More and more doctors are fed up with private insurers. It’s not just a question of how stingy they are, but how difficult it is to get reimbursed. Paperwork, phone calls, insurers who play games by deliberately making reimbursement forms difficult to interpret…
Some physicians have just said “no” to insurers.
What does this mean for patients? Business models vary. Some doctors charge by the minute. I recently read about a physician who punches a time-clock when the appointment begins. She has calculated that her time is worth $2 per minute. Fifty-nine minutes = $118. Will you be paying cash, or by charge today?
Somehow, I think the meter would make me nervous. I suspect I might begin talking very quickly. But this is only one model.
Rather than charging by the minute, some doctors charge fee-for-service. In those cases, many physicians mark up their fees well beyond what an insurer would pay. But, they point out, they also spend more time with their patients. No one feels rushed.
A story in a New Jersey newspaper describes how physicians in Northern Jersey have begun following in the footsteps of “elite Manhattan doctors and are withdrawing from all insurance plans.” The article compares fees with and without insurance. On the right, the fees that insurers typically pay for these services; on the left, the fees that Jersey doctors who don’t take insurance charge:
- Mastectomy: $5,000 / $900Ruptured abdominal aneurysm: $8,000 / $1,800
- Routine screening mammogram: $350 / $100
- Initial neurological consultation: $400 / $100
Some Doctors Share Savings with Patients
Other physicians find that if they don’t take insurance, they can cut their overhead, and actually charge patients less.
Over at Revolution Health “Dr. Val and the Voice of Reason” tells how Dr. Alan Dappen has set up his practice:
“He is available to his patients 24 hours a day, 7 days a week, by
phone, email and in person. Visits may be scheduled on the same day if
needed, prescriptions may be refilled any time without an office visit,
he makes house calls, and all records are kept private and digital on a
hard drive in his office.”
“How much do you think this costs? Would you believe only about $300/year?”
Dappen has stream-lined his practice. It’s not just that he doesn’t
need an assistant to keep up with stacks of insurance paper work. In
general, he keeps his overhead low, offers full price transparency, has
“physician extenders” who work with him, and “charges people for his
time, not for a complex menu of tests and procedures.”
The key is that Dappen practices very conservative medicine.
"I believe in doing what is necessary and not doing what is not
necessary,” he says. “The healthcare system is broken because it has
perverse incentives, complicated reimbursement strategies, and cuts the
patient out of the billing process. When patients don’t care what
something costs, and believe that everything should be free, doctors
will charge as much as they can. Third party payers use medical records
to deny coverage to patients, collectively bargain for lower
reimbursement, and set arbitrary fees that reward tests and procedures.
This creates a bizarre positive feedback loop that results in a feeding
frenzy of billing and unnecessary charges, tests, and procedures.
Unlike any other sector, more competition actually drives up costs."
Dappen has it right about competition in the healthcare marketplace.
Studies show that in areas where there are more hospitals competing
with each other, hospital bills are higher. This is in a part because
hospitals jousting for market share all invest the same cutting-edge
equipment. The only way to pay for it is to use it. So they do more
tests and more procedures, driving hospital bills higher.
Dappen, who practices in Fairfax Virginia, told Dr. Val Jones that
“after building a successful traditional family medicine practice he
felt morally compelled to cease accepting insurance so that he could be
free to practice good medicine without having to figure out how to get
paid for it. He noticed that at least 50% of office visits were not
necessary—and issues could be handled by phone in those cases. Phone
interviews, of course, were not reimbursable by insurance.”
Dappen also casts a skeptical eye on the pricey annual physical: "The
physical exam is a straw man for reimbursement. Doctors require people
to appear in person at their offices so that they can bill for the time
spent caring for them. But for longstanding adult patients, the
physical exam rarely changes medical management of their condition. It
simply allows physicians to be reimbursed for their time.”
Again, Dappen is spot on, as Niko reported on HealthBeat here.
“Cutting the middle man (health insurance) out of the equation allows
me to give patients what they need without wasting their time in
unnecessary in-person visits,” Dappen explains. “This also frees up my
schedule so that I can spend more time with those who really do need an
How many readers have found themselves sitting in a doctor’s waiting
room, not because they were sick, but because they needed to renew a
prescription? Since insurers don’t pay doctors for the time it takes to
read an e-mail or to take a phone call and then write a new
prescription, many insist that patients come in whenever they need a
renewal—that way, the doctor can bill the insurer. This makes sense if
the doctor needs to check your blood pressure to see whether the
medication is working. But if he’s simply going to chat for a few
minutes and write the script, the visit is a waste of time.
“Health insurance is certainly necessary to guard against financially
catastrophic illness. And the poor need a safety net beyond what Dr.
Dappen can provide” Johnson observes.
“But for routine care,” a practice like Dappen’s “can make heathcare
affordable to the middle class, and reduces costs by at least 50% while
dramatically increasing convenience.”
Dr. Val calls Dappen’s practice “concierge medicine for the masses.”
Other physicians practice more traditional “concierge medicine”:
customized, round-the-clock care for the elite.
In California, the Ventura County Star reports that local doctors opting out of insurance “spend more time with patients—and make more money.”
Some doctors charge payments an annual “membership fee”—rather like the fee you might pay to belong to a country club.
“I wish I had done it a long time ago," says Dr. Edward Portnoy. An
internist, Portnoy once had a practice of about 2,800 patients. Now he
sees roughly 380 people but takes home “about the same profit” thanks
to the $1,800 membership fee that each patient pays yearly.
Portnoy spends roughly twice as much time with each patient as he did
when he accepted insurance. He explains that he “has more time to do
intensive physicals and help patients stay healthy, rather than running
from one crisis to the next like a war surgeon doing meatball surgery.”
At Dr. Stanley Frochtzwajg’s family practice in Ventura, patients don’t
face annual fees but pay “at the office for whatever services they
receive,” the paper observes. “A routine office visit is about $80.”
Patients are then given the paperwork to submit to their insurance
companies themselves. “One patient said she ends up paying about 30
percent of the bill but is happy with her care and willing to pay for
The paper reports that doctors “don’t really like the term ‘concierge’
or ‘boutique’ medicine. They prefer labels like personalized,
That’s understandable; they don’t want to sound snobbish. But in
truth: "There’s not a lot of people who can afford it," says Anthony
Wright, executive director of the consumer advocacy group Health Access
California. "The reason some people call it boutique medicine is that
this is for a well-to-do clientele."
Wright is concerned: “I don’t think systems that shift more burden
onto the patients are the answer to our broken system or will evolve
into more than an isolated alternative…The trend of boutique medicine
sends the consumers in the direction of you’re on your own. Everyone
On the other hand, the paper notes, “Carol Miller of Thousand Oaks
thinks the $3,600 she and her husband pay in annual fees to see Portnoy
is worth it because it brings peace of mind. The money covers an annual
physical and a battery of screenings for everything from Alzheimer’s to
sleep apnea. The fee also covers follow-up that focuses on preventive
“There are other perks. People in Portnoy’s waiting room find a basket
filled with Cliff bars, crunchy peanut butter and chocolate chip bars.
Tea and Snapple is served.
Crunchy peanut butter and chocolate bars? Is this part of the emphasis on preventive care?
Some worry about what the larger trend means. Are the Millers, who
receive an annual “battery of screenings” being overtreated? If
insurers reimburse for even 70 percent of unnecessary treatment, are we
all paying for boutique medicine?
Dr. Bob Gonzalez, medical director at Ventura County Medical Center,
also talked to the reporter and confided that he worries “that less
reliance on insurance means fewer people getting healthcare. They won’t
be able to afford it.
“The specter of more doctors downsizing their practices and seeing
fewer patients also alarms Gonzalez. It means patients won’t be able to
find any doctors or could be dumped on an already overburdened doctor.
“So yes, he said, more money, less insurance and more time with patients may be good for individual doctors.
“But whether it’s good for society or good for patients is the overall question.”