My motivation for starting this blog is a passionately held view that medical care in the U.S. desperately needs a change of direction. I believe health care needs to be RESTORED closer to the way it was prior to the advent of Medicare and third-party domination. The bandaid “reforms” that have been passed into law over the past 20 years are not getting the job done; they have actually perpetuated the worst characteristics of the current system. All the “reforms”, including the PPACA, have focused on the wrong thing: They focused on coverage and ignored the real cost drivers. While well intended, ObamaCare (ACA) just doubled-down on the dysfunction because it failed to focus on the fundamental problem: The real cost drivers.
After working in primary care and urgent care for more 25 years, I became convinced that change could not be affected from working WITHIN the system. With every passing year, things seemed to get more complicated for doctors and patients. Some colleagues and patients would speak out and some just shrugged their shoulders, but virtually no one thought it was getting any easier to navigate the increasingly complex, confusing and frustrating system of third-party networks; including Medicare.
The changes needed to restore our healthcare system won’t happen in a vacuum. That is why this blog also emphasizes and promotes the importance of returning to a true free-market based economy (not the crony capitalism that is so prevalent in the U.S today which is used by politicians to play favorites and pick winners and losers) and achieving a sustainable national fiscal policy.
I believe we need a fundamental shift in the way we deliver and pay for routine medical care. If we continue the path we’re on, EVERYONE will lose. This is not a partisan political issue for me. It is one derived from careful experience-based observation for many years of trying to do the right thing for patients, while being beholden to payer contracts and bureaucratic priorities that were often in deference to the patient’s best interests.
Below is a list of 10 fundamental professional & economic beliefs that I embrace related to the relationship between a physician & patient and the role of insurance. I am sorry to say that most, if not all, of these principles are not operational in the third-party dominated healthcare market of today. I believe we should work towards restoring these principles to preserve a really precious thing: the sanctity, privacy and respect of the Patient-Doctor Relationship:
I am convinced…
…of the sovereignty and good judgment of the individual patient to seek care as they see fit at a transparent price and in the absence of insurance network constraints.
- …that quality medical care starts with an unencumbered Doctor-Patient relationship.
- …a doctor serves their patient’s needs better if they work directly for the patient, and not within the constraints, mandates or barriers of a provider contract with a third party.
- …that only by creating free-agents of both physicians and patients will we bring together the stakeholders for a meaningful exchange of value, thus substantially lowering medical costs in the outpatient arena.
- …that the main driver of health care costs in the outpatient arena is not malpractice costs, but rather expensive third party pre-paid policies that utilize “first dollar” benefits for virtually any physician interaction, regardless of how minor.
- …to gain control of spiraling medical costs in the U.S, health “coverage” needs to become a true “insurance” policy such that it only insures unexpected losses that we otherwise couldn’t afford on our own.
- …that health insurance works best when it is portable, personal, private and not linked to employment, nor zoned by networks. This approach would allow insurance policies to be tailored to individual needs, cut down on the number of uninsured due to job changes and other life events, thus obviating the need for expensive COBRA coverage.
- …that the true costs of medical care is much lower than that reflected by the cost of a co-pay based health coverage policies offered in the workplace today.
- …only by creating free agent of physicians and patients will the economic forces of supply and demand exert their desired effect, thus determining fair market value of routine medical services.
- …that better informed consumers make better patients and unrestricted patients make better consumers.
Robert Nelson, MD
i am right there with you. Funny, I was about to give Dr. lab and a high five until I read the end of his piece. Fortunately that led me to read your comment then blog. I am on the insurance side and would love to work with you to solve this problem one employer group a t a time until we can have a real debate about Single Payer – either the government or the individual. The ironic thing is that Dr. lab and was so close when he brought in the Life insurance market. That shows what happens with limited regulation and competition – an affordable way to finance the chance of dying prematurely or of protecting the estate from taxation. In fact, DPC + a sensible financial structure to finance the catastrophic loss is the perfect model for the US.
Would love to talk.
Thank you. Is this Leslie?
Yes, I would be interested in your perspective being from the insurance side. We (direct primary care / direct pay advocates) need to know how to reach out to employers with an alternative message that makes sense for their business, saves money and provides higher employee satisfaction. Here is my professional email and my website, respectively: RobertNelsonMD@mydoc-pps.com and http://www.mydocpps.com
Feel free to contact me. I have some questions and ideas and would love to hear your perspective/solutions for the employer side.
Robert W. Nelson, MD
I was thinking perhaps being forced off current insurance by Obamacare may be a blessing because it is such an upgrade from the underinsurance they are paying for now. My son had a very cheap one with Aetna partially paid by employer – covered only 4 doctor visits a year and $1,000 total hospital benefit per year. That kind of stuff is a ripoff. What is your opinion?
Yes, some of the skimpier policies will get beefed up, but many will just be gone with the ACA, unless they contain the 10 core benefits. Those are required by smaller employers offering health plans and those purchased individually in the private market.
The one you referenced that your son had through Aetna is sometimes called a “skinny” plan. Those remind me of some of the dental plans out there; very low total benefit amount. I would say, why bother? Those low end things can be paid for out of pocket anyway with saving the amount of the premium cost and paying as you go. Now if those visits are to an expensive specialist, then that kind of policy might make sense if you have a low risk of being in hospital. As we all know, just setting foot in the hospital is guaranteed to eat up that $1,000 benefit in a hurry. I suppose if you know what you are getting and the price is reasonable, then there is nothing wrong with them. It is hard for me to imagine a price point that would make that kind of lean coverage a value.
I am curious, if you recall, what was the monthly premium for that Aetna policy?
Perhaps in the $35 dollar range each bimonthly paycheck and was a mandatory deduction five years ago. I am so grateful I will be unaffected as I have medicare advantage plan. No premium, no copay, most meds free. I don’t know why most seniors are not onto med adv. Med adv don’t need to be paying $3,500 a year for that supplemental for uncovered 20%. Med adv cover 100%. Ophthalmologist and Psychiatrist were hard to find nearby(Miami Dade County is pretty big) but in Adventura(NE corner of Miami Dade) has bazzilions of other types MD’s that take Preferredcare Partners.
So about $70 per month or $840 for the year which would have more than covered 4 doctor visits per year, unless there were a lot of labs or other tests associated with the visits. For $750 per year, I offer my patients 4 house calls, 4 remote (telemedicine) encounters, a lab panel, a physical, 24/7 access, flu shot, etc…
Yes, hang on to your Medicare Advantage Plan, because you won’t likely get it back if you ever drop it. Medicare Advantage took a big hit to help fund the ACA; to the tune of about 500 billion.