Swarley Posted March 14, 2013 Share Posted March 14, 2013 Hi everyone, I read an article about physicians shunning insurance and going to cash only practice at Reason.com. I was hoping to hear some input and thoughts. Jim Epstein on Doctors Fighting Back Against Obamacare Dr. Ryan Neuhofel, 31, offers a rare glimpse at what it would be like to go to the doctor without massive government interference in health care. Dr. Neuhofel, based in the college town of Lawrence, Kansas, charges for his services according to an online price list that's as straightforward as a restaurant menu. A drained abscess runs $30, a pap smear, $40, a 30-minute house call, $100. Strep cultures, glucose tolerance tests, and pregnancy tests are on the house. Neuhofel doesn't accept insurance. He even barters on occasion with cash-strapped locals. One patient pays with fresh eggs and another with homemade cheese and goat's milk. "Direct primary care," which is the industry term for Neuhofel's business model, does away with the bureaucratic hassle of insurance, which translates into much lower prices. And as Jim Epstein explains, direct primary care is also part of a larger trend of physician-entrepreneurs all across the country fighting to bring transparent prices and market forces back to health care. This is happening just as the federal government is poised to interfere with the health care market in many new and profoundly destructive ways... The article in full (its 2 pages) http://reason.com/archives/2013/03/13/the-obamacare-revolt-physician-fight-bac The article embedded a link to an essay about Milton Friedman’s take on fixing health care The article embedded a link to a paper by John Cochrane about fixing health care Link to comment Share on other sites More sharing options...
jmj11 Posted March 14, 2013 Share Posted March 14, 2013 As a practice owner, I estimate that over 50% of our financial resources and 75% of our emotional resources are completely wasted on dealing with insurance companies (credentialing, re credentialing, claim submission, claim re submissions, prior authorizations, medicare rules, HITECH rules for which we reap no benefit because I'm a PA and the list goes on and on and on). I'm trying to create more and more cash only patients (especially my patients from Canada). I could drastically reduce our rates without insurance manipulations on us. It is hard for patients to get their heads around the concept of paying cash, even if that cash is a very good investment. They have a psychological barrier thinking that because they pay premiums, they deserve free care. For example, I can't get, even rich, patients to pay $50/month for a great medication because their insurance says it "isn't covered." So they will pay their $20 co pay and choose a far less effective (and sometimes more dangerous) treatment for them while paying $1,000 a month for recreation would phase them a bit. My dream is to create a cash only, Internet-based practice, where I could support myself, give excellent care . . . from my humble villa in Italy . . . or Morocco. I'm meeting next week with our web page gurus as we start taking the next step in that direction. Link to comment Share on other sites More sharing options...
physasst Posted March 14, 2013 Share Posted March 14, 2013 Laissez Faire nonsense. Epstein is a devoted free market hack who never examines the other side of issues. Freidman BTW, for those who don't know, also supported Medicaid/Medicare (and welfare as well). While he did support people having to pay for their healthcare directly. Freidman also said that the government's role should include "financing care for the hard cases". Of course in true Hayekian fashion, he never details what those "hard cases" are, but the point is, it's not that simple. This kind of concierge care will remain a novelty. It may increase in size for some things, but it's not the person on one medication or who comes in for a physical, or who has mild hypertension that is driving healthcare costs. It's the person with COPD, CHF, Diabetes, peripheral neuropathy, etc..the multimorbid patient if you will that drives costs. FWIW, you need to examine price elasticity models and income elasticity......which of course Epstein never does. There's reason that serious economic journals rarely publish any of the austrian school stuff. They don't provide data to back up their assertions. Hayek was renowned for this, stating on several occasions that human behavior was simply to complicated to be quantified accurately enough to make predictions about....but then he would go ahead and make predictions anyway without trying to model or construct his thoughts. It's nice coffeehouse banter material, and while some of his criticisms regarding econometricians do have some validity (it is NOT a hard science, despite some of their assertions, it is a social science) and some of his theories may hold some water, his refusal to try and PROVE them is a major problem for anyone serious about studying economic behavioral models....which is what we are talking about. Anyway.....it's interesting only in that it's a Randian fantasy...otherwise.....useless. Link to comment Share on other sites More sharing options...
discogenic Posted March 14, 2013 Share Posted March 14, 2013 . This kind of concierge care will remain a novelty.... This type of practice won't save healthcare but may work out well for individual practices. Link to comment Share on other sites More sharing options...
Contrarian Posted March 14, 2013 Share Posted March 14, 2013 Monday-> Friday from 0800 until 1730... I work in settings that are 100% state pay (Medicare/Medicaid), accept and deal with the inherent inefficiencies that comes along with this ... as far as I'm concerned, that IS my Zakah. Wednesday-> Fri from 1730 until 2100... I see patients in the CASH ONLY clinic I own. As far as I'm concerned, this is my personal, private time and therefore shouldn't be encumbered by the inherent inefficiencies and hassles that comes along with insurance companies. My setup is simple. $300 for initial intake evaluation which takes about 3 hrs. Then $150 per visit thereafter. Each vist about 15mins. I accept Cash, Credit Card, Electronic Check Month # 1 --> Initial Intake ($300) plus 3 follow up visits about 15mins each =$700 Month # 2--> 2 follow up visits about 15 mins each = $300 Month # 3 until discharge from practice --> 1 follow up per month = $150 Working great with 34 ($5,100) monthly patients and counting.. Contrarian btw... total overhead is about $1000/month Link to comment Share on other sites More sharing options...
rcdavis Posted March 14, 2013 Share Posted March 14, 2013 http://Www.Palmettoproactive.com A friend of mine owns this clinic, and is both serving a large patient population ( including referrals from a large regional medical center, and multiple colleges and one medical school) by offering creative pricing, costs up front, and accepting no insurance. Is opening two other clinics, ( his primary one is in Spartanburg, but will be expanding to Greenville and rock hill). The patient crept acne rate is extremely high, as is their satisfaction. Despite physassist opinion on the concept in general, for routine family practice, this model seems to be an economically viable and profitable alternative to the typical insurance only clinic. They make no apology for not accepting Medicaid patients.. Noting that many lifestyle choices most Medicaid patients make could change and allow them to afford the "menu"... Even so, they will see ED. Follow ups who have Medicaid until a Medicaid accepting clinic can be found for them ( or the patient choices not to use their Medicaid). Many, many patients are very happy with their service. Give hem a call, check out their website, check it out.. May not be nirvana, but it is, for these guys, a way to avoid all of TGE insurance problems.. And make the patient more of a partner. Link to comment Share on other sites More sharing options...
discogenic Posted March 14, 2013 Share Posted March 14, 2013 Www.Palmettoproactive.com A friend of mine owns this clinic, and is both serving a large patient population ( including referrals from a large regional medical center, and multiple colleges and one medical school) by offering creative pricing, costs up front, and accepting no insurance. Is opening two other clinics, ( his primary one is in Spartanburg, but will be expanding to Greenville and rock hill). The patient crept acne rate is extremely high, as is their satisfaction. Despite physassist opinion on the concept in general, for routine family practice, this model seems to be an economically viable and profitable alternative to the typical insurance only clinic. They make no apology for not accepting Medicaid patients.. Noting that many lifestyle choices most Medicaid patients make could change and allow them to afford the "menu"... Even so, they will see ED. Follow ups who have Medicaid until a Medicaid accepting clinic can be found for them ( or the patient choices not to use their Medicaid). Many, many patients are very happy with their service. Give hem a call, check out their website, check it out.. May not be nirvana, but it is, for these guys, a way to avoid all of TGE insurance problems.. And make the patient more of a partner. It would be nice to think that someday PAs all over the country could open similar clinics on their own. Link to comment Share on other sites More sharing options...
villa6 Posted March 14, 2013 Share Posted March 14, 2013 Hmmm..there is an idea; PAs only operating in cash only family practice clinics and let the docs have the specialty fields and insurance hassles. That's right. I said it. Link to comment Share on other sites More sharing options...
villa6 Posted March 14, 2013 Share Posted March 14, 2013 Swarley, here is a link to a discussion a while back on similar. http://www.physicianassistantforum.com/forums/showthread.php/33375-Cash-only-practices-that-refuse-insurance?highlight= Link to comment Share on other sites More sharing options...
Gordon, PA-C Posted March 15, 2013 Share Posted March 15, 2013 Hmmm..there is an idea; PAs only operating in cash only family practice clinics and let the docs have the specialty fields and insurance hassles. That's right. I said it. Ummm you're dreaming. Yeah sure a few cash only practices will always exist, but if you think that its going to turn into some kind of widesweeping trend you are sorely mistaken. Whats the highest percentage of medical delivery that will ever exist as cash only? 2%? 5% maybe? Link to comment Share on other sites More sharing options...
villa6 Posted March 15, 2013 Share Posted March 15, 2013 Ummm you're dreaming. Whats the highest percentage of medical delivery that will ever exist as cash only? 2%? 5% maybe? True I wouldn't argue that. I'm just poking some fun. I would like to see new graduates not leave primary care though. Link to comment Share on other sites More sharing options...
SocialMedicine Posted March 15, 2013 Share Posted March 15, 2013 i could imagine the cash only practice getting awkward once a patient needs a referral or lab work and the base price becomes alot more.... i guess in psychiatry thats not so common though. I have heard of some insurances not filling scripts and lab work by providers not in network. The lab work issue is somewhat common i believe. I have seen a number of practices in NYC charge a baseline fee to enroll ... one group initially advertised "WE GUARANTEE YOU MEET WITH YOUR MD". Essentially it seemed they charged money so you could email your doctor and never meet with a non MD ..... .fast fwd a year or two they have a ton of PAs even in leadership roles within the company (one medical group) and it seems every practice in the area now offers email and online scheduling without a fee Link to comment Share on other sites More sharing options...
jmj11 Posted March 15, 2013 Share Posted March 15, 2013 i could imagine the cash only practice getting awkward once a patient needs a referral or lab work and the base price becomes alot more.... i guess in psychiatry thats not so common though. I have heard of some insurances not filling scripts and lab work by providers not in network. That is one of the problems. I have a group of cash patients who their insurance, Group Health, refuses to allow them to come to our clinic because it is PA owned. Yet, so far, they have honored my Rx, labs and scans even though they (the insurance) refuses to pay for their visits to me. I think the later is slipping in beneath the radar. One thing insurance companies are doing that is changing the medical practice landscape is making it almost impossible for small, independent practices to exist. We have no bargaining clout. About 90% of the practices in our region have sold out to large systems, then the large system can negotiate with the insurance companies for better rates and can push back against unreasonable insurance requirements. For us small guys, they are bullies and we are vulnerable. They threaten me all the time to drop us . . . and if they did . . . we are toast. To have any hopes of continuing to exist, we independents need to create large associations of collective bargaining. My dream (as I close in on retirement) is to take my expertise and experience into a role of a "coach." It would be cash only, Internet based visits, but where I would not be an "ordering" provider, but a creator of very detailed and precise diagnoses and treatment plans as well as education. This way, I would avoid the problem of prescribing across state lines or international boarders and remove the vulnerability of being limited by not having laid eye-balls on the patient. But that is pie in the sky. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted March 15, 2013 Share Posted March 15, 2013 http://Www.Palmettoproactive.com A friend of mine owns this clinic, and is both serving a large patient population ( including referrals from a large regional medical center, and multiple colleges and one medical school) by offering creative pricing, costs up front, and accepting no insurance. Is opening two other clinics, ( his primary one is in Spartanburg, but will be expanding to Greenville and rock hill). The patient crept acne rate is extremely high, as is their satisfaction. Despite physassist opinion on the concept in general, for routine family practice, this model seems to be an economically viable and profitable alternative to the typical insurance only clinic. They make no apology for not accepting Medicaid patients.. Noting that many lifestyle choices most Medicaid patients make could change and allow them to afford the "menu"... Even so, they will see ED. Follow ups who have Medicaid until a Medicaid accepting clinic can be found for them ( or the patient choices not to use their Medicaid). Many, many patients are very happy with their service. Give hem a call, check out their website, check it out.. May not be nirvana, but it is, for these guys, a way to avoid all of TGE insurance problems.. And make the patient more of a partner. Sounds like my kind of place! Link to comment Share on other sites More sharing options...
physasst Posted March 15, 2013 Share Posted March 15, 2013 That is one of the problems. I have a group of cash patients who their insurance, Group Health, refuses to allow them to come to our clinic because it is PA owned. Yet, so far, they have honored my Rx, labs and scans even though they (the insurance) refuses to pay for their visits to me. I think the later is slipping in beneath the radar. One thing insurance companies are doing that is changing the medical practice landscape is making it almost impossible for small, independent practices to exist. We have no bargaining clout. About 90% of the practices in our region have sold out to large systems, then the large system can negotiate with the insurance companies for better rates and can push back against unreasonable insurance requirements. For us small guys, they are bullies and we are vulnerable. They threaten me all the time to drop us . . . and if they did . . . we are toast. To have any hopes of continuing to exist, we independents need to create large associations of collective bargaining. My dream (as I close in on retirement) is to take my expertise and experience into a role of a "coach." It would be cash only, Internet based visits, but where I would not be an "ordering" provider, but a creator of very detailed and precise diagnoses and treatment plans as well as education. This way, I would avoid the problem of prescribing across state lines or international boarders and remove the vulnerability of being limited by not having laid eye-balls on the patient. But that is pie in the sky. This is because of the ACO model and changing reimbursements which will force networks to exist, either through affiliation or outright ownership. What I support, and interestingly, so do most of the docs here, is a move towards all providers being salaried employees of a network. Elimination of bonuses on productivity (incentivizing the wrong thing) and perhaps small bonuses based on quality outcome measures when available. This is eventually going to happen, whether many providers like it or not. Link to comment Share on other sites More sharing options...
rcdavis Posted March 15, 2013 Share Posted March 15, 2013 This is because of the ACO model and changing reimbursements which will force networks to exist, either through affiliation or outright ownership. What I support, and interestingly, so do most of the docs here, is a move towards all providers being salaried employees of a network. Elimination of bonuses on productivity (incentivizing the wrong thing) and perhaps small bonuses based on quality outcome measures when available. This is eventually going to happen, whether many providers like it or not. And what happens then, if the docs all become employees, is that productivity decreases, waiting times increase. Medical practice becomes nothing but industry algorithms which allow no variance.. ( generating the question as to where innovations will come from). Already private practice is being systematically priced out of business by governmental requirements ( a la The requirement for All practices to have emr) The state needs doctors to be forced into ACOs... Doctors as employees are easily controlled.. Private practice doctors not so much. The goal is that Medicine will become an arm of the state. Link to comment Share on other sites More sharing options...
Contrarian Posted March 16, 2013 Share Posted March 16, 2013 The goal is that Medicine will become an arm of the state. Sadly... The dude who posted this is HOPING and bubbling over in his slacks thinking that this is gonna happen... A unfortunate manifestation of the true definition of the word "TOOL"... :saddd: Link to comment Share on other sites More sharing options...
rcdavis Posted March 16, 2013 Share Posted March 16, 2013 Sadly... The dude who posted this is HOPING and bubbling over in his slacks thinking that this is gonna happen... A unfortunate manifestation of the true definition of the word "TOOL"... :saddd: C I am not hoping that this happens, I am afraid that it will. I know it sounds extreme, but is what I believe, not hope, will happen. I hope just the opposite. I hope that Obama care gets gone, that ACOs fail, that medicine ( which I never reLly thought to be broken), gets handed back to the providers. Do I think the above will happen?. Probably it will not. But I can hope.. so, what have I said that warrants the ubiquitous "tool" designation? Link to comment Share on other sites More sharing options...
drholmes Posted March 16, 2013 Share Posted March 16, 2013 Interesting discussion! My dream is that not only does medicine get back into the hands of the providers but that freedom-loving folks are able to join with their providers and push back against the insurance companies and governmental agencies. Further, (and, here's a new concept...), medical decisions at the point of care. Patients negotiating with their physicians directly for levels/types of services. That action alone would limit the presence of insurance companies - relegating them into the catastrophic care coverage arena where they belong. To use an analogy: I don't need insurance for my oil change. However, if a drunk driver rearranges my back-end I would like the assurance that I have paid for it (the insurance) to be there and help out. Once the insurance companies have been reduced to an appropriate presence; then the incentive for governmental control is diminished - Note: I did not say removed; they love to control. The patient and their provider need to be in control (to the extent possible) of directing patient care. Standards of care need emerge from within the industry not arbitrarily imposed by third parties. Private (concierge) practices can then flourish in such an open environment. Not opposed to the hospital owned/administered medical communities either. Even in that environment, arrangements can easily be made for the sharing of medical information for the benefit of patient care. Lots of more details. The take-home is: (1) let the provider-patient relationship be the driving force behind the medical decision making. (2) Limit Insurance/Government intrusion. (3) Allow the local medical landscape determine the best model to deliver its services to its population. Link to comment Share on other sites More sharing options...
Contrarian Posted March 16, 2013 Share Posted March 16, 2013 C... so, what have I said that warrants the ubiquitous "tool" designation? RC.... Twas NOT directed at YOU... The "TOOL" designation was directed at the individual on this site (who YOU quoted) that is hoping this occurs... Link to comment Share on other sites More sharing options...
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