“Health” Insurance companies have begun moving into the realm of delivering, or even more specifically - rationing, “healthcare” more and more over the past 10-20 years. Once upon a time, the doctor made the medical decisions for a patient - he or she knew the patient well, weighed risks and benefits, had a conversation with the patient and chose the best course of action. Today, the doctor’s role has been diminished in large part due to the interference of insurance companies.
If I want to order an MRI of my patient’s shoulder (of course following clinical guidelines on timing and indication) I cannot just send an order and have the patient get the MRI. Nowadays, I have to ask permission first. When I call the insurance company, I am usually sent to a “third party” - a company who handles prior authorization requests for that insurer. When I finally connect with a person (which often takes more than 30 minutes) I have to play a game of cat and mouse, answering questions in just the right way so that the non-medical-person on the other end checks off the right boxes that allows the automated system to determine whether my medical order for my patient is “approvable.”
Last year around this time, I wrote a blog about the open enrollment season and things folks should think about when purchasing health insurance. Most of the information is consistent this year, though I’ve updated things a bit below:
Whether you purchase your insurance through the state, government, employer or directly from the vendors, this can be a daunting process. There are often many choices, with slight differences that are difficult to decipher. Beyond that, because price transparency is such an issue in healthcare, it is often hard to plan or budget for future costs when there is no way to find out how much these services actually cost! Below, I’ve tried to outline a couple tips while going through this process.
Well that’s a novel concept, isn’t it?!? I was reading an article today in the Wall Street Journal about the rising costs of healthcare and how deals between hospitals and insurance companies are contributing to the problem. Try reading this piece… doesn’t it make your head spin? Hospitals do this and try to block that, and insurance companies do this and switch plans and so on and so on. In the end, none of these decisions and maneuvering are really about patient care. They are strictly about market share, controlling health care utilization and profits. Too much of our current healthcare system places multiple barriers in between doctors and patients. Additionally, many medical decisions now are based solely on insurance coverage and their “protocols,” and not what is best for the patient.
If you’re someone who travels a lot for work or pleasure, or you just happen to find yourself on the rare trip, you may imagine a scenario where you fall ill and need care. You’re away from home and from your primary care doctor. You’re in an unfamiliar location where you don’t recognize the local medical options. This is a scenario many of us have experienced or at least have known someone who has.
What do YOU do when this happens? The most common answer is that you go to the local emergency room or urgent care. This may be fine OR it may result in a big bill or in care that is disjointed from your typical doctors. Disjointed care sometimes leads to patients being prescribed medications that cause side effects or interfere with existing medications or issues, which renders them in worse shape in the long run. If you don’t need to see a doctor at a more emergent setting, you may be charged a larger copay for having gone there instead of to primary care (even though you couldn’t get back home to do it!).
Doctor Google is great. When you’re in a pinch. No one is available to answer your medical question. You just can’t wait until Monday at 9am to call the office. If you could wait, you know you’ll be put on hold and won’t get a call back for hours - if you’re lucky. You know if you do get a call back, it will likely not be from YOUR doctor. So, why not just Google?
So let’s say you’re young and relatively healthy. You can’t remember the last time you went to a doctor for anything. You are not on any prescription medications and do not require many routine screenings at your age. You also have a busy career that makes the slog of a traditionally inefficient practice impossible to deal with but cannot imagine paying a monthly fee for a Direct Primary Care Practice… why would you do that?
Well I can think of a few reasons, actually. I bet if you think back over the past couple of years, something came up at one point that required a visit to a doctor. You probably went to an urgent care or ER since you had no established primary care doctor. It may have been for a laceration that needed a few stitches, or an ankle sprain while playing sports on the weekend, or a bad cold that you just could not shake at home and needed to be seen. All of these things can easily be handled by a primary care doc who is easily accessible and can see you that day. Without that access however, many patients have no choice but to visit a much more costly health care setting and spend hundreds to thousands of dollars on a one time visit fee. For this same cost, you can get several months to a year of direct access to your personal doctor. Many of our younger patients have high deductible plans. So even if they do not utilize our services frequently, they often save money by avoiding expensive health care costs.
A common theme in medicine is that many patients worry about their health. For patients, this can take many forms. Some patients avoid the doctor, deciding “what I don’t know won’t hurt.” Others worry for days or months leading up to their check-ups, worrying their doctor will “find something bad.” And, still others go in to see their doctors much more regularly in hopes of getting answers to their questions to help calm their fears.
Have you ever had to call your traditional primary care doctor's office for a general question? It probably goes something like this:
Patient calls at 9am, and before getting a word out:
Receptionist: “Thanks for calling Slow Family Practice, please hold.”
10 minutes later: “How may I help you?”
Patient at 9:10am: “Hi, I have a question for Dr. Too Busy and was hoping to speak with him.”
Receptionist: “Let me check with his nurse to see if he’s available.”
10 minutes later: “Dr. Too Busy is currently with patients, but I can have him call you back when he’s available.”
Patient at 9:20am: “Ok, please have him do that.
Several hours later:
Nurse: “Hi this is Dr. Too Busy’s nurse returning your phone call.”
Patient at 12:30pm: “Oh hi, I had a question about a rash that I’ve had and my blood sugars today.”
Nurse: “Ok, well why don’t we schedule an appointment for you.”
Patient: “That would be fine, though Dr. Too Busy can probably help me over the phone.”
Nurse: “Well we really need to see you in the office. He has an opening 2 weeks from today!”
While we have many patients in Direct Primary Care Practices, like here at Direct Doctors, who do not have many or any chronic medical conditions, we also have a number who do. Patients dealing with chronic illnesses or unexplained symptoms often feel bounced around from specialist to specialist, test to test, either without answers or without organization.
While we obviously believe that DPC is the future of primary care in the United States, we do think that insurance plays a vital role in our health care system. Unfortunately, health insurance is so expensive that many folks think that spending more for a direct primary care membership is not something they can afford. This is often not the case, especially for patients who get insurance through an employer or buy it themselves directly from the insurance company or on the exchange.
Lauren Hedde, DO and Mark Turshen, MD are Family Physicians and Founders of Direct Doctors, Inc. a Direct Primary Care Practice.