Doctors Perspective on Today’s Health Care-a ramble of thoughts

I want to let you know that Doctors have the same concerns as the patients when it comes to this Affordable Care Act (ACA). I am a physician and I have had experience with being a patient too.  This is tough for me to separate the two but I will try.

As a doctor and owner of my clinic, I have chose to exclude all insurance providers in my practice.  This has much controversy and so I will brief the reason below.

I educate daily to why I do this both to patients and to fellow doctors.  I encourage both populations to take into consideration that health insurance was created by the American Medical Association (AMA) to spread the cost among the population for drugs, surgery and hospital stays of many sorts.  Remember that this is treatment not prevention.  When this type of insurance was created there were expectations that the patient would be paying for their check ups and preventative visits which guides the patient in the right direction with proper self care, etc.  This does a few things.  One, helps keep the cost of care minimal and two, enables the proper profit to be made to the insurance company and the clinic including the doctor providing the service to stay in business.  (There are many reasons to why the AMA created HMO’s and PPO’s etc., we will not get into that in this discussion.)

The AMA created HMO’s with an algorithm that fits the model of the medical field today: treatment based care.  Here is the tricky part.  Read this carefully and fully before you make judge of your thoughts.  Prevention is something that is not included in the traditional HMO or private health insurance.  The reason is simply that medical doctors (MD’s) are not trained to prevent you from having a heart attack, they are trained and great at treating you when and after you have a heart attack (treatment). And they rock at this! The algorithm was created in mind that a certain amount of people will have gull bladder surgery and brain tumors, etc.  The statistics from this were then analyzed to come up with pricing based on age, sex and lifestyle combined.  You payed accordingly.

Take a second now to think about what adding preventative care will do to the same algorithm?!  I am not a mathematician but I can do simple math…

EXAMPLE : If you have a group of 100 patients.  In this group of 100 patients over the course of 100 years: 10 have a heart attack (HA), 10 get their gull bladder removed, 2 have metastatic cancer needing surgery of some sort and ALL 100 people pay $100 per month for care.  That means $100 x 12 months x 100 people = $120,000.00 annually into the fund.  Over 100 years this is $12 million dollars.

Average cost of Heart Attack = $38,501.00 x 10 = $385,010.00

Average cost of Gull Bladder Removal = $94,897.00 x 10 = $948,970.00

Average cost of Metastatic Cancer Treatment = (varies) $100,000.00 x 2 = $200,000.00

*these are moderate guesses for in network insurance coverage with insurance 2016.

Total pay out from insurance for cost of care in 100 years for 100 patients = $1,533,980.00

Profits by insurance companies = approximately 10.47 million (plus compound interest, minus other incidence, etc.)

This example above is very vague and is only used to show examples for what the health care by the AMA was created for.  This is all good but now we have changed the services but the algorithm is the same or similar.  So this means that the same people pay and the total of payment is still $12million.  The change is now every patient paying into the insurance is now expecting preventative care to be included.  How does this look?

$12 million – $1,533,980.00 (surgeries, cancer, HA’s) – $1500 per patient for prevention per year for 100 years ($15 million) = -$4,533,980.00

For most of us we can see that those numbers leave nothing for the insurance companies.  Which is fine by me and most of you guys are probably saying something like, “they can afford to pay us back after all of the money they have made from us in the past”.  Yes, in theory you are correct.  But they are a business and as we know businesses have to make a profit to stay in business.  YOUR TAKE AWAY:  preventative care in this treatment based algorithm thru HMO’s and PPO’s (health insurance) doesn’t and cannot work.  This is why your PREMIUMs have risen over the past few years and will continue to rise.

When you are a “self payer” meaning you pay cash these prices are drastically lower.  Why? No middle man.  No insurance liability or coverage.  No billing or coding person that needs to be paid.  No wait time on payment.  It’s patient paying the doctor for service.  That is exactly why I recommend self pay for preventative services: massage, supplements, chiropractic visits, nutrition education, etc.  My clinic handles ALL cash/self pay for care.  This is a way for me to build my relationship with my patients and do my part to keep costs of health care down and focused on what it should be focused on: Treatment and Surgery coverage.

Focus now!  To do your part you need to know what that is.  Your part is to take care of yourself and live a quality life.  To see a primary care provider regularly (annually at least) and pay for it yourself to know how to prevent illness.  Have a de-stress protocal for yourself to maintain your health.  To be proactive in YOUR care is YOUR job.

Side Note: 

MD’s are hired to perform when working for the clinics and hospitals (big business called Fairview, Allina, etc).  I know many doctors who have been made to make numbers of patients per day and per week or they were scolded and sometimes fired.  They are also made to bill out or code a certain amount to create the revenue that has been recommended for their position in the clinic.  This is also a place where doctors have been let go or made to retire early.  They are also requested and required to refer within the clinic system.  This makes it hard for the doctor to refer to an outside practitioner like myself when the patient needs an adjustment (now they are starting to hire DC’s within their systems as adjusters only, not to use our full scope of practice) or to a holistic doctor to fulfill care within their belief system and have insurance coverage for the patient.

There are many things to discuss about the set up of the large or moderate sized MBA ran clinics.  These are what I term Big Business clinics or hospitals.  They are ran by business men and woman who apply what they know (business) which in anything but health care works great.  The doctors are the employees and the patients are required to go to the clinic that is covered in network to their insurance.  Most of the MD’s and specialists are having a difficult time treating their patients the way they would like to due to the constraints of the big business occurring around them.



Author: Dr. Nicole

Enjoyment of discussion, inspiration and sharing stories and life experiences is part of who I am. I have a lot of great ideas but no time to share them. Here I can write at my leisure. I am a mom, a student and a professional.

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