Doctor Diaries: Exiting the Game

Dr. Kathleen Brown freed herself from the insurance game, converting her practice to cash-only last fall in Oregon. She is a registered doctor with MediBid. Since she no longer has to deal with all of the overhead involved in dealing with third party she is able ot dedicate her resources ot serving the patient.

Doctor Diaries: Exiting the Game

Posted on Feb 25, 2012

Doctor Diaries: Exiting the Game

Guest Post, authored by Dr. Kathleen M. Brown, MD

Or, as in the Eagles’ “Hotel California,” “you can check out any time you like, but you can never leave”.  The GAME is the third-party reimbursement system for health care, and it is very difficult for doctors (and patients) to LEAVE this game.

Most people agree that the way we pay for health care in the USA is broken, but they do not agree on the “fix.”  First, most health insurance is not true insurance.  It is a mix of true insurance and pre-paid care.  As such, it is something of a scam, if you look at what we all pay and what we get.  Second, over the years, the third-party reimbursement “system” has caused massive distortions in the health care market, leading to extremely high prices for health care, increasingly poor access and service, and severe drag on the economy.  PPACA (“Obamacare”) was marketed as the “fix” for all this, by way of more rules, more mandates, more taxes, more financial carrots and sticks, and more enforcement.  Right…..  And the cost?  Some of the costs include further loss of patient choice, and a bigger, more expensive GAME, whether it morphs into a single payer system or not (single payer means that insurance companies become government contractors).

Games are often defined as fun, but we all know that many games are actually deadly serious.  Games can also be defined as a “competition conducted according to rules, with the participants in direct opposition to each other” (Merriam-Webster online dictionary).  The third party health care reimbursement system thus qualifies as a very complex and serious game, and it is funded by “other people’s money.”  More and more people have their hands in the big health care money pot, and less and less value is achieved, as the game becomes more complicated and expensive to play.  For one of the best explanations of how we got into this situation, I highly recommend 2 Days That Ruined Your Health Care, by William C. Waters III, MD, 2008, Logikon Press.

Physicians, patients, and many others have benefited financially over the years from playing this game; a game that destroys value, and siphons resources from the rest of the economy.  To be fair, many participants never realized what they were getting into, or reaped the big benefits, or even felt that they had a choice, because the game started so long ago.  Now we find ourselves trapped in a Faustian Bargain, or find that we have “sold our souls to the devil.”  Instead of only earning honest profit (profit defined as the reward for creating value), physicians and others in health care have benefitted from various forms of subsidy and coercion.  We are also victims of our own successes; a longer life expectancy and more technological medical miracles have created additional financial challenges.  Now that doctors are feeling financially squeezed by high educational debt, high taxes, high office overhead, rigid fees and rules set by others, we want our souls back, so to speak.  We want to practice high quality medicine, to be paid well, and to not be “owned”.  AND, we do not want to be agents of rationing, whether overt or covert.  Well, it isn’t going to be easy.  Once you have sold your soul, it might be unaffordable to buy it back!

To truly exit the game, and get back to working directly for the patient, a doctor must get rid of all contracts with government and insurance companies, dramatically reduce overhead, and accept the possibility of a steep pay cut or even business failure.  A doctor has to become completely responsible for his or her own financial survival.  However, it also becomes possible and necessary to offer affordable and transparent pricing, and to cater to patients with no insurance, or high deductibles.  It becomes possible and necessary to offer great service.  It becomes possible to do a great job for those patients who need extra time, and to better accommodate new patients and those who need to be seen urgently.  Patients become empowered to ask about costs and necessity of treatment.  Patients who want services that aren’t “truly necessary” become completely responsible for paying for those services, instead of having the doctor in the middle of it.  On the other hand, those services become more available and affordable again.

So, why don’t more doctors exit the game, in exchange for the freedom to practice high-quality, affordable, patient-centered medicine?  Well, several things make doctors feel locked in.  One is the Medicare patients.  Doctors feel guilty for “leaving” them, especially since we like them so much!  The answer is that doctors who have a large percentage of Medicare patients don’t have much of a choice, anyway.  It has gotten where doctors must herd Medicare patients through in a hurry, because of high overhead and fearsome regulations, OR virtually work for free.  If overhead is covered, but nothing is left over, you are working for free.  Doctors who continue to practice high quality medicine by giving away a lot of their time may end up with either no free time (or, no paycheck, amazingly), but patients certainly feel they have paid!  Nobody but doctors and their families care whether doctors have time for life outside of medicine, but eventually these doctors will stop giving away that time, or stop taking Medicare patients, or retire, burn out, leave medicine, or somehow find a way to escape the excessive work load.  The third choice is to opt out of Medicare.

Sadly, Medicare patients are starting to learn that care within Medicare is getting to be a lack of care, lack of access, and that it is likely to get worse.  Seeing a doctor who is opted out of Medicare may be a good choice for many Medicare patients.  Fortunately, many Medicare patients are not poor, and could afford a few reasonably-priced doctor appointments here and there, if their doctors opt out.  It is still perfectly legal to opt out, but Medicare patients must pay the doctor directly, and WILL NOT get reimbursed.  Doctors may choose to do some charitable work for some of those patients, but on their own terms.

The second big obstacle to exiting the game is opposition by commercial insurance companies, who CONTROL the game, along with government.  The CPT billing system (owned by the AMA, and a main source of their income) is at the heart of the GAME, and a requirement to play.  Using CPT billing is incompatible with affordable, transparent pricing.  If doctors decide to bill by time, (to make things simple, affordable, and transparent), the insurance companies will strongly resist or refuse to reimburse their subscriber (resist honoring their contract with their subscriber for out-of-network care).  State “consumer insurance advocates” are not eager to side with the subscribers and independent doctors against the insurance companies on this one.  Insurance companies also tend to tell their “members” to choose another doctor; one who will follow their rules.  This can discourage those brave patients who are willing to stick with independent physicians, pay at the time of service, and endure the hassle of filing their own claims.  The CPT billing system is the primary cause of the huge amount of staffing per physician, driving up costs.  Why shouldn’t insurance companies embrace lower fees, and more patient “skin in the game”?  It doesn’t make any sense.  Could it be that they are waiting for their “bail-out” by PPACA?  Could it be that they don’t want other doctors to get any ideas?

Well, I haven’t entirely figured it out yet, but am working on it.  I am trying to clear a path, here in Oregon, for the practice of medicine, free from government and insurance control, and free of billing dictates and collusion between “payers” and the AMA.  I sure do appreciate the support of my patients!

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