We acquire health insurance, either on our own or by our employer. With a sigh of relief we feel comfortable, until we read the coverage.
Suddenly we realize that despite paying 500-2000 a month our insurance requires three additional monetary contributions:
- Co-Pays; every time you see the doctor or nurse practitioner you have to provide money upfront. Anywhere from 25-50 dollars unless it’s a specialist then 75-100 for the office visit.
- Urgent cares (100) and emergency departments (300)
- Large deductibles – money required prior to your health coverage starts covering; anywhere from 4000 to 10000.
- If that weren’t enough; many insurance plans, particularly the more affordable, once the deductible is met still won’t pay 100% of the health care. Many, will require you still be held responsible for 20% of the bill.
- It may not seem like much, but consider a severe automobile accident that requires a 7-day hospitalization. If you enrolled in the typical Affordable Medical Care Act plan, after being responsible for 10K deductible you are saddled with 20% of a 300K bill! 60,000.
Traditional Health Plans
They see their patient. Each visit is pre-calculated based on diagnosis or type of visit how much will be reimbursed.
This is assuming the patient is seen physically in a set window of time and does not allow any other medical problems to be involved for reimbursement.
In other words, you may be there for a headache and hypertension, but the doctor has to choose one or the other to be paid, not both.
Furthermore, the insurance company determines if all has been documented appropriately. With just one error in the documentation, they reject payment entirely.
Text messages, phone conversations, renewal of medications, even regular physical exams for sports or travel are not covered.
As all is assessed, the doctor realizes that their average reimbursement for each patient will be 25-50 each visit
(YES THAT INCLUDES CO-PAY)
Therefore see as many as you can, overbook (who cares if they wait), and bill as much as you can. If you have a diagnosis that is obvious on the phone, still come in, otherwise, there is no reimbursement.
Put ANYONE under that stress – they won’t be able to do what they want, be your doctor. This is what has destroyed the doctor-patient relationship.
Direct Primary Care
DPC offers transparency in cost and ideally service. What is actually provided is up to the practitioner. You could have 24/7 instant call back, regular office visits with a few labs included, or only tele-medicine.
DPC can be created in many different ways, but the bottom line is set cost for direct service.
Insurance companies hate this. It bypasses their ability to control and make money for themselves.
My own American Academy of Family Practice suggests this concept is the fall of medicine itself. Why, because it is a fundamental loss of control for the medical community.
What can occur with DPC is the development of a relationship with your doctor without required office visits. Reliability and open communication. I am allowed to help you without the constraints created by insurance companies.
Now each physician interprets this differently. It is important as you enter an individual practice to understand expectations and mutual goals. In the end; you will have the opportunity for the traditional patient-physician relationship.
Disadvantages — it is a cash-only system for health care. Your insurance will only be effective for lab, radiology, or consults. Should you have some form of insurance? Yes. Even if it’s just catastrophic, it will help if some life-altering event occurs.