pay the doc’s bill. The dedicated docs make less & less because they won’t kick out their patients with worse paying insurance plans, and the only way to increase your income is to only see pts from the better paying plans or run the patients through your clinic like a meat packing plant. So you have a situation where the best & most dedicated get paid the least and the less scrupulous prosper. As if the payment disparity b/w PCP’s & specialists weren’t bad enough, the payment system makes it even worse!

By: Will

Will — Sat, 10 Oct 2009 16:07:54 +0000

As a 4th year med student going into family practice, I agree with you 100%. The current payment system discourages primary care to the point where it is assumed that students interested in primary care must be either very lazy or very stupid. In reality, many of the smartest people go into primary care (it’s just 2-4% of a given class), but this perception is very common among med students and attending physicians. Something absolutely needs to be done, or we will only have specialists who do procedures, and I hope that’s one thing we can all agree is a bad idea.

By: Jared

Jared — Sat, 10 Oct 2009 15:37:35 +0000

I was eating lunch yesterday, and I think I came upon a good analogy. Primary care is the spork of modern medicine. It is very useful, very modern, but orphaned and maligned.