Physicians have long expressed dissatisfaction
with the amount of time and money it takes to deal with insurance companies
, but the alternative, going insurance-free, may seem a risky, problematic model of operation that could send patients fleeing from their practice—something no physician wants to happen.
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Going to an insurance-free model of practice can mean a variety of options. Some practices stop contracting with insurers altogether and only accept cash from patients, either at a set rate, or they negotiate with them individually. Other practices transition to a concierge model in which their patients pay a monthly or annual subscription fee that includes various amenities like an annual physical and 24/7 access to practice doctors. Depending on the model, physicians may submit insurance paperwork for patients for special services, or give the patients the forms to do it themselves.
Patients who have high deductible health plans—which the IRS defines as $1,300 or more for an individual or $2,600 or more for a family—pay out of pocket until they meet their deductible anyway, so an insurance-free practice might not be a problem.
“Many of my friends and colleagues thought I was insane. They said no one will ever see you,” says Larry Good, MD, a gastroenterologist affiliated with Concierge Choice Physicians in Lynbrook, New York, speaking about his transition to an insurance-free practice.
“About eight to 10 years ago, the functional and economic changes in medicine that were happening at the time became progressively more intolerable and so I began, over a period of several months, to drop those insurances that made it more difficult for me to provide the quality care that I truly believe my patients deserve,” says Good.
He eventually dropped all commercial insurers except Medicare for a few elderly patients who had been with him more than 25 years.
“It’s just not emotionally comfortable for me to abandon them now,” he says.
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But being insurance-free doesn’t emancipate a physician from some of the perils of the insurance industry, warns Good. You still need things like prior authorization for special testing and procedures for your patients, and for prescribing medications that may not be on their insurer’s formulary since your patients have to deal with their insurance in order to get reimbursed.
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But by setting your own reasonable fees for services, physicians can see 15 to 18 patients per day rather than the 60-patient cattle-call model you might find while practicing under insurers’ thumbs. Plus, you won’t need to bring in a physician’s extender, such as a nurse practitioner or physician’s assistant, to help manage the patient load, nor the extra management staff to deal with endless insurance issues.
A 2009 survey in the journal Health Affairs
found that physicians reported spending three hours weekly interacting with insurance plans, while nursing and clerical staff spent even more time. The national time cost to practices in an insurance model was $23 billion to $31 billion annually, approximately $26-$33 billion using 2016 figures.
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Today, Good spends the bulk of his practice time in a concierge setting, where patients pay an annual $1,800 fee and in turn, receive a comprehensive annual exam and a host of ancillary services—such as keeping patient’s medical records on a thumb drive for portability, a monthly newsletter, an on-staff healthcare coach for weight control issues, exercise advice and dietary counseling, as well as 24/7 access to Good.
“If I’m home or away, they have access to my cellphone and there’s never a time they cannot reach me,” he says. Good has 94 patients in his part time concierge practice. The typical concierge model has about 600 patients vs. 2,500 or more in an insurance-based practice. https://conciergemedicinetoday.org/2014-concierge-physician-salary-report/
The American College of Physicians has criticized the way doctors are paid by insurance carriers, saying that it has warped the way medicine is practiced, devaluing vital services such as doctor-patient discussions while pumping up rewards for expensive procedures and bigger volumes.
“We used to submit a claim, and two or three weeks later we got reimbursed. Then it became five weeks and six weeks, and then they said they never got that claim even though it was sent electronically,” says Craig Koniver, MD, an insurance-free primary care physician in Charleston, South Carolina, and author of Connected: The New Rules of Medicine
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Koniver says insurers then needed notes to support each visit or procedure, found cause to deny claims repeatedly and eventually his practice was spending inordinate amounts of time chasing down insurance reimbursements. It was time being taken away from patient care.
Good says many of his colleagues have either sold their practices to hospital systems or for-profit corporations, losing their autonomy, or formed concierge practices.
Next: Tips for Going Insurance-Free
“It’s virtually impossible for someone to run a one, two or three-man practice in this environment,” he says.
The reality of going insurance-free is that some patients will leave the practice. Good says he lost perhaps 25%, but many came back.
In fact, a 2013 JP Morgan white paper
, Key Trends in Healthcare Patient Payments,
showed that 74% of insured consumers are both able and willing to pay their out-of-pocket medical expenses up to $1,000 per year, and 90% would pay for medical expenses up to $500 per year.
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“I believe I provide a very valuable service—my patients know that I’m 100% committed to their welfare—and that I’m their advocate come what may—and that counts for something,” says Good. “I was not drinking the conventional Kool-Aid.”
For the patients that remain with an insurance-free practice model, physicians are able to offer higher quality patient care, more time, an improved doctor-patient relationship, elimination of the middle-man—the insurer—and a selection of treatment based on physician knowledge and expertise, not necessarily what a third party insurer deems appropriate.
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While transitioning to an insurance-free practice can require balancing profit and compassion, quality of care and autonomy, the pros seem to outweigh the cons for those that have taken the journey.
Tips for Going Insurance-Free
You have to be committed to your patients and your practice. You must believe in the relationship you have with your patients and believe in yourself. You have to believe that you provide a high quality, excellent service that has value.
Whether you transition to a cash practice or concierge model should depend on your personality. If it’s not an imposition to get a call late at night or early on a weekend morning, a concierge practice may be a good fit. If after hours calls are an imposition, an insurance-free model may be a better match.
Be upfront with patients. In fact, announce in writing what your plan is—to drop certain insurers, to become a cash-only practice, or to become a concierge practice. And do it well in advance of the changes.
Explain your rationale. Patients may not understand the dynamics of dealing with insurance companies, so explain the reasons you’re going this route, such as to provide them better care, spend more individual time per patient and to provide individualized services that aren’t possible when you accept insurance.
Have confidence in your decision to go insurance-free. A portion of your patients will leave the practice and you must remain steadfast and committed to your decision for the good of your patients.
Offer to file patient’s insurance for reimbursement for special services or give them all appropriate forms so they may complete them easily.