The Messy Doctor-Patient-Insurance Relationship

Let’s talk about the doctor, patient, and insurance relationship. You have insurance for your health. You’ve gotta have insurance, it’s the law. Not only that, it’s the smart thing to do. Everyone agrees with that. Something catastrophic could happen to you or a member of your family, and how would you afford the bills?

That’s always been the case, and health insurance was a good idea.

It protects us in case something terrible happens to us or somebody we love, and gives us the means to take care of that problem.

Gradually, insurance has become much more than this.

It’s become the day-to-day manager of our health decisions.

Management or Interference?

Unfortunately, over the past decades we’ve become increasingly unhealthy, chronic diseases have escalated, and the use of extensive treatments has escalated. Human life has become prolonged with more diseases treated later into life, and now insurance costs a lot more money. For most, the cost of a comprehensive insurance plan is unaffordable, but they have to have it.

It’s interesting to think about when you’ve got health insurance, because people often believe they’ve just bought health.

Well, they haven’t bought health.

They’ve simply bought a financing plan in case they have health problems.

Actually, most families who purchase through the Affordable Care Act what they can afford without subsidies purchase bronze plans. These cover very little and have high deductibles and often what’s called “no co-pays,” meaning you pay all the bills until you meet your deductible. At this point, your insurance has done very little for you and certainly hasn’t given you health.

It’s also costing you a lot of out of pocket money, impacting your ability to invest in other things of high value. Now, if our office takes insurance, we try to work with all of our patients’ different insurances:

  • Medicare

  • Medicaid

  • Private insurance

It doesn’t matter. We feel a duty to our patients to work with the only way they have to pay for healthcare. We prefer not to have to. Our services aren’t that expensive. A lot of what we do for our patients could probably be handled through case payments in an affordable way.

It would certainly make our lives easier not to work through insurance. The administrative costs are enormous, and we have to wait weeks or months to receive the payment for the services rendered, unlike your grocery story that gets paid as you check out. This creates a lot of business challenges for us.

Not only that, insurance complicates billing issues, so oftentimes you find additional charges you didn’t anticipate, which causes frustration for you.

Now, if you call your insurance company, it’s doubtful you’ll get to speak to a person, so you call us. So we end up doing customer service for the insurance company, explaining to you the benefits written into the contract that you signed for your insurance. At some point you realize, “I guess I signed that contract, and I understand that it’s really not my doctor’s office’s fault. I’m just frustrated that after all the money I spent, I still owe more.”

The administrative costs are enormous, and we have to wait weeks or months to receive the payment for the services rendered.

Free” Physical/Preventative Exam

Now, you’re insurance wants to advertise the idea that they give you a free physical exam or preventative exam every year. It is true that all plans compliant with the new healthcare law must provide a once a year preventative exam that covers basic services recommended by the United States Preventative Task Force and the Department of Health and Human Services. They market this to you as free. Do you see the irony in that? They charge you possibly $1,000.00 a month for a plan that covers virtually nothing. They’re taking $1,000.00 a month out of your pocket while giving you almost nothing in return, and they have the audacity to actually call your one preventative exam free.

But here’s the catch.

That preventative exam is a limited exam.

Our patients with these policies typically save all of their problems up for that one exam because they believe that’s the only visit they have to the doctor that year. So they come in with their own agenda:

  • pains

  • aches

  • rashes

  • changes in energy,

  • concerns about various chronic conditions

They want to get all of that managed during a preventative exam. I actually try to do that for them, because I understand the situation they’re in.

They need to get as much as they can manage in this one visit, because they don’t have a lot of money to spend on healthcare otherwise, and they really have difficulty taking time off of work anyway to come to the doctor.

So we try.

But you have to remember your insurer has an agenda for that visit.

In fact, that visit is more about their agenda than yours.

They’re interested in ensuring your blood pressure is checked, that your body mass index is recorded and that if it’s high, you’re talked to about your weight, that you’re counseled about tobacco cessation and quitting alcohol, and any other high risk behaviors you may engage in. In addition, they want to know if you have high cholesterol that you’re taking a statin, and if you have diabetes, that you’re actually getting some form of diabetic coaching, which ironically they’re not going to pay for.

By the time we’ve checked off the list of their concerns, there’s very little time left for your concerns. No, this is not about you at all. It’s about your risk to your insurer. But they advertise it to you as such a great benefit. Now what happens? You have more problems than what are covered in a preventative visit. You need additional tests, perhaps for asthma, maybe an EKG because you’re worried about your chest pains. Perhaps you have severe pain in your shoulder restricting range of motion, and you need an injection, or you have a precancer on your face that needs cryotherapy.

Coverage Gaps

Well, none of those things are covered in your free physical. Every single one of those services will cost extra. You wonder why, and we begin to explain to you that these services cost us time and money and supplies, and we have to be able to charge for those things. We give you the cost of those things, and you decide whether or not to get them. Perhaps you get the precancer treated and don’t have to go later for an $800.00 procedure to get a skin cancer removed. Perhaps you let me inject your shoulder and give you a home therapy program while agreeing to pay the $120.00. Perhaps you don’t, and now you need surgery for adhesive capsulitis six months from now. By then, at least you’ll meet your deductible and then you can get some other things done.

The bottom line is all these services cost you more money.

The time we needed to really examine them hasn’t even been spent on them anyway, so you’ll have to come back for another visit.

Because the amount of money your insurer pays me for your free preventative physical covers only about 15 minutes of my time.

What I mean by that is the amount of payment I’m going to get covers my time and our office costs for about that long.

Or put another way, the time you get for that payment amount is about 15 minutes. That’s what I have to generate to make sure that my leases are paid, my staff are paid, and that I earn enough money to pay my mortgage.

I’m a primary care doctor, so I’m not talking about the mortgage on my second home or my yacht loan. I’m talking about the mortgage on the home my family lives in and perhaps the pair of shoes I need to buy for my son because his old ones are worn out. Ultimately, I have to earn a certain amount of money per hour on my face-to-face time or I can’t be here for you. So now there’s friction between you and me, because you have problems you for which want to find the solutions. I may have the solutions for those problems, and I want to give them to you, but….

The Doctor/Patient Understanding

But you’ve come for your once a year free physical and your insurance company controls the agenda.

Your other problems aren’t really their concern right now because they’re not gonna pay for them. So now you and I have to work out a solution.

  1. We have to start with agreeing that I care for you, and you value me and my expertise. I want to help you.

  2. We have to start with the understanding that I’m actually trying to help you through your insurer despite the hardships it places upon me and see to it that you get the care you need.

  3. I can help by working out payment plans, unlike your insurer who demands the premium paid every month or they cancel your insurance and refuse to pay for your conditions.

  4. On the other hand, I need you to trust me and understand that the additional charges that accumulate have to be paid. If they’re not paid, I’m can’t be here for you, and you won’t have a primary care office. You’ll have, perhaps, a healthcare center run by a large hospital system, and the charges will be three times what I charge you. So you have to trust me and believe that I’m in this to care for you, that my charges are fair, and you have to value me enough to be willing to pay my charges, to agree that my services are worth something to you.

Now, if my services aren’t worth anything to you, and if you feel like your time in my office is wasted, then I think that’s fair not to want to pay more money or come to my office. If I can’t help you, it’s fair that you don’t spend your time or money with me. But if you think I can help you, and you want my expertise and my time, then we have to agree I provide a certain amount of value to you regardless of the type of insurance plan you have.

If it were up to me, we’d get the insurance out of our office.

We’d work with just you.

We’d be there for you and not for data collection, not worrying about how we’ll bill for your services or how we’ll have to advocate for you to your insurance company to get the care you need.

We’d just care for your needs to the best of our ability and as quickly and affordably as possibly.

But that’s not the case. I have to work with the insurers because they control the pocketbooks of the American people. So I will, and I’ll do my best to align with them, to provide the data they need to properly care for you, to look out for the things that are risky for you in the long run, and help protect their concerns or their fiscal risk in the future. I’ll actually try to be a very good collaborator with them despite the fact they’re not good collaborators with me.

The Ideal Doctor/Patient Relationship

We need to get the concept of the insurer out of our relationship. Our relationship is about you and me, our trust for one another, and our value for one another.

If the insurance companies enter the room with you, through their care requirements or your concerns about payment, they’re intrude on the relationship. It’s unfortunate that it is this way. Interestingly enough, if you have a chronic disease, they may insist you’re seen every so often and get certain tests done in order for you to remain a compliant patient, but they’re not even paying the bill for those visits.

They mandate the course of treatment and they’re not even paying the bills. It’s an interesting situation. I hope it’ll change. We’re advocating for change. We offer collaboration with the largest insurers in our state, but no one’s been forthcoming. We’ll keep trying, and we’ll try for you. In the meantime, let’s have a great relationship.