Food for thought: Primary Care + Insurance

[Michelangehands]

When most people think of “cash-only” medical practices, plastic surgery and dermatology procedures are top of mind. But there is a small contingent of primary care physicians who offer low-cost “pay-as-you-go” services. Yearly physicals, well-child visits, screening tests, vaccinations, and chronic disease management are all part of comprehensive primary care options available. And this costs the average patient only $300 a year.
It is estimated that 75% of Americans require an average of 3.5 office visits per year to receive all the medical care they need. If the average office visit is 15-20 minutes in length, then that averages out to 1 hour of a physician’s time each year. How much should that cost? Dr. Alan Dappen (founder of Doctokr Family Medicine, a cash-only primary care practice in Vienna, Virginia) says, “$300.” But insurance premiums are often closer to $300 per month for these Americans, and that doesn’t include co-pays for provider visits.
So why aren’t people buying high deductible insurance plans, saving thousands on premiums per year, and flocking to cash-only primary care practices? Dr. Dappen says it’s a simple matter of mindset - “People have been conditioned to believe that if they pay their insurance premiums, then healthcare is ‘free.’ In reality, their employers are taking out $3600 or more per year from their paychecks for this ‘free’ care. But since employees don’t see that money, they don’t miss it as much.”
A high deductible health insurance plan (where insurance doesn’t kick in until you’ve paid at least $3000 out of pocket in a given year) costs about $110/month for the generally healthy 75% of Americans (you can check rates at eHealthInsurance.com). That’s a savings of at least $2280/year for those who switch from a regular deductible plan to a high deductible plan.
What are the odds that the average, reasonably healthy American will outspend $2280/year? I asked Alan Dappen how many of his 1500 patients spent more than $2000 on his services per year. The answer? Three.
“Most Americans who buy-in to low deductible plans pay a lot more in premiums than they’ll ever use. They’re essentially betting against the casino, and we all know who wins on those bets.”
So I asked Alan Dappen if “the casino” was making most of its money on the “healthy” 75% of its enrollees to subsidize the cost of the sick 25%.
“Sure they are. And I suppose if enough people saw the light and switched to high deductible plans with cash-only physicians, it might force change in the health insurance industry. Perhaps the government would use our taxes to help subsidize the sicker patients.
The bottom line is that at this very moment, 75% of Americans could be saving thousands of dollars per year on their healthcare costs - and have their very own cash-only primary care physician available to them 24-7 by phone, email, home visit, or office visit. The cash-only doc can afford to offer these conveniences because they are paid by the hour to do whatever the patient needs done, without forcing the relationship to conform to insurance billing codes. In fact, the physician saves a bundle on coding and billing fees - and can pass that on to the patients.”
I wondered about the outrageous costs of laboratory fees and radiology charges for people who don’t qualify for the insurance company negotiated rate. Dappen explained:
“My practice has negotiated similar rates with local labs and radiology groups. Screening tests and x-rays are very reasonable.”
I asked Dr. Dappen who uses his services.
“I see both ends of the spectrum. The high-powered executives who don’t have the time to wait in a doctor’s office and enjoy the convenience of handling things with me via phone or house call. For them, time is money, and by losing half a day or more traveling to a doctor’s office and waiting for their 15 minute slot, they might lose $5000 in billable work time. On the other end I see patients with no insurance or high deductible plans. They enjoy the same conveniences, and end up paying an average of $300/year for their healthcare. This is high quality care that they can afford.”
I guess the only thing preventing this model of healthcare from taking off is the courage of individuals to try something new. I myself have switched to a cash-only practice with a high deductible health insurance plan, and have saved myself thousands a year in the process. I love the convenience of knowing that my doctor has all my records in his EMR, I have his cell phone number, and he can renew my prescriptions with a simple email request. I can’t imagine why more people aren’t doing this.
Alan Dappen says, “They just have to wake up out of the Matrix.”


http://www.icyou.com/events/3rd-ann...hcare-congress/dr-chris-ewin-fee-care?&page=2

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[starfishprime]

If you're a healthy 21-year-old and are cool with a $5k deductible, you can get a policy for less than $400/year.

Of course, it helps a lot if you have an old-school doctor with the stones to diagnose and treat an uncomplicated broken arm without sending you the the ER for a $3000 workup at 10AM on a Tuesday.

 

[Michelangehands]

In response to your reply, starfishprime.

This is the exact mindset insurance companies want their patients to have, and it is is one that doctors have accepted without considering the alternative. 3,000 dollars for a workup is about the same that the average person pays for traditional HMO or PPO health insurance per annum. Unless you plan on having catastrophic health problems every year, this seems like a comparatively bad deal to me.

Secondly, your scenario is far from realistic. Under my originally proposed model, primary care doctors would have a more personal and time-invested relationship with their patients. In addition, patients would choose their provider based upon whether they essentially like him/her. Why would a provider screw over one of his patients by referring them to the ER for an uncomplicated fracture when there is the risk this patient might retaliate by leaving the plan and joining a more frugal provider?

It's all about mindset. You can choose to pay 3000 per annum to wait weeks or months to see a primary care doctor for 15 minutes and have catastrophic insurance coverage identical to that of an HSA, or you can choose something akin to the alternate plan being proposed above.

 

[Bonesaw45]

I think the point he was trying to make was more of a defensive medicine issue not so much about the doctor trying to screw the patient with unnecessary workups.

This point his been made over and over again and i think it is a valid on, insurance of any type was meant to be used in catastrophic terms. I don't call my car insurance in on a scratch or ding that I can handle myself and I don't call my home owners in when I need a plumber or electrician to come in and repair something. Medical insurance should be the same thing the bare minimum should be pay out of pocket, that will diminish the increased costs that you incur with a middle man, I like the idea because it also allows more relationship building.

My biggest problem with the 'new' American plan which is basically a copy of the old European and Canadian plans in many ways is that when you go into a doctors office you typically won't get the same doctor.

Having talked to some Canadian friends in the past few months they say the nature of the practice is that you go to the first open doctor. All I have been taught through clinical skills as an MSI (so this is limited and non practical skills) has been that continuity of care and doctor patient relationship are paramount to better outcomes for chronic multifactorial disease like diabetes, htn, obesity and all the big guys on the list. So +1 for your plan OP because it allows for lower costs with better doc/patient communication.