In April, I wrote a post about my doctor’s departure from the American health insurance system.
In short, he now operates his practice as “direct primary medical care.” You sign up for his service, pay a set monthly cost, and come in, call, email, or text when you have a health issue. It’s so simple, and yet the experience feels revolutionary.
Urgent need? He’ll respond to your text right away.
Wondering if a symptoms requires an office visit (and time off work, fighting traffic across town, etc.)? You can spend as much time as you need explaining your concerns on the phone. There’s no push to make every question an office visit, unlike with providers who are only reimbursed by insurance for in person consultations that correspond to specific codes.
There’s also no bureaucracy, and no paperwork. Unless you have labs, there’s no need to take out your wallet. Remember, you’ve paid up front for whatever care you need. You pay cash for lab work done in the office, but, without insurance markups, these costs are reasonable—perhaps a few dollars.
I almost forget how wasteful, time consuming, and inefficient it is to get care elsewhere. I forget, that is, until I’m not feeling well, and I visit a specialist’s office or a local hospital. That’s what I did the other day, and it all came rushing back to me.
Insurance companies profit by wasting your time
I needed some blood tests, but I didn’t think I had time to drive through a major road construction site to reach my doctor two towns over. He was perfectly willing to call the orders in to the local hospital lab, which is on the same side of the bridge project as my home. I still have every right to use my insurance coverage for the tests, and my doctor retains the privilege of ordering them for me, so my out of pocket costs remain low.
In this scenario, what I lost was time.
I forgot that stepping foot into a modern medical practice begins with several pages of paperwork—repeating information I’ve provided again, and again, and again. Most of this is collected—and my ID is verified from my driver’s license—to prevent the poor, suffering insurance company from fraud.*
I waited about ten minutes to be seen by a registration clerk, who spent a similar amount of time filling out forms to initiate my lab visit.
Note that paying cash for this collection of tests at my doctor’s affiliated retail lab would be something like $25-50. Insurance billing is likely to be 10 times as much. I’ll try to update this post with actual figures if I receive an Explanation of Benefits statement.
Twenty minutes later, I can walk down the hall to the lab to wait my turn (again) in a different place. Fortunately, I’m the second patient called today (about seven minutes later.) The phlebotomist is very kind, and does her job quickly and efficiently.
Before she can, however, we spend another several minutes re-verifying my identity, though I’m now wearing a hospital bracelet from registration. My blood draw is unlikely to make me sick or injure me, so I’ve got to assume this is yet another roadblock put up to prevent unauthorized (uninsured) patients from making use of a friend’s identity.
The actual medical procedure takes about five minutes. I’m at the hospital for a little over an hour. I might have been better off braving summer road work and Friday afternoon traffic. It would have taken the same amount of time, but might not have raised my blood pressure as much!
Convoluted systems must be gamed by skilled users to receive necessary medical care
Another source of pain—psychological, this time, even more than chronological—is the effort required to book a specialized procedure. Nothing groundbreaking or experimental, mind you, but also not a quick office visit.
A rational person might be forgiven for expecting that a phone call to the main number for the office of the doctor ordering the test should be sufficient to make an appointment. Instead, that call somehow gets routed to a general scheduling office. The nice lady on the phone, though you explain who your existing doctor is, the specific test you need, etc., books you an appointment:
- as a new patient of a new doctor for a general exam, who
- doesn’t see adult patients, only children.
That’s a natural byproduct of a byzantine system that requires a battalion of billing specialists, schedulers, and receptionists to handle reams of anonymous paperwork for every patient passing through distant exam rooms. There is no direct correlation between a person making the appointment and either medical knowledge or, apparently, common sense.
I turned out to be “fortunate” that my health went downhill. I needed to check in with the specialist a month before what I thought was my scheduled procedure. She saw that I wasn’t booked for what I needed at all; the appointment I’d been given was not the next step for my full diagnosis.
My specialist gave me the direct phone number for the nurse of the other doctor who would perform my procedure. I was told to call her directly so I could avoid a similar mishap with the scheduling office.
How can it be possible that the only way to get appropriate health care through the system is to circumvent the system? In what universe does this make sense?
Careful consumers can’t compare costs, even when they want to, because they are hidden
As a final complaint about the system and advocation for my primary care doctor’s choice of direct medical care, I’d like to make another point about costs and insurance.
I require specialized care from an ophthalmologist rather than a standard annual eye exam. I was having trouble booking a “new patient” appointment with a local specialist before a lengthy trip out of state to see my parents, so I decided to inquire about the cost of paying cash in the town where I grew up instead of using my insurance coverage where I live.
An appointment was available during my visit, and the scheduler knew the practice was happy to accept cash, but it took almost a week before someone from the billing office could calculate what my exam would cost. I think that’s a vital piece of information when I’m choosing whether to pay cash for convenience.
It’s common for politicians to decry entitled healthcare consumers as a primary driver for spiraling insurance costs, and I’ve heard it stated that patients with more financial skin in the game would make more cost-conscious decisions. I don’t believe that, at all.
Now that I’m actively comparing costs before obtaining services, hoping everywhere to duplicate the ease and success of my relationship with my primary care doctor and his direct care model, I can say definitively:
- It is preposterously difficult to get a quick answer on the cost of any medical products or services from participants in the health insurance system.
I’ve experienced long waits on hold on the telephone to learn the retail price of a drug before I decide where to fill my prescription. Most pharmacies won’t give you prescription drug prices on their websites. Costco pharmacy online is the best resource I’ve come up with. You’re often asked to enter insurance information to be told “your” price for a medication, which means it isn’t the information I seek at all.
Every cost is hidden. Most of them are inflated for the artifice of marking them down when big insurance companies pay.
I’m well educated, and I have a fair amount of time on my hands. Dealing with the healthcare system when I’m feeling poorly borders on torture. I can’t imagine how hard it is for those less enfranchised to advocate for themselves.
*I might disagree with the idea that necessary medical care be conducted as a for profit enterprise, but I reject fraud as a countermeasure. Laws must be followed, or changed by civil means when possible. The burden for fraud that results directly from the institutionalization of health care (and removal of the natural safeguard built by establishing a trust relationship between provider and patient) should be borne more by the profitable insurance company, in my opinion, rather than an ill or injured party during a time of crisis.