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Millions of Americans are eligible for health insurance for the first time through the Affordable Care Act, but a small segment of doctors say they want out of the third-party payer system.
The practice models vary considerably, from low-overhead cash practices to direct primary care. But the reasons for parting ways with insurance companies are pretty much the same. Physicians say they are fed up with declining payments, stacks of preauthorization forms, and the hamster wheel of 8-minute patient visits.
So they’re taking a leap of faith, tearing up their insurance contracts, and in some cases, opting out of Medicare.
"I was really scared that I wouldn’t have patients," said Dr. Juliette Madrigal-Dersch of Marble Falls, Tex., who started her own cash-only practice about 11 years ago.
For the first 6 years, Dr. Madrigal-Dersch’s internal medicine–pediatrics practice was cash only but accepted Medicare patients. But she soon realized she wanted out of Medicare too. That was the scary part for her. She said she worried that she wouldn’t have any patients over age 65 once she made the switch.
Her fears turned out to be unfounded. Although many of her Medicare patients did leave the practice, some stayed and then some returned. The ones who came back told her that they missed the long visits – typically 20 minutes to an hour – and felt like they couldn’t always get the care they wanted from other doctors who participated in Medicare.
Leaving Medicare
Dr. Madrigal-Dersch, who is a past president of the Association of American Physicians and Surgeons (AAPS), is part of a growing and vocal minority of physicians who are opting out of Medicare.
The AAPS, which is outspokenly critical of the Affordable Care Act (ACA), has been hosting a series of workshops providing tips to physicians on how to move to cash-only practice and how to drop Medicare. The sessions are in high demand, said Dr. Jane Orient, AAPS executive director.
Dropping insurance and going cash only is a model that works not just for primary care physicians, but for lots of specialists too, she said, including surgeons. It can be harder to do in fields like neurology where most of the patients are older and the procedures are expensive, she added.
Although the number of physicians who are opting out of Medicare is still small, the momentum is growing, Dr. Orient said. "I think some of the physicians who do it want to stay under the radar, particularly with Medicare."
Federal officials have acknowledged the trend, but said it is not impacting access to care. A recent analysis from the Health and Human Services department shows that about 650,000 physicians participate in the Medicare program nationwide. In 2012, 90.7% of physicians were accepting new Medicare patients, up 87.9% in 2005, according to the report.
Dr. Lee H. Beecher, a psychiatrist and addiction specialist in St. Louis Park, Minn., said he also maintains a cash-only practice. He stopped accepting all insurance, including Medicare, about 8 years ago.
The problem, he said, is that he started to feel like an employee of the insurance companies.
"I felt that the quality and nature of my practice was being challenged and actually subverted in many ways by the third-party payer system," said Dr. Beecher, who is also the president of the Minnesota Physician-Patient Alliance, a nonprofit think tank.
The transition was pretty straightforward for him, Dr. Beecher said, because psychiatrists are paid basically for their time. Despite this, he said that it is difficult for patients to learn what psychiatric services cost. When patients asked around to find out the cost of psychiatric consultations and care at Minnesota’s large clinics, they were told that no one knew the actual cost and that the charge was determined by the patient’s insurance.
"Unless psychiatrists have direct pay practices, their fees are not visible to patients," Dr. Beecher said.
Prices on display
Price transparency is a big part of the appeal of the cash-only model, said Dr. Brian R. Forrest, a family physician in Apex, N.C., who started a direct primary care practice called Access Healthcare.
At Access, the prices for each type of office visit are displayed on a large menu in the waiting room. The most expensive visit is $59.
Patients who don’t want to pay a la carte can join the practice as "members." For a monthly membership fee of $39, a patient can come in for any reason and pay a $20 per visit fee. That fee includes most lab work.
This pricing structure saves their uninsured patients about 80% on their out-of-pocket costs, Dr. Forrest said. But it’s also a money saver for insured patients, he said.
The reason Access can keep the prices low is the lack of overhead costs associated with participating in insurance contracts. Dr. Forrest estimated that by not billing insurance, a typical practice can decrease its overhead costs by about $225,000-$250,000 per physician per year.
"We don’t need that heavy staffing because we’re not filing or coding or billing or anything like that," Dr. Forrest said.
Dr. Forrest’s model – known as direct primary care – has attracted interest from businesses that want to provide access to primary care to their employees.
For instance, a local sushi restaurant wanted to provide health care for its 12 employees but couldn’t afford the cost of health insurance for the group. The owner contracted with Dr. Forrest’s practice and pays $39 per month per employee.
This type of model allows patients to get nearly unlimited access to primary care at a low and predictable price. However, it doesn’t cover services outside of primary care such as specialist visits, hospitalizations, and surgeries. As a result some employers have chosen to couple the direct primary care option with high-deductible insurance plans.
Putting the focus on primary care helps keep down costs in other areas too, according to Dr. Forrest. Patients at Access have lower than average hospitalization rates, he said.
Next steps in direct primary care
The direct primary care model has advantages over simply going cash only, said Dr. Erika Bliss, the president and CEO of Qliance Medical Management, a company that has pioneered the direct primary care model on the West Coast. Qliance charges a flat monthly fee for unrestricted primary care services at its five primary care clinics in the Puget Sound area of Washington.
The biggest advantage to the monthly fee approach is that it moves away from fee for service, Dr. Bliss said. Going cash only is a start, but it still leaves physicians stuck with volume incentives.
"When you’re getting paid by the service, it changes the way you think about it," Dr. Bliss said. "You’re thinking, ‘If I’m going to make enough money, I need to see X number of patients a day and I need to get paid X amount per visit.’ It’s hard to layer on top of that true population-based care."
Qliance is taking the direct primary care model farther. Qliance, which already contracts with large employers like Expedia, is now being offered on the Washington state health insurance exchange as part of the Coordinated Care Ambetter health plan for individuals.
On Twitter @MaryEllenNY
Millions of Americans are eligible for health insurance for the first time through the Affordable Care Act, but a small segment of doctors say they want out of the third-party payer system.
The practice models vary considerably, from low-overhead cash practices to direct primary care. But the reasons for parting ways with insurance companies are pretty much the same. Physicians say they are fed up with declining payments, stacks of preauthorization forms, and the hamster wheel of 8-minute patient visits.
So they’re taking a leap of faith, tearing up their insurance contracts, and in some cases, opting out of Medicare.
"I was really scared that I wouldn’t have patients," said Dr. Juliette Madrigal-Dersch of Marble Falls, Tex., who started her own cash-only practice about 11 years ago.
For the first 6 years, Dr. Madrigal-Dersch’s internal medicine–pediatrics practice was cash only but accepted Medicare patients. But she soon realized she wanted out of Medicare too. That was the scary part for her. She said she worried that she wouldn’t have any patients over age 65 once she made the switch.
Her fears turned out to be unfounded. Although many of her Medicare patients did leave the practice, some stayed and then some returned. The ones who came back told her that they missed the long visits – typically 20 minutes to an hour – and felt like they couldn’t always get the care they wanted from other doctors who participated in Medicare.
Leaving Medicare
Dr. Madrigal-Dersch, who is a past president of the Association of American Physicians and Surgeons (AAPS), is part of a growing and vocal minority of physicians who are opting out of Medicare.
The AAPS, which is outspokenly critical of the Affordable Care Act (ACA), has been hosting a series of workshops providing tips to physicians on how to move to cash-only practice and how to drop Medicare. The sessions are in high demand, said Dr. Jane Orient, AAPS executive director.
Dropping insurance and going cash only is a model that works not just for primary care physicians, but for lots of specialists too, she said, including surgeons. It can be harder to do in fields like neurology where most of the patients are older and the procedures are expensive, she added.
Although the number of physicians who are opting out of Medicare is still small, the momentum is growing, Dr. Orient said. "I think some of the physicians who do it want to stay under the radar, particularly with Medicare."
Federal officials have acknowledged the trend, but said it is not impacting access to care. A recent analysis from the Health and Human Services department shows that about 650,000 physicians participate in the Medicare program nationwide. In 2012, 90.7% of physicians were accepting new Medicare patients, up 87.9% in 2005, according to the report.
Dr. Lee H. Beecher, a psychiatrist and addiction specialist in St. Louis Park, Minn., said he also maintains a cash-only practice. He stopped accepting all insurance, including Medicare, about 8 years ago.
The problem, he said, is that he started to feel like an employee of the insurance companies.
"I felt that the quality and nature of my practice was being challenged and actually subverted in many ways by the third-party payer system," said Dr. Beecher, who is also the president of the Minnesota Physician-Patient Alliance, a nonprofit think tank.
The transition was pretty straightforward for him, Dr. Beecher said, because psychiatrists are paid basically for their time. Despite this, he said that it is difficult for patients to learn what psychiatric services cost. When patients asked around to find out the cost of psychiatric consultations and care at Minnesota’s large clinics, they were told that no one knew the actual cost and that the charge was determined by the patient’s insurance.
"Unless psychiatrists have direct pay practices, their fees are not visible to patients," Dr. Beecher said.
Prices on display
Price transparency is a big part of the appeal of the cash-only model, said Dr. Brian R. Forrest, a family physician in Apex, N.C., who started a direct primary care practice called Access Healthcare.
At Access, the prices for each type of office visit are displayed on a large menu in the waiting room. The most expensive visit is $59.
Patients who don’t want to pay a la carte can join the practice as "members." For a monthly membership fee of $39, a patient can come in for any reason and pay a $20 per visit fee. That fee includes most lab work.
This pricing structure saves their uninsured patients about 80% on their out-of-pocket costs, Dr. Forrest said. But it’s also a money saver for insured patients, he said.
The reason Access can keep the prices low is the lack of overhead costs associated with participating in insurance contracts. Dr. Forrest estimated that by not billing insurance, a typical practice can decrease its overhead costs by about $225,000-$250,000 per physician per year.
"We don’t need that heavy staffing because we’re not filing or coding or billing or anything like that," Dr. Forrest said.
Dr. Forrest’s model – known as direct primary care – has attracted interest from businesses that want to provide access to primary care to their employees.
For instance, a local sushi restaurant wanted to provide health care for its 12 employees but couldn’t afford the cost of health insurance for the group. The owner contracted with Dr. Forrest’s practice and pays $39 per month per employee.
This type of model allows patients to get nearly unlimited access to primary care at a low and predictable price. However, it doesn’t cover services outside of primary care such as specialist visits, hospitalizations, and surgeries. As a result some employers have chosen to couple the direct primary care option with high-deductible insurance plans.
Putting the focus on primary care helps keep down costs in other areas too, according to Dr. Forrest. Patients at Access have lower than average hospitalization rates, he said.
Next steps in direct primary care
The direct primary care model has advantages over simply going cash only, said Dr. Erika Bliss, the president and CEO of Qliance Medical Management, a company that has pioneered the direct primary care model on the West Coast. Qliance charges a flat monthly fee for unrestricted primary care services at its five primary care clinics in the Puget Sound area of Washington.
The biggest advantage to the monthly fee approach is that it moves away from fee for service, Dr. Bliss said. Going cash only is a start, but it still leaves physicians stuck with volume incentives.
"When you’re getting paid by the service, it changes the way you think about it," Dr. Bliss said. "You’re thinking, ‘If I’m going to make enough money, I need to see X number of patients a day and I need to get paid X amount per visit.’ It’s hard to layer on top of that true population-based care."
Qliance is taking the direct primary care model farther. Qliance, which already contracts with large employers like Expedia, is now being offered on the Washington state health insurance exchange as part of the Coordinated Care Ambetter health plan for individuals.
On Twitter @MaryEllenNY
Millions of Americans are eligible for health insurance for the first time through the Affordable Care Act, but a small segment of doctors say they want out of the third-party payer system.
The practice models vary considerably, from low-overhead cash practices to direct primary care. But the reasons for parting ways with insurance companies are pretty much the same. Physicians say they are fed up with declining payments, stacks of preauthorization forms, and the hamster wheel of 8-minute patient visits.
So they’re taking a leap of faith, tearing up their insurance contracts, and in some cases, opting out of Medicare.
"I was really scared that I wouldn’t have patients," said Dr. Juliette Madrigal-Dersch of Marble Falls, Tex., who started her own cash-only practice about 11 years ago.
For the first 6 years, Dr. Madrigal-Dersch’s internal medicine–pediatrics practice was cash only but accepted Medicare patients. But she soon realized she wanted out of Medicare too. That was the scary part for her. She said she worried that she wouldn’t have any patients over age 65 once she made the switch.
Her fears turned out to be unfounded. Although many of her Medicare patients did leave the practice, some stayed and then some returned. The ones who came back told her that they missed the long visits – typically 20 minutes to an hour – and felt like they couldn’t always get the care they wanted from other doctors who participated in Medicare.
Leaving Medicare
Dr. Madrigal-Dersch, who is a past president of the Association of American Physicians and Surgeons (AAPS), is part of a growing and vocal minority of physicians who are opting out of Medicare.
The AAPS, which is outspokenly critical of the Affordable Care Act (ACA), has been hosting a series of workshops providing tips to physicians on how to move to cash-only practice and how to drop Medicare. The sessions are in high demand, said Dr. Jane Orient, AAPS executive director.
Dropping insurance and going cash only is a model that works not just for primary care physicians, but for lots of specialists too, she said, including surgeons. It can be harder to do in fields like neurology where most of the patients are older and the procedures are expensive, she added.
Although the number of physicians who are opting out of Medicare is still small, the momentum is growing, Dr. Orient said. "I think some of the physicians who do it want to stay under the radar, particularly with Medicare."
Federal officials have acknowledged the trend, but said it is not impacting access to care. A recent analysis from the Health and Human Services department shows that about 650,000 physicians participate in the Medicare program nationwide. In 2012, 90.7% of physicians were accepting new Medicare patients, up 87.9% in 2005, according to the report.
Dr. Lee H. Beecher, a psychiatrist and addiction specialist in St. Louis Park, Minn., said he also maintains a cash-only practice. He stopped accepting all insurance, including Medicare, about 8 years ago.
The problem, he said, is that he started to feel like an employee of the insurance companies.
"I felt that the quality and nature of my practice was being challenged and actually subverted in many ways by the third-party payer system," said Dr. Beecher, who is also the president of the Minnesota Physician-Patient Alliance, a nonprofit think tank.
The transition was pretty straightforward for him, Dr. Beecher said, because psychiatrists are paid basically for their time. Despite this, he said that it is difficult for patients to learn what psychiatric services cost. When patients asked around to find out the cost of psychiatric consultations and care at Minnesota’s large clinics, they were told that no one knew the actual cost and that the charge was determined by the patient’s insurance.
"Unless psychiatrists have direct pay practices, their fees are not visible to patients," Dr. Beecher said.
Prices on display
Price transparency is a big part of the appeal of the cash-only model, said Dr. Brian R. Forrest, a family physician in Apex, N.C., who started a direct primary care practice called Access Healthcare.
At Access, the prices for each type of office visit are displayed on a large menu in the waiting room. The most expensive visit is $59.
Patients who don’t want to pay a la carte can join the practice as "members." For a monthly membership fee of $39, a patient can come in for any reason and pay a $20 per visit fee. That fee includes most lab work.
This pricing structure saves their uninsured patients about 80% on their out-of-pocket costs, Dr. Forrest said. But it’s also a money saver for insured patients, he said.
The reason Access can keep the prices low is the lack of overhead costs associated with participating in insurance contracts. Dr. Forrest estimated that by not billing insurance, a typical practice can decrease its overhead costs by about $225,000-$250,000 per physician per year.
"We don’t need that heavy staffing because we’re not filing or coding or billing or anything like that," Dr. Forrest said.
Dr. Forrest’s model – known as direct primary care – has attracted interest from businesses that want to provide access to primary care to their employees.
For instance, a local sushi restaurant wanted to provide health care for its 12 employees but couldn’t afford the cost of health insurance for the group. The owner contracted with Dr. Forrest’s practice and pays $39 per month per employee.
This type of model allows patients to get nearly unlimited access to primary care at a low and predictable price. However, it doesn’t cover services outside of primary care such as specialist visits, hospitalizations, and surgeries. As a result some employers have chosen to couple the direct primary care option with high-deductible insurance plans.
Putting the focus on primary care helps keep down costs in other areas too, according to Dr. Forrest. Patients at Access have lower than average hospitalization rates, he said.
Next steps in direct primary care
The direct primary care model has advantages over simply going cash only, said Dr. Erika Bliss, the president and CEO of Qliance Medical Management, a company that has pioneered the direct primary care model on the West Coast. Qliance charges a flat monthly fee for unrestricted primary care services at its five primary care clinics in the Puget Sound area of Washington.
The biggest advantage to the monthly fee approach is that it moves away from fee for service, Dr. Bliss said. Going cash only is a start, but it still leaves physicians stuck with volume incentives.
"When you’re getting paid by the service, it changes the way you think about it," Dr. Bliss said. "You’re thinking, ‘If I’m going to make enough money, I need to see X number of patients a day and I need to get paid X amount per visit.’ It’s hard to layer on top of that true population-based care."
Qliance is taking the direct primary care model farther. Qliance, which already contracts with large employers like Expedia, is now being offered on the Washington state health insurance exchange as part of the Coordinated Care Ambetter health plan for individuals.
On Twitter @MaryEllenNY
