My Return to the Doctor-Patient Relationship
Updated: Aug 19, 2020
As I’ve said before, I like getting to the root of the problem in order to solve the problem. Another reason Americans are so unwell is the healthcare system does not prioritize making people well. The American healthcare system has shifted to prioritizing making profit for managed care and other corporations over patients and healthcare providers. This reality has become more apparent to me as I practiced inside the system over the years. Then the novel coronavirus (COVID19) pandemic hit and it became even more apparent how broken America’s healthcare system really is. There are for profit companies with their hand in the middle taking time and money away from patients and doctors. The system is so inefficient and disjointed that it is hurting instead of helping how the pandemic is affecting our country. https://promarket.org/2020/03/25/americas-broken-health-care-system-is-the-biggest-obstacle-to-containing-the-coronavirus/
To get to root of problem, let’s go back to before the problem. For centuries, since Hippocrates, healers gave care in the patient's home and were paid directly from the patient for services they provided.
Then insurance companies started coming between the doctor and patients in America about 50 years ago. Managed care and insurance companies are called “3rd party payers”, because the employer and patient pay the insurance companies, and then the insurance companies are supposed to pay the healthcare providers. Originally started as a benefit from employers, it initially worked pretty well: was a benefit employers could offer employees and helped manage costs. Then, as many companies in America that go unchecked in our capitalistic society, they became corporations, which put profit over people. https://stanmed.stanford.edu/2017spring/how-health-insurance-changed-from-protecting-patients-to-seeking-profit.html
The corporations got bigger and greedier. To make profits, they either increase their revenue or decrease their expenses. To increase revenue they increase premiums to employers and out of pocket costs to patients through copay/deductibles/co-insurance. To decrease expenses they decrease reimbursement to doctors, not only by making doctors sign contracts with low reimbursements, but also adding multiple hoops doctors have to jump through to get their payment for their services. In fact, approximately 25% of a medical provider’s time is spent doing administrative tasks linked to 3rd party payers. For family practitioners, that time wasted is equivalent to 170,000 full-time doctors per year. We don’t have a doctor shortage, we have an inefficiency problem. And health care workers keep doing the work as the workload increases because it is our ethos to do what we can for the patient. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html?fbclid=IwAR3leZFVVW7oMo0TFuG4HoGon3JGprBzhXppVNbAa_9fi5nNHW267kOTxx8
Healthcare workers in America are being used to make corporations money, not just insurance, but also for-profit health systems. Doctors are being manipulated and controlled by these ever growing health systems, and patient care is suffering for it: The Healthcare Blog: How to discourage a Doctor
Independent physician’s practices are disappearing. The system is getting so complicated that they have to spend much of their business overhead on billing and collections. This is driving small practices to have to join larger health systems, so the larger health systems become a monopoly and make more money: Washington Times: Hospital Insurance Collusion
The pandemic is also causing many of these practices to downsize or close because their margins were thin even before the pandemic put even more strain on them. https://www.prnewswire.com/news-releases/pmi-reports-growing-uncertainty-for-the-future-of-pediatric-practices-as-the-covid-19-pandemic-evolves-301042204.html
All of this transfers more expenses to the doctors and less revenue. Therefore, healthcare providers had to find ways to decrease costs and increase revenue to keep their business open and make a living. This is why doctor home visits became phased out: the doctor couldn’t “waste time” going to the patient and spending time with them. Instead, over the last 50 years, doctors had to move exclusively to clinics where they could see as many patients as possible. To make up for costs and decreased revenue, more extenders such as nurses, physicians assistants, and nurse practitioners were added. And of course as administrative work increased and payment decreased, doctors had to fit more patients into less time. And less time with patients means less quality of care. Doctors are being forced to put quick fixes to problems such as medications, referrals to specialists, lab and radiology tests. Doctors also have pressure from insurance companies and administration to meet "quality measures" to get paid, such as following vaccine schedule and prescribing inhalers for asthma. https://www.modernhealthcare.com/article/20150530/MAGAZINE/305309979/physician-quality-pay-not-paying-off
This one of the reasons America is so unwell: the system rewards and perpetuates “sickness” care instead of wellness care. Doctors are frustrated because they are spending more time on administration than with patients, are restricted by insurance and administration pressures, and aren’t able to give the care they want or need. Patients are frustrated because they get less time and less access to their doctor, less trustworthy care, and not getting well. Due to this inability of the system to fulfill the needs of doctors and patients, more and more doctors and patients are turning to alternative models of care outside of the system. https://www.physicianspractice.com/article/alternative-practice-models-and-why-doctors-are-switching
And that is what happened to me this year. I became tired of fighting the system to provide the care I wanted to provide. I have training in nutrition and integrative medicine, and a passion for holistic care, so I wanted to use those skills to make children more well instead of just “less sick”: but that takes more time, more access, and more flexibility than the current American healthcare system allows. I decided the only way for me to help children the best way I could was for me to go outside the system. My main goal is to provide individualized holistic care and to be able to directly answer my parent’s questions and concerns. The major barriers to this is the managed care system: taking away time, money, decision-making, and control from physicians. So I had to take 3rd party payers out between me and my patients. This type of practice is called direct primary care, meaning provide direct care and get paid directly. This means out of network with insurance companies. https://www.aafp.org/about/policies/all/direct-primary.html
When I started planning, it was eye-opening the profit and loss statements of in network vs. out of network practice. The out of network practice has 1/10th the amount of expenses and loss of revenue as being in-network with insurance companies. This means much of the work I was doing in-network was going to the system and not to the patients or myself. In my out of network practice I only need 1/10th the number of patients because it is more efficient, so I can spend 10 times as much time doing patient care. I had always wanted to be a small town doctor where the doctor truly knows the family and could spend the time and energy on each individual patient. Now without having to answer to insurance, pharmaceutical, or hospital systems I can be free to give truly individualized care. This practice model is a way for modern doctors to go around the system and go back to old-fashioned healthcare.
I have only worked in my new practice for a month, but it has changed my life and my patient’s lives. Parents aren’t frustrated and having to play doctor or talk to a nurse line that doesn’t know their child: they can reach me and I get to be their own doctor to guide them. Since I am not pressured by insurance and administrative incentives, I can be more flexible with my care and supportive of parent's medical choices. They don’t have to sit in a waiting room or urgent care and spend little time with the doctor. Instead they get ample amount of my time to provide individualized care instead of cookie-cutter care. https://diagnosislife.com/cookie-cutter-medicine-fails/ The kids love it: they don’t have to go to a stressful clinic. I have noticed kids are less anxious and are opening up to me more, which allows me to gather more information. Instead of 10-15 minutes with a child where the child barely has time to warm up, I can spend an hour where the child warms up to me first and then is more comfortable and cooperative with the visit. And they are more calm with vaccines in their own home, and I can take time to use calming and emotion regulation techniques instead of just holding them down and rushing to get it done. All of this means my care revolves around the patient's needs, not the system's needs.
Besides health benefits to direct primary care, there are also time and cost benefits. If you compare loss of work and school, urgent care/ER visits, this equals a significant amount of time and money that direct access and home visits can decrease. Insurance companies are putting more out of pocket costs onto the patient, and out of pocket copays/co-insurance/deductibles are significant and can equal the out of pocket costs of paying an out of network provider (especially when you factor in time and lower quality of care that increases costs down the road). For my practice, parents are provided invoices to turn into insurance for out of network reimbursements, and/or use HSA money. This does put some of the responsibility of 3rd party payers on the patient, but insurance companies are more cooperative with the insured who are the consumers vs. the doctors who are the “cost’. I have done this for my own out of network providers, and I can tell you it is much easier being on the patient side than the doctor side of dealing with 3rd party payers. For families that need tangible comparisons, here is a chart comparing out of pocket costs for an average high deductible insurance plan. Of course, consult with your own plan for it's policies. Note the out of pocket costs are similar, it is just how and when you pay for it. In network, with low access to doctor, there tend to be more urgent care visits, referrals, and quick fixes. With direct primary care, you have more access to the doctor that can save urgent care visits, specialist visits, and improve wellness which saves future costs. Keep in mind, when insurance "pays" for things, such as a well check, the low payment and high overhead only allows the doctor limited time and access. You get what you pay for: 15 minute well child check vs. 1 hour well child check.
I wish America had a better system that was focused more on patients and healthcare providers than the corporation’s profits. I believe the silver lining to the pandemic is it is revealing a need for our culture to return to priorities and a shift towards simplifying things. 3rd party payers have definitely made healthcare more complex and lost sight of priorities. So my practice, Mindful Pediatrics, is going back to prioritizing the patient and the simpler ways of direct doctor and patient relationship!