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The invasion of third parties into DPC is highly worrisome


DPC, billing confusion and defensive medicine are the hot topics in this issue's Your Voice.

This letter is in response to Dr. Scherger’s article, “Direct primary care may become the norm (June 25, 2016).”  While I am heartened by the growth of direct primary care (to the point of leaving a full-time academic position to start my own DPC practice), there is one aspect of the article that I found chilling:

 “Commercial insurance companies, Medicare and even Medicaid are starting to provide contracts to direct primary care physicians for populations of patients.”

 One of the great joys of DPC is regaining one’s sense of professional agency and collaborating with patients in a way not possible in the insurance-based system.  I am not surprised that commercial and governmental third-party payers want to co-opt the success of the DPC movement and get ahold of the “special sauce” that makes it so successful.

 I am fearful that the efforts of DPC practitioners to accommodate “contracts” with these third parties will lead us down the same path that gave rise to the DPC movement in the first place.  

What is needed is more accountability between doctors and patients, not an encroachment of insurance and government into our practices.




James O. Breen, MD

Greensboro, North Carolina



Billing confusion abounds with hybrid payment model

I recently read with interest the article by Dr. Joseph Scherger (“Direct primary care may become the norm,” June 25, 2016), in which he explores a hybrid payment model for primary care. 

 Although I find this very interesting, the fact of the matter is the insurances that I contract with indicated that this is in direct violation to our contractual agreement. They said that I may not charge the patient for any services whatsoever, that I must submit all bills to the insurance company for their review. 

 Services that are not covered by the insurance are not billable. For example, I offer a travel medicine clinic. I will have patients from other practices arrive indicating that since I participate in their insurance company that I may not charge them for the immunizations and must bill the insurance company. 

 I am required to give immunizations and then, after doing so and submitting the bills, the insurance company indicates that it is not a covered service and I may not bill the patient for such.  

 This is all, unbelievably, apparently legal according to the contracts that I have with the insurance company. Therefore, I find it highly unlikely that attempting to bill a patient $50 a month for the secretarial services, etc.,  will be allowed by any of the insurances.


M. Niziol, MD

Dryden, New York



Physicians should be in charge of how their services are sold, priced

 think it is sad the way the business of medical practice in individual offices is constantly squeezed the way it is. 

From the extraordinary costs of malpractice insurance, license fees, maintenance of certification (MOC), hospital fees for privilege renewal, electronic health records (EHR), supplies, staff salaries as well as the usual expenses of rent, utilities and so on, that I’m constantly attacked for being expensive. 

There’s the silliness of value-based pay, Merit-based Incentive Pay System, Alternative Payment Models and all the rest of the complicated systems just to get paid for an office visit. We have lost sight of the fact that office-based medical practice is a private business. 

You need to remember the amount of money I make is directly related to the number of patients I see and the work I do. How is that any different than the company down the street that changes the oil in your car? The amount of income they have is based on if they change the oil in one car a day or 50 cars a day.

I don’t read anything about the huge profits that insurance companies make off patients. Rarely, do you hear about how services are denied by these companies although we experience this on a daily basis. 

If I order a test/medication for a patient, it is because, after taking a history and doing the appropriate physical exam to determine what is needed by the patient, an educated medical decision is made. The test/medication is denied and I have to explain my reasoning to someone over the phone who doesn’t know the patient, doesn’t know their complaint and hasn’t done a history and physical.

I believe that the country needs to realize that the cost of healthcare is not due to what I get paid for an office visit. It is driven by the insurance with outrageous premiums.

I have read this before and it is true: “Physicians, like other companies in a competitive market, should be free to price and sell their services as they choose according to the market and the physician’s own policies.” 

The government and insurance companies have no place dictating how medicine is practiced or paid for.

Stop with all the nonsense by the payers. Just pay me for what I do and stop practicing medicine unless you have a medical license in my state.


Lawrence Voesack, MD

Odessa, Texas



There is a reasonable solution to minimizing defensive medicine

In “Defensive medicine versus value-based care (March 25, 2016),” Richard Roberts, MD, JD, suggested that a no-blame compensation system would be a good alternative to the current way of dealing with malpractice litigation.

Based on the workers’ compensation model, such a system would, as he said, treat patients fairly and get compensation to them much quicker than the time it takes with current methods. 

At the same time, administrative costs would be minimized.

Physicians would be spared the threat of frivolous suits and the constant stress surrounding the adversarial litigation process that can go on for years.

This is a reasonable way to treat patients and doctors fairly and minimize defensive medicine.

One can only wonder why, during the past two decades or more, that physicians have voiced strong opposition to the current malpractice system and our lawmakers for the most part have been ineffective and made little headway in improving the system.

No-blame compensation systems (like health courts, another alternative model) have great potential and lawmakers are wrong not to take them seriously.


Edward Volpintesta MD

Bethel, Connecticut 

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