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Practicing with, and without, payers

Medical Economics JournalMedical Economics October 2020
Volume 97
Issue 14

If you are in a membership medicine model, is working with payers the right way to go?

Stay in network or out? Accept Medicare or don’t? What’s better for physicians or more appealing to patients?

For physicians changing to a membership medicine model, these are some of the most pivotal questions to consider. Under the membership medicine umbrella, concierge models usually accept insurance while direct primary care (DPC) generally does not. The lines, however, are not solidly drawn, and in certain situations and markets, concierge physicians have launched thriving payer-free practices in an effort to simplify payment arrangements for themselves and their patients.

The majority of physicians in our concierge medicine network do choose to participate in both Medicare and remain in-network with commercial insurance, which is a decision fueled by patient preference. From the patient’s perspective, the ability to use Medicare, a program they’ve paid into for decades, is a valued benefit. It’s also important to note that the entire insurance submission process is not as unwieldy or time-intensive for physicians caring for between 300 and 600 members in our concierge model versus nearly 2,000 patients in traditional fee-for-service practices.

But our model is tailored to reflect each doctor’s individual vision while ensuring optimal care and convenience for their patients. We have successfully partnered with doctors who prefer to practice outside of insurance networks and be freed of the need to file or submit claims, enter insurance data into the EHR or comply with insurance oversight and restrictions.”

For Chicago-based internist and endocrinologist Robert Sobel, M.D., who changed to concierge medicine with the help of Specialdocs in 2016, the decision to practice without payers was carefully considered but seemed almost inevitable.

“The direction of reimbursement payments continued to go south over the last two decades, and cost controls and increased regulations for professional services were becoming unmanageable for our practice,” Sobel explains. “In my opinion, more bureaucracy seldom means better care. Our healthcare system is evolving with increasing complexity as more advanced diagnostic and therapeutic tools are introduced, and it’s vital that we use only the best clinical decision-making to incorporate and implement these into our practice.”

Sobel stresses that being out of insurance networks does not eliminate interaction with their systems and processes.

“We are still intimately involved in advocating for our patients’ treatments and medications, and in providing referral entities with essential information,” says Sobel. “However, practicing in this model allows me to focus on making the right clinical decisions for my patients as well as the time and resources to fight through bureaucratic tangles to help them get what they need.”

Family medicine physician Larry Leibowitz, M.D., who hasn’t participated in any type of insurance network since establishing his Connecticut-based Matrix Personalized Medicine practice with Specialdocs’ support in 2017, says he’s never regretted his decision.

“There’s really no advantage to patients by my accepting insurance or Medicare,” he says. “If I were in-network, patients would be responsible for copays and would incur out-of-pocket costs for office visits and other procedures until they met their deductibles, on top of my annual membership fees.In my model, they’re responsible for none of that.”

Once he clarifies for prospective patients that all services beyond the ones he renders will continue to be covered by insurance, patients rarely object to the arrangement. In fact, Leibowitz says he has never had a prospective patient opt to not enroll as a member of his practice because of insurance concerns.

“On a personal and professional level, I couldn’t have anticipated how much more unfettered I feel over the course of the day,” he says. “While I still need to obtain prior authorizations for medications and imaging studies for my patients, I no longer have to please insurance companies or Medicare or meet the proper metrics for reimbursement.”

The decision to stay in-network or remain outside of it is a personal one for physicians, not based on finances, but on their perception of how they can make it easier for their patients to receive care. The concierge medicine model is not sustained by insurance reimbursement but by membership fees. On average, 87% of a concierge physician’s revenues come from members paying an annual fee, while only 13% of revenues are realized through insurance reimbursement.

Leibowitz acknowledges that he’s leaving a relatively small amount of money on the table by not filing for reimbursements, but says the resulting independence is worth every penny.“I’m able to care for patients without the daunting administrative burdens that most participating providers face.And the personal and spiritual freedom I’ve gained in this model has been priceless to me.”

He adds: “I’m also able to modify my fee schedule as I please in order to accommodate a patient who has fallen on hard times. I can simply say ‘I’ve known you for years... so let’s make this work for you’ without concerns about insurance backlash.”

My advice for physicians weighing whether to accept insurance as they make the change to a personalized practice model is keep in mind the potential downside of not accepting insurance in terms of practice growth. Insurance coverage remains the top-ranked factor influencing American consumer decisions about where and with whom to seek medical treatment. Other surveys show that patients typically first evaluate potential providers by posing just one question: Do they take my insurance? And if you do feel strongly that remaining outside of insurance networks is the right choice for you?

Here are some tips:

Consider your patient panel carefully. Doctors who successfully practice without accepting insurance have exceptionally loyal patients who stay with them because of the value placed on their relationship.

Thoroughly understand your community’s demographics. Price your services in a manner that both sustains your practice and is affordable for current and future patients.

Work with a partner who is flexible in considering your best options when making the change to a concierge medicine practice with or without payers, and has the experience and compassion to support your decision. Our approach has always been to manage the business for our physician clients according to their values and preferences, and enable them to focus solely on the business of caring for their patients.

Terry Bauer is CEO of Specialdocs, a leading concierge medicine transition and practice management company.

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