Healthcare Persecution

“Things get worse for you only when you try to accommodate your persecutors”

This is a quote from a book I just finished, “The Charm School” by Nelson Demille.

Definition of persecution: Persecution is persistent mistreatment of an individual/group by another group. The most common forms are religious persecution, ethnic persecution, and political persecution, though there is naturally some overlap between these terms.

How does this relate to healthcare and the transition of my practice?

I will call it Healthcare persecution.

And it depends on who are your persecutors and what type of system you are working. I have heard some physicians complain and complain again about how patients are overly demanding and aggressive about their care. They want everything and they want it immediately. These physicians appear to consider patients as their persecutors.

Insurers have persecuted physicians by making managed care contracts more and more one-sided. No one is forcing physicians to sign these contracts. Yet, physicians over the past twenty years have persecuted themselves and their patients by continuing to participate with these managed care organizations.

A result has been that physicians gave up control of healthcare decisions without even blinking. Can anyone order a MRI without prior approval? Try to get a new pharmaceutical covered. Are we truly making decisions or just asking “Mommy May I?” Are our medical decisions being tainted by trying to avoid the managed care bureaucracy? Do you avoid ordering tests or medications that need managed care prior approval? Is that the type of care you went to medical school to learn? Is that the type of healthcare system you enjoy working in?

Our patients no longer feel that we are their advocates and that we do not have their best interests in mind. In today’s managed care environment, Can you blame them? Our patient’s want our help and want it unconditionally. They want the trust back in the doctor-patient relationship. But until we give up delegating healthcare decisions to insurers, we will not get the trust back.

Why did I stop participating with insurers?

“Things get worse for you only when you try to accommodate your persecutors”

Preparing yourselves for the transition away from third parties

Preparing yourselves for the transition away from third parties:

I have been asked by other members of the physician community to write about my practice transition and the different feelings, thoughts and reactions I have had as well as those of my peers, patients and community.

A few necessary items to make the transition are listed below in no particular order:

Courage- I have learned that the path to success is not to always follow the crowd. Watch for patterns and trends and determine what you feel is sustainable and what areas are not.

Thick Skin- There will be many parties that will try to throw mud at you. Face it. A majority of the public does not like change!

Marketing Plan- Be prepared to lose a good portion of your practice. But a good marketing plan outlining the positive and valued aspects of your practice will help you to retain your existing patients while growing your practice with new.

Good communication skills- Goes hand in hand with good marketing. If you or your staff can not communicate the purposes of your transition, it will not succeed.

Savings or a spouse that works- Be prepared for a possible decrease in your revenues. It should increase as patients who desire your new style of practice join you, but how long it will take is not possible to predict.

Ability to stay within a budget- You had better have a firm grasp on your practices finances. Knowing where every dollar goes and being able to determine how much overhead you can cut to keep the practice going and to keep your income flowing is an absolute necessity.

Proactive and visionary- If you wait until everyone else is doing it, you will be left behind.

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Patient’s reactions:

Yelling and Screaming- There have actually been patients who have called up my office yelling and screaming that I no longer work with insurers. They do not understand the concept of a doctor-patient relationship without third party intrusion. I find that these are the patient’s who trust doctors the least.

Abandonment- Some patient’s feel abandoned. Again, you or your staff need to explain to all your practice that they are all still welcome, only that they will be responsible for payments as opposed to insurance.

Entitled- These are the patient’s who feel that they bought a product (insurance plan) that entitles them to free or low priced care.
"I already pay too much for insurance": Some patient’s, no matter how much they like you, feel that healthcare costs too much already by complaining about their insurance premium. It is a difficult concept for patient’s to understand but health insurance and healthcare are two different entities.

Excited and understanding: I like these patients. They understand the issues facing physicians, and they also value our services.

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Doctor’s in the community:

Inquisitive: I have had responses from other docs such as, "You are doing what?, I wish I had the courage to do that!, and "You’ll end up going back to insurers"

Watching from afar: These same docs are also watching from afar. Many pharmaceutical reps have taken questions from other docs in the community asking how my transition is going.

Eager to steal your patients: Soma, albeit a minority of doctors, actually badmouth me and my new practice style to patients who have transferred out. This is the part I do not understand and is one of the main reasons our profession has been taken over by the big business interests.

Trying to find the courage to be the next to transition: There is one other doctor in my community who has given up insurance and switched to a Concierge practice. In speaking with him, so far he is very happy, and he feels that he has his patients respect.

Respect: Whether other physicians approve or disapprove of my transition, I have earned their respect for making a bold move.
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My feelings through the transition:

Excitement: It is exciting to start over again. Now I have not totally started over as about 40-50% of my patients have remained in my practice. But it feels good for the ego when you find out that people do value your services and that you are not just another name in the insurance directory.

Pissed off at Insurance lies to patients: I get calls from patients who tell me that the insurance company will not cover testing if it is ordered by a non-participating doctor. Unless the patient is in a managed care setting, this is wrong and disingenuous on the part of the insurance industry. A good article on the above abuses can be found by following this link to an article entitled "The Health Insurance Mafia."

Fear: On the days when I see 6 patients instead of the 25 I would usually average, it can get depressing or fearful. But then the next day comes and I have 20 patients and the fear fades.

Boredom: What do I do with all the free time I have at the office when I am not seeing patients. Well so far, I have had all my paper charts scanned into electronic format, and all the paper and filing cabinets stored in a basement. I am cleaning out some exam rooms and decluttering the other office rooms. I am preparing to give some rooms a new look, new paint and more open airy feel. I have time to journal my thoughts on this transition by use of this blog, and also posting to SERMO, a physicians online community.

Like a doctor again: Imagine you are a primary doctor and you want to send a patient for some tests. You hand them a prescription and send them to your medical assistant who helps the patient schedule the test. No referrals needed. No time consuming bureaucratic waste, a happy patient who feels the office is truly helping them get through the maze of the healthcare system.
More time to spend with family and friends: The best part of the process so far. While I am a physician, I am first a husband, father, friend and neighbor.

Enjoyment of the challenge: Whenever I get bored, I look for a new challenge. I have found it. While my office is low in patient volume, it will increase within a few years, and I will look back on the boredom and wish I had some of it again.

More info on my office can be found on my website at http://www.drhorvitz.com/

Why did I choose to take the risk of alienating patients by refusing to work with insurance?

I often post on Sermo, an online physicians community. I have been asked to comment on parts of my transition to a cash practice:

Why did I choose to take the risk of alienating patients by refusing to work with insurance?

Look closely at the question.

Risk? I look at it as being more risky to my patients, my practice and my profession if I continued to participate with insurers. My job, first and foremost is to my patients. I have mentioned in previous posts and blogs that my father was a family doc. He always put his patients first. “Treat your patients like you would want to be treated, or how you would want your family member treated. Always remember without patients, you have no practice and no career.” I have always practiced by these values. I do not worry about the finances of my practice when I am with a patient. If I do right by my patients and have their trust, there is no need to worry. The practice will do fine!

Alienating patients? I treat patients not their insurance. Every patient I have is an individual, not an insured member, and not a capitated life. If patients choose to leave my practice, it is their choice to leave. I have not discharged one patient from my practice. The patients who have chosen to remain value my practice and the care they receive. Those that do not value my services will go elsewhere. What is the old adage, “You get what you pay for?”

Refusing to work with insurance? I have never worked for insurance. I always work for my patients. Insurance just gets in the way. In the past , how did insurance help me to care for my patients?Oh yea, I remember how! With managing referrrals , preauths, precerts formularies, etc. All of those office tasks were very helpful to my patients and my practice. And the insurance premiums kept going lower and lower, right?????

1st quarter 2008 transition to cash practice

January-March 2008 transition to Cash Only + Medicare Solo physician, suburban practice, large HMO penetration. Conversion to cash practice, Medicare, and Wellness-Retainer model at affordable market based prices. January and February’s numbers contained some old insurance money and is included in percentages given. Also 2 insurers remained thru part of January due to their contractual terms that I chose not to fight as it only set me back a few weeks. But February and March had little if any old insurance money and was very low compared to January.
------------------------------------------------------------------------------------------------- Comparisons given below are percentages comparing Jan-March 2008 to January-March 2007.

Patient Volume decreased by 40%

New patients seen decreased by 50%

$ per patient seen DOUBLED

Revenues increased by 18%
------------------------------------------------------------------------------------------------ More Analysis:

$ per patient visit for 1st quarter 2007 was $63.40

$ per patient visit for 1st quarter 2008 was $128.00

My practice has multiple payment options for patients. These range from selfpay, to Medicare, to Wellness and retainer options. More info on how these options differ can be found by clicking here.

The breakdown is patient visits is as follows:

Selfpay 40%

Wellness 20%

Medicare 20%

Old Insurance-Ancillary 18% and dropping

Retainer 2%

The breakdown in % revenues per patient visits is as follows:

Wellness 35%

Selfpay 29%

OldInsurance-Ancillary 25% and dropping

Medicare 8% and slightly rising as we wait for money to come in and deductibles to be paid.

Retainer 3%

$ per patient visit is as follows:

Wellness $289

Retainer $244

Selfpay $95

Medicare $40 - but waiting on billing-collections-deductibles

Other-ancillary $38 - these are quick 5 minutes visits overseeing a Naturopathic doc.
------------------------------------------------------------------------------------------------ Further analysis: A good percentage of revenues came in from Wellness Plan fees, which is upfront money. This may skew the numbers at the beginning of the year. My job is to market my office to new Wellness patients throughout the year. If I do not get these new Wellness patients, the revenues will slow.

Selfpay averaging $95 per visit. That is $32 more per visit than I received last year, or a relative increase of 33%. Also I have more time open in my schedule to fit in these patients, as I am not seeing the $10 copays or capitated patients.

Medicare averaging $40 per visit. This is skewed as I am waiting for payments to come in. But why should I have to wait? And why should I have to pay a billing specialist to get the money that I earned? Even if this number goes up to $65 per visit , it is still much lower than the selfpay, and a pittance compared to Wellness and Retainer.
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I have had a good number of patients leave my practice due to the dropping of insurance. Some have been nice about it and understanding, and some have been downright rude and insulting. So be it, i do not take it personally. Each patient may make their own decision. I am still available to anyone who wants my services, they just have to be willing to pay me directly for my services, which are priced at an extremely reasonable rate.
The feedback I have received from the patients who have remained has been terrific. While they wish they could pay me less, they have all been happy with the type of non-hurried care they recieve. They can get appointments same day. We have time to help them coordinate their care with specialists. All things that were difficult in the old-insurance driven model.
------------------------------------------------------------------------------------------------ Other Good Effects: Expenses have gone down. My medical billing expenses have been slashed by at least 75%. I have eliminated one medical assistant during my day hours, and went from two to one medical assistants during evening hours. I anticipate my payroll expenses to be slashed by about 25-30%. For other good effects for my patients please see my blog post of 2-20-2008.
------------------------------------------------------------------------------------------------ My goal is to get to about 1000 patients in my practice, instead of the average of 2500 in my community. If I can get 50% and up in the wellness and retainer plans, my revenues will be higher, and patient care will be much improved.

I call that a Win-Win!!!!