What do you guys think of doctors that that are cutting out insurance companies?

[Proudfather94]

So I was watching some virtual shadowing videos and some of the doctors in California that I saw are starting to do something like a subscription service. The patient pays so much a year out of pocket that ends up being cheaper than their deductible would have been scheduling appointments. One of them also mentioned a deal they made with a company that tests blood results and said the rates were lower than they would have paid with insurance.

Do you guys think this will be the way a lot of physicians will be heading in the near future? These docs saw a fraction of the pts they would have seen had they accepted insurance, spent more time with each patient, made a similar income, and charged the pt less. It seems like insurance companies have gotten so bad with their scummy practices that some people and doctors are deciding they're better off without them.

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[SurfingDoctor]

I mean, sometimes the no insurance works, sometimes it doesn't (no insurance okay for primary care, not so much for hospital-based care). But medical insurance has only been around for over a century... so good luck getting rid of it.

 

[Lem0nz]

So I was watching some virtual shadowing videos and some of the doctors in California that I saw are starting to do something like a subscription service. The patient pays so much a year out of pocket that ends up being cheaper than their deductible would have been scheduling appointments. One of them also mentioned a deal they made with a company that tests blood results and said the rates were lower than they would have paid with insurance.

Do you guys think this will be the way a lot of physicians will be heading in the near future? These docs saw a fraction of the pts they would have seen had they accepted insurance, spent more time with each patient, made a similar income, and charged the pt less. It seems like insurance companies have gotten so bad with their scummy practices that some people and doctors are deciding they're better off without them.

This really only makes sense in primary care/initial access facing fields. The second you step off the deep end into even a mildly specialized care path or have a diagnosis that requires a second doctor, all of that falls apart without insurance.

Take what I do for example - cancer. Who on Earth would keep a heme/onc, rad/onc, and surgical oncologist on retainer? What if you never get cancer? Now look at what happens if you DO get cancer and you attempt to pay out of pocket. If it isn't super early stage and cured by surgery only (~10k at least) you're looking at hundreds of thousands of dollars when you get your diagnosis. Insurance is just cost sharing for the inevitable illness that nature will throw someone's way. If one person had to absorb that cost they would likely just not get care and die. If its spread a cross 100 people of varying ages than it isn't that big of a deal because tendency is only a few will be sick at one time at the extremes of the age spectrum.

What you will see is that people with money who can afford to have both, will. And they'll get immediate access to primary care for all their needs and be like "dang, this is awesome". And if something goes super sideways and they get a bad diagnosis, they will still have insurance. Everyone else will have insurance and the system we have as it currently is.

Edit: That said, what you might see at some point in America is true capitation. The closest thing we have is Kaiser. Where instead of paying an insurance company, you pay a healthcare system a set amount of dollars (very similar to the retainer fee for direct access primary care) and then you have access to the entire system. But this won't mean you get seen the same day in your house, it is rather just an attempt to reduce costs and bloat that you allude to from the administrative/profit oriented capitalist piece of insurance. It would not surprise me if we see Walmart and Amazon have their own health care systems in the next decade or two similar to Kaiser where there is no insurance - you just get healthcare if you work for them and it is what it is. The downside of this model is that you are generally stuck with whatever they give you, even more so sometimes than with insurance. No shopping around providers. No going out of network without paying $$$.

 

[xffan624]

In medical school, I rotated with a primary care doctor who had a relatively successful traditional (but independent) practice but transitioned to this model of practice (commonly known as direct primary care). As stated above, it only really works with primary care. People still need catastrophic coverage for major illnesses or injuries. For her, it greatly improved her practice as she didn't have to balance meeting the metrics/standards of all the insurance companies that covered her patients and she could simply focus on seeing patients and giving them the best care. She also contracted with labs, radiology, and pharmacy suppliers to provide those services at discounted, near cost prices. For some patients, that itself was almost the worth the cost of the DPC monthly payments.

In summary, it's a care model option for enterprising primary care doctors that I hope will spur greater transparency in the current black box that is health care costs, but it's not the end all of health care. Hospitalizations and long term care for serious illnesses are expensive enterprises that someone has to pay for.

 

[iqe2010]

Concierge Care/Direct Primary care is great. It works especially well when the practice has agreements with other facilities like labs and other doctors offices. You can get labs done for 5-10 dollars and certain imaging can be done at a fraction of the traditional cost.

I don’t think the practice model works outside of primary care tho.

 

[Wolvvs]

Edit: That said, what you might see at some point in America is true capitation. The closest thing we have is Kaiser. Where instead of paying an insurance company, you pay a healthcare system a set amount of dollars (very similar to the retainer fee for direct access primary care) and then you have access to the entire system. But this won't mean you get seen the same day in your house, it is rather just an attempt to reduce costs and bloat that you allude to from the administrative/profit oriented capitalist piece of insurance. It would not surprise me if we see Walmart and Amazon have their own health care systems in the next decade or two similar to Kaiser where there is no insurance - you just get healthcare if you work for them and it is what it is. The downside of this model is that you are generally stuck with whatever they give you, even more so sometimes than with insurance. No shopping around providers. No going out of network without paying $$$.

Kaiser's a great example of vertical integration between health systems and insurance, but capitation-style payment models are becoming more common elsewhere too, including through traditional payors. In Massachusetts, since 2009 BCBS has run what they've called the Alternative Quality Contract which is essentially ACOs, and right now around 80% of docs in MA participate with BCBS via the AQC. Medicaid in MA is also primarily run through ACOs.

 

[operaman]

I think direct pay models are fascinating. The subscription model seems to work well for primary care. Other cash pay models have been used in procedural fields for decades: derm, cosmetic procedures, pain, all dental, OMFS, etc. There are definitely people willing to pay cash for care. A great example of cash based surgical care would be the surgery center of Oklahoma where they list prices on their website. The rates are actually very competitive relative to traditional hospitals

The expansion of high deductible plans will probably drive more young healthy people to cash pay options. If I had a $10,000 deductible and needed a procedure that costs $12k at the insurance approved hospital but $4k at a cash pay center, I’d probably pay cash if I knew I would be unlikely to hit my deductible that year.

For now you would still need hospital insurance to cover for major injury/illness. Ironically, that’s what health insurance used to be called back in the day. I’ve helped a number of self employed friends cut their insurance costs dramatically by dropping to a major medical plan and using a direct primary care model.

 

[lumya]

I took a couple classes on this in school, but basically the model could work, but only in some populations where the outcome is predictable. Typically people buy insurance not for the day to day, but in event of a catastrophe. There are lots of primary care settings where a subscription model makes sense, especially for patients with limited incomes like the elderly. The issue arises if there are big ticket items.

If health insurance only paid for the high cost items, then premiums would go up. But the idea is that you pay into health insurance and you're keeping the waters steady so that big costs like hospitalizations or expensive chemo drugs don't rock the boat too much. Of course there's a lot of issues with price transparency and administrative burden which contributes to the whole "wow my hospital charged me $60,000 but my insurance paid 90% of it with 'negotiations'."

There's a really interesting health system in Arizona called Valleywise Health that provided a non-insurance maternity package that lays out set prices for labor and delivery. They seem to be pretty sustainable, but I think they have clauses where they will transfer you in certain cases because they can't handle high risk cases.

 

[aldol16]

No. Insurance addresses a market gap. The gap is that everyone wants to offload risk but nobody wants to take on additional risk unless it also benefits them. So you need a mechanism through which a large pool of people can offload their risk in a systematic way. Subscription services only work at the local scale where you have doctors who contract with patients living nearby to provide services at some cost. The doctors are then taking on the risk. But for it to work large scale, you'd need large networks of providers which don't exist outside of traditional insurance networks.

Also, insurance networks are really just huge subscription services if you think about it. You pay some subscription fee (premium) to receive some services (healthcare). It's just that insurance companies can coordinate at the national level and work with thousands of individual facilities and hundreds of thousands of providers to offload risk in a systematic way.