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Insurance and DPC … Married or Just Dating?

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By Michael Tetreault, Editor

Editor-In-Chief, Michael Tetreault, Author, Speaker, Educator, Media Liason

Editor-In-Chief, Michael Tetreault, Author, Speaker, Educator, Media Liason

MAY 1, 2014 – Over the years, we’ve surveyed, polled and interviewed hundreds of direct-pay and cash-only doctors in this industry and asked them if they still participate in insurance. What we found was, ‘Yes!’ Approximately 70-80% of physicians and medical offices in this industry still participate in ‘some’ payor and insurance contracts. Why? Because it’s considered a safety net for the bottom line. But the reality is that most doctors who practice traditional medicine in our current third-party payer system have a glaringly obvious conflict of interest.

If you pursue a career path in direct primary care (DPC) or the like, you may hear some of your colleagues argue that by charging a fee, you limit access to patients, thus, your way of doing business is not ethical. So, just how reliant on those HMO, PPO and MCO contracts are you? Are you married to them or just dating them for a while? It’s also important to note that while the number of DPC doctors not participating in insurance carrier contracts whatsoever is slowly increasing and becoming more popular, some physicians enter into the water of DPC more slowly and cautiously than others.

According to Dr. Steven Knope, ‘They sign contracts with HMOs and insurance companies in exchange for patient referrals from these companies. In many of these contracts, doctors agree to limit or ration care to patients to maximize profits for these companies, their Wall Street shareholders and their CEOs. Some contracts even prevent the doctor from sharing this information with their patients. By any reasonable assessment, this third-party payer system is intrinsically unethical. Concierge medicine, by contrast, has no third-party conflicts. Patients pay their doctor directly for his services in the concierge model, just as they did in the days of Marcus Welby. In the concierge model, the doctor is the advocate for one party and one party only: the patient. He/she has no allegiance to or conflicts with third parties.’

For Dr. David Bisbee, the son of a seventh-generation Vermont dairy farmer, the motivation for switching to a concierge practice in late 2013 was only partly financial. The 59-year-old family practitioner says he was driven more by a desire to regain his “autonomy” as a physician and get back to the basics of why he got into medicine 27 years ago.

“I do house calls, I deliver babies, I go to the hospital and the nursing home,” explains Bisbee, who is also the Medical Director of a long-term nursing facility in Morrisville. (He waives his annual fee for most of his elderly patients and allows others to pay in installments.) “This is what I call a modern medical practice with a lot of old-fashioned notions.”

Dr. Robert Nelson of Atlanta, GA

Dr. Robert Nelson of Atlanta, GA

Dr. Robert Nelson, a direct primary care physician at MyDocPPS in Cumming, GA notes “One cannot legislate or mandate professional ethics; a physician either possesses it or not. Physicians (providers) will NOT be more likely to put patient welfare first in a third – party payer, heavily regulated system as compared to a system where the patient also acts as the consumer, not just a passive recipient of care. In fact, the opposite is true. Our present system encourages providers to only do the minimum to satisfy audit requirements of payers. A consumer-driven system where the provider works FOR the patient, not as a bill collector for the insurance company, would be MORE responsive to patient needs and wishes; working with the patient to establish an agreed upon level of care based on an informed patient who is exercising choices allowed because they are both the consumer AND the patient.”

Donald O. Clifton said in the book Now, Discover Your Strengths’ “There is one sure way to identify your greatest potential for strength: Step back and watch yourself for a while. Try an activity and see how quickly you pick it up, how quickly you skip steps in the learning and add twists and kinks you haven’t been taught yet. See whether you become absorbed in the activity to such an extent that you lose track of time. If none of these has happened after a couple of months, try another activity and watch and then another. Over time your dominant talents will reveal themselves, and you can start to refine them into a powerful strength.”


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Categorised in: Business, DPC News, Inside A Practice, Insurance, Trends

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