Sunday, July 25, 2010

Sorry, We Don't Take Health Insurance

"Ok Sarah, that will be $1,576 for today's visit," the receptionist at the doctor's office said. That was for a new patient consultation including labs sent to a private laboratory (not Quest or Labcorp, the only ones that have contracts with major health insurers). Granted, the appointment was for a very, very specialized doctor who is one of only 30-40 practitioners of this kind in the United States. I look forward to sharing the details about this with you once the problem is, God willing, solved.

One of the harsh realities of living in the Washington, D.C., area is that fewer and fewer doctors and other health care practitioners take any health insurance. I first encountered this with my therapist, thinking it was an anomaly, but its not. There are whole medical practices here, including gastroenterology practices that charge $3,000 for a colonoscopy that have opted out of health insurance entirely and have no trouble attracting patients. One of my friends from a country with a robust government-run health care system paid $4,000 for all of her prenatal care (minus labs and sonograms, which she got from in-network facilities) from a local pair of obstetricians after being treated like a farm animal at a massive ob-gyn practice that did accept her insurance. She doesn't regret it.

That there are healers who have opted out of taking insurance used to offend me on a deep, guttural level, and frankly, for the therapist, it kinda still does. The main thing that helped me get over resenting doctors who opted out of the insurance system was experiencing the higher caliber of care that I receive from them. At this point, most of my health care practitioners do not take any health insurance. This isn't because I love spending $200 for a follow-up visit to my Lyme doctor when I could see an internist for $10; I need the complex care that these doctors and complementary medicine practitioners excel at providing. They schedule adequate time for appointments (45 minutes) that insurance companies would cap at 10 minutes. My calls get returned promptly, instead of my message languishing at the bottom of someone's in-box.

A good example of this is the time I had a tricky problem involving a drug contraindication. I needed to take an antifungal drug for a gastrointestinal yeast infection, but the drug my yeast was susceptible to impeded metabolization of another drug I take that could kill me if not metabolized prompty. I called my doctor who prescribed the drug I was on already and he told me it was a tricky situation that would take a few days to work out. When he called me back later in the week, he had formulated a plan for me with the National Institutes of Health's lead investigator in the clinical trials of that drug. I thought at the time, "This is why I pay you $500 an hour." In an ideal world I could expect the same degree of effort and resolution from my internist who does accept insurance, but let's get real!

Besides the noticeable increase in the quality of care, the other factor that softened me to seeing docs who don't take my insurance is that I feel like its the crappy policies of the insurance companies themselves that have led to this phenomenon. They pinch pennies so hard, they scream. They will not compensate doctors for appointments that last more than 10-15 minutes, and their reimbursement rates for docs are based on what a doctor's visit cost circa 1969. Most disturbingly, all of the insurance company policies actually put them in the position of practicing medicine without a license; how else can I explain the menacing letters my doctors get asking them if it's ok to switch a prescription drug of mine for another one that is better placed on their formulary? How else can we explain restrictions on the length of appointments they will compensate docs for? One of my doctors told me that he doesn't feel that he can ethically practice medicine within the restrictions set by the insurance companies, so he doesn't try anymore.

Then there's the good old principal of supply and demand: if people in D.C. have the money to pay out of pocket, would you rather make $35 or $200 for an appointment? I thought so. The one thing that sticks in my craw about this is that although medicine is a livelihood, I still harbor some idealism that it is a calling, and that doctors should want to maximize the people they can heal. Limiting their practice to a small subset of the population means that some of the people who most need their care can least afford it. I'm sympathetic to this: my husband David and I made the choice to completely go outside the system in 1999 when money was very tight for us. We just decided that my health care was a top priority, and that we were willing to go into debt to do so. That means that quite a few doctors visits were paid for on credit cards back then. Granted, you have to be at least basically financially stable to have this option open to you; if we were living on the streets, we couldn't have charged doctors visits to Visa. Interestingly, David has had a complete conversion on this issue; he initially went along with my out-of-network jaunts begrudgingly, and now has seen the difference in my care and has come to Jesus, as we say in the south.

Another interesting twist on this is the increase in concierge medicine, like MD-VIP. My old internist joined that program. He still accepts many insurance plans and you still pay for every visit, but in addition you fork out $1500 a year for the privilege of retaining him as your doctor. In return, you're promised good customer service and communication and same- or next-day appointments. It also includes a really thorough annual physical. Of that retainer, my physician gets $1000 per patient and MD-VIP gets $500. I was one of only a few patients who declined to follow him into this program, but he still is my pulmonologist and he's an amazing doctor. When I learned he was joining MD-VIP, I wasn't surprised; not any slouch can command a hefty retainer fee. I wish I had thought of concierge care first.

After reading this, if you're asking, "Why does she still pay for health insurance?" I will tell you in my next post.


David said...

I've definitely had my on-the-road-to-Damascus moment on this issue: I've pretty much come to the belief that health insurance is the problem, not the solution, especially as we use "insurance" to also mean "maintenance plan" rather than "shared risk pool."

Anonymous said...

You nail the issue quite well and in granular terms, i.e., ethical divide as well as the practical realities faced by physicians in the prevailing mangled, I mean 'managed', care billing and collections insurance model.

IMJ, docs opting for alternative concierge, boutique, membership or retainer based medical models are rational responses to an irrational system that is imploding on itself as we speak. Thanks for your post, I tweeted it this AM via @2healthguru.

Sarah said...

I agree with you, David, and that will be the subject of my next post. Gregg, thank you for the tweet. I appreciate it! I enjoy your blog.