Does anyone bypass insurance for primary care?

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sergio
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Does anyone bypass insurance for primary care?

Post by sergio » Fri Feb 14, 2020 1:26 pm

For the last two years I've gone to one of the large clinics near my house for annual physicals. The visits were super rushed, doctors were seemed somewhat uninterested, the physical exams seemed superficial. To top it off, one year I got hit with a $200 "office visit" charge because I asked about an intermittent hand cramp I was having. The physician looked at it for a minute and said it'd go away on its own. :x

At the suggestion of a friend I went to a cash-only physician a few days ago. The waiting area looked like the lobby of 4/5-star hotel, the visit was nearly 30 minutes long and much more thorough, the doctor seemed incredibly relaxed and more of a friend or ally. And shockingly, the whole only cost $160 which included a bunch of labs and a 10-minute follow up call with him if I want.

Apparently he charges straight time ($120/half hour visit + any labs or fees) and you can talk about anything you want in that time.

This got me thinking - are there other opportunities like this in health care to get better service by paying cash? Does anyone bypass insurance for all but the most severe issues?

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Kenkat
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Re: Does anyone bypass insurance for primary care?

Post by Kenkat » Fri Feb 14, 2020 1:30 pm

I’ve been bypassing my insurance more and more for prescription drug coverage and using GoodRX instead. One recent prescription $70+ through my insurance, $20 through GoodRX.

squirm
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Re: Does anyone bypass insurance for primary care?

Post by squirm » Fri Feb 14, 2020 1:32 pm

More people are using the consierge route.

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Re: Does anyone bypass insurance for primary care?

Post by gbronc » Fri Feb 14, 2020 1:40 pm

This is especially useful if you are using an HSA plan (which have very high deductibles) and it's not the one annual free physical you get under the HSA plans. We have nothing like what you describe in our area, but it would be a no brainer under an HSA. I mostly use the annual physicals for the lab tests anyway since the actual physical seems to have limited value and is rushed through by the doctor or PAs. Most lab tests (but not all) are free once per year and you don't really need a doctor's input to decipher what they are saying.

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dm200
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Re: Does anyone bypass insurance for primary care?

Post by dm200 » Fri Feb 14, 2020 1:59 pm

Before my wife was on Medicare (where blood tests are no charge), her Obamacare plan had significant charges for the various blood tests.

over45
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Re: Does anyone bypass insurance for primary care?

Post by over45 » Fri Feb 14, 2020 2:03 pm

We are able to buy 90 day prescriptions for less money outside of insurance, than if we bought them with insurance. GoodRX has saved us a ton and it never hurts to ask especially when you have to first cover the copay amounts before actual insurance kicks in.

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Re: Does anyone bypass insurance for primary care?

Post by jpelder » Fri Feb 14, 2020 2:09 pm

I don't do this, but visits to my designated PCP are only a $20 copay (an annual physical is $0 copay), and I usually don't have any balance bills for my annual visit

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Re: Does anyone bypass insurance for primary care?

Post by VictoriaF » Fri Feb 14, 2020 2:15 pm

I have ordered some blood tests on my own. I also wanted a prescription that my regular physician would not write, and I went to see a specialist who accepted only cash. I consider my approach as being half-way between traditional and concierge: I do my own research, get tests I am interested in, and find doctors to follow up.

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Re: Does anyone bypass insurance for primary care?

Post by sport » Fri Feb 14, 2020 2:19 pm

Our MA plan provides primary care office visits for $15 and all other doctor visits at $25. One well check per year at no charge, and one eye exam per year at no charge. We have no reason to bypass insurance.

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Re: Does anyone bypass insurance for primary care?

Post by niceguy7376 » Fri Feb 14, 2020 2:50 pm

sergio wrote:
Fri Feb 14, 2020 1:26 pm
one year I got hit with a $200 "office visit" charge because I asked about an intermittent hand cramp I was having. The physician looked at it for a minute and said it'd go away on its own. :x
I had this experience during my last physical visit last year. When I received the bill, they added a "15 minute doctor visit" for the extra questions and charged me $80. I asked the office manager to send me the time the doctor came into the room and time they left because doctor spent less than 4 minutes total including the annual check up.

If I had the option OP had, I would gladly pay since we are on HSA HDHP plan anyway.

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Re: Does anyone bypass insurance for primary care?

Post by LadyGeek » Fri Feb 14, 2020 2:58 pm

A number of replies concerning medical advice have been removed (skipping annual exams, benefits of certain tests). As reminder, see: Medical Issues
Questions on medical issues are beyond the scope of the forum. If you are looking for medical information online, I suggest you start with the Medical Library Association's User's Guide to Finding and Evaluating Health Information on the Web which, in addition to providing guidance on evaluating health information, includes a list of their top recommended sites.
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Re: Does anyone bypass insurance for primary care?

Post by lthenderson » Fri Feb 14, 2020 3:09 pm

sergio wrote:
Fri Feb 14, 2020 1:26 pm
This got me thinking - are there other opportunities like this in health care to get better service by paying cash? Does anyone bypass insurance for all but the most severe issues?
Pre-Affordable Care Act days, both my parents went to a cash only doctor and just had a catastrophic health insurance policy. They were farmers so didn't have any subsidized premiums and it was cheaper to do it that way than for a policy without a lot of riders for pre-existing conditions. Also like you mentioned, the service seemed a lot more personal and better. Post-ACA, the doctor closed up shop for various reasons so they had to get an expensive policy through the ACA until eligible for Medicare.

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Re: Does anyone bypass insurance for primary care?

Post by go140point6 » Fri Feb 14, 2020 3:53 pm

My wife has been having issues with her hip, affecting her running (we're both active as my handle suggests) and after almost a year of dealing with the HMO provided care and physical therapy, she started going to a cash-only place recommended to her. We live in Southern California, and she has to drive up to Hollywood (so that sucks) but she has been amazed at the difference in care and the level of care. One PT on the HMO plan had a piece of paper with "exercises" for her to do that he had ready before he had even met her or discussed her problem with her! The cash-only place actually examined her before suggesting treatment. Needless to say, the new place is money well spent (happy wife, happy life). To avoid the traffic this week, she made the appointment for 6 AM... try and do that with an HMO provided office visit.

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Re: Does anyone bypass insurance for primary care?

Post by oldfatguy » Fri Feb 14, 2020 3:55 pm

go140point6 wrote:
Fri Feb 14, 2020 3:53 pm
My wife has been having issues with her hip, affecting her running (we're both active as my handle suggests) and after almost a year of dealing with the HMO provided care and physical therapy, she started going to a cash-only place recommended to her. We live in Southern California, and she has to drive up to Hollywood (so that sucks) but she has been amazed at the difference in care and the level of care. One PT on the HMO plan had a piece of paper with "exercises" for her to do that he had ready before he had even met her or discussed her problem with her! The cash-only place actually examined her before suggesting treatment. Needless to say, the new place is money well spent (happy wife, happy life). To avoid the traffic this week, she made the appointment for 6 AM... try and do that with an HMO provided office visit.
Anyone NOT doing that should be reported to their licensing agency.

mega317
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Re: Does anyone bypass insurance for primary care?

Post by mega317 » Fri Feb 14, 2020 3:58 pm

Why do you think the waiting room is nice and the doctor is happy? Those things are not necessarily indicative of good care.
https://www.bogleheads.org/forum/viewtopic.php?t=6212

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sergio
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Re: Does anyone bypass insurance for primary care?

Post by sergio » Fri Feb 14, 2020 5:12 pm

mega317 wrote:
Fri Feb 14, 2020 3:58 pm
Why do you think the waiting room is nice and the doctor is happy? Those things are not necessarily indicative of good care.
The waiting room is not indicative of the level of care, but it was nice to sit in a pleasant environment with bottled water and plants rather than the usual dingy waiting room. I don't understand why a doctor that's relaxed/laid back (which is what I said, not "happy") could be any worse than the rushed, inattentive corporate drones I had the previous two years.

And the physical exam included several things the previous two physicians didn't do: testicular cancer check, full upper/lower body exam, oxygen level check, (optional) prostate exam, and so on. He asked several questions about diet, exercise level, sex drive/performance, stress levels, things like depression and anxiety and so on to make sure there wasn't anything suspicious. And gave me lots of advice and suggestions for health improvement going forward.

It was surreal to have that comprehensive of an exam, all with an MD (no PAs there).

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Re: Does anyone bypass insurance for primary care?

Post by JoeRetire » Fri Feb 14, 2020 5:22 pm

sergio wrote:
Fri Feb 14, 2020 1:26 pm
This got me thinking - are there other opportunities like this in health care to get better service by paying cash?
Google "concierge medicine".
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cyclist
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Re: Does anyone bypass insurance for primary care?

Post by cyclist » Fri Feb 14, 2020 6:02 pm

We're recently retired and not yet eligible for Medicare. The cost to us (after premium tax credits) of the best HMO plan available through our state's exchange was about half of the cost of a good PPO plan, but DW has long-term relationships with some of her docs. It was cheaper for us to go the HMO route and pay her docs out of pocket than to buy the PPO insurance that would cover them.

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Re: Does anyone bypass insurance for primary care?

Post by dm200 » Fri Feb 14, 2020 6:24 pm

cyclist wrote:
Fri Feb 14, 2020 6:02 pm
We're recently retired and not yet eligible for Medicare. The cost to us (after premium tax credits) of the best HMO plan available through our state's exchange was about half of the cost of a good PPO plan, but DW has long-term relationships with some of her docs. It was cheaper for us to go the HMO route and pay her docs out of pocket than to buy the PPO insurance that would cover them.
Cyclist
Just my two cents -- but I feel that keeping a relationship with a particular doctor is very, very overrated, as long as you do not have to switch all your physicians every year. A few years ago, when I went on Medicare and moved to the Kaiser plan, I had to switch 4 or 5 doctors - all of whom I was happy with. With 20/20 hindsight, I now have concluded that my Primary Care Doctor now is much better than my previous PCP. All of the others are fine - some a little better and some a little worse -- but all very competent.

My wife feels the same way as well.

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Re: Does anyone bypass insurance for primary care?

Post by bbqguru » Fri Feb 14, 2020 6:41 pm

My wife and I went the direct primary care (concierge) route three years ago. My wife has a chronic condition that required coordination of several specialists and our traditional PCP wasn't equipped to handle it. And then he left the local health system and our clinic couldn't find a MD for several months.

We pay around $120/month for both of us and it includes same day appointments for up to an hour, phone/text/email, prescriptions & labs at cost +10%, and a long list of other basic services included in the fee. When my wife had pre-surgical labs done, our cost was less than $20. The hospital did a set as well and insurance paid over $400. We've never used it, but they do have Face Time available for after-hours and will make house calls if requested. One monthly script went from a $35 with insurance to $5/month from the Dr.'s office.

Long story short, we find it extremely valuable and worth the cost. When we first signed up, my wife was visiting our PCP every other month at $30/visit, so the premium to make the switch wasn't that great. In the past year, she's had a couple of surgeries that made a 1000% improvement and now we don't have office visits but probably 3-4 times per year.

It's still a shock when you call the office to schedule an appointment or ask a question and it's the actual Dr. that answers the phone. And the convenience of email for script refills and the like is phenomenal.

toofache32
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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Fri Feb 14, 2020 8:49 pm

go140point6 wrote:
Fri Feb 14, 2020 3:53 pm
My wife has been having issues with her hip, affecting her running (we're both active as my handle suggests) and after almost a year of dealing with the HMO provided care and physical therapy, she started going to a cash-only place recommended to her. We live in Southern California, and she has to drive up to Hollywood (so that sucks) but she has been amazed at the difference in care and the level of care. One PT on the HMO plan had a piece of paper with "exercises" for her to do that he had ready before he had even met her or discussed her problem with her! The cash-only place actually examined her before suggesting treatment. Needless to say, the new place is money well spent (happy wife, happy life). To avoid the traffic this week, she made the appointment for 6 AM... try and do that with an HMO provided office visit.
I'm not sure what's so surprising about this. HMO providers are rewarded by providing less care.

I am a different type of physician but I work in both models depending on the day of the week. One is my private practice and the other is the institutional hospital clinic where I am merely an employee. My private practice patients get longer visits and my cell phone number. I do my own wound care, suture removal, consents, H&Ps, etc. I sometimes meet patients in my office after hours and weekends if needed. For the hospital clinic, I am only given about 7-8 minutes for each visit then a few more minutes to document the visit. Everything possible is offloaded to less expensive nurses for many follow-up appts such as wound care and suture removal. A nurse does the H&P and consents, and for after hours problems they go to ER or urgent care. Instead of my cell number, there is a generic nurse line who will take a message and triage it to either give you an appt soon or tell you to go to the ER. A discount plan does not pay for my cell number and immediate availability. Actually the opposite.

The hospital clinic still meets the minimum standard of care and is cheaper. It just depends on what level of service you value. You don't always get what you pay for, but you will never get what you don't pay for.
Last edited by toofache32 on Fri Feb 14, 2020 8:58 pm, edited 2 times in total.

stoptothink
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Re: Does anyone bypass insurance for primary care?

Post by stoptothink » Fri Feb 14, 2020 8:53 pm

bbqguru wrote:
Fri Feb 14, 2020 6:41 pm
My wife and I went the direct primary care (concierge) route three years ago. My wife has a chronic condition that required coordination of several specialists and our traditional PCP wasn't equipped to handle it. And then he left the local health system and our clinic couldn't find a MD for several months.

We pay around $120/month for both of us and it includes same day appointments for up to an hour, phone/text/email, prescriptions & labs at cost +10%, and a long list of other basic services included in the fee. When my wife had pre-surgical labs done, our cost was less than $20. The hospital did a set as well and insurance paid over $400. We've never used it, but they do have Face Time available for after-hours and will make house calls if requested. One monthly script went from a $35 with insurance to $5/month from the Dr.'s office.

Long story short, we find it extremely valuable and worth the cost. When we first signed up, my wife was visiting our PCP every other month at $30/visit, so the premium to make the switch wasn't that great. In the past year, she's had a couple of surgeries that made a 1000% improvement and now we don't have office visits but probably 3-4 times per year.

It's still a shock when you call the office to schedule an appointment or ask a question and it's the actual Dr. that answers the phone. And the convenience of email for script refills and the like is phenomenal.
My employer has 6 DPC clinics all over the country, including one on-site at our global headquarters (where I work). HUGE, MASSIVE, employee perk. I'll hopefully never have to back to dealing with insurance.

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Re: Does anyone bypass insurance for primary care?

Post by Sandtrap » Fri Feb 14, 2020 9:13 pm

DW and I have always gone where the best medical care is available regardless of insurance coverage.
At times, it has been costly but well worth it.
It is in our best interest to be our own advocates when it comes to quality medical support and care.

When we were in ACA coverage (dismal and expensive) for several years before Medicare, we really bit the bullet paying for outside insurance quality care, yet having the ACA Coverage policy expense (just in case).

At present, not all medical clinics and specialists take Medicare.

* There's a danger in limiting one's medical care and treatment, etc, to only what is covered by insurance.

**It is well worth it to be sure one has more than adequate financial resources in retirement to cover all insured and uninsured quality medical services.

j :happy
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Re: Does anyone bypass insurance for primary care?

Post by Dottie57 » Fri Feb 14, 2020 9:36 pm

Sandtrap wrote:
Fri Feb 14, 2020 9:13 pm
DW and I have always gone where the best medical care is available regardless of insurance coverage.
At times, it has been costly but well worth it.
It is in our best interest to be our own advocates when it comes to quality medical support and care.

When we were in ACA coverage (dismal and expensive) for several years before Medicare, we really bit the bullet paying for outside insurance quality care, yet having the ACA Coverage policy expense (just in case).

At present, not all medical clinics and specialists take Medicare.

* There's a danger in limiting one's medical care and treatment, etc, to only what is covered by insurance.

**It is well worth it to be sure one has more than adequate financial resources in retirement to cover all insured and uninsured quality medical services.

j :happy
Unfortunately most people will never have the resources you are talking about. I don’t have any idea how much would be needed to cover uninsured quality medical services.

mega317
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Re: Does anyone bypass insurance for primary care?

Post by mega317 » Fri Feb 14, 2020 9:40 pm

Why don't you give your cell phone to your hospital clinic patients?
https://www.bogleheads.org/forum/viewtopic.php?t=6212

quantAndHold
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Re: Does anyone bypass insurance for primary care?

Post by quantAndHold » Fri Feb 14, 2020 10:03 pm

When I had a terrible doctor, I just changed doctors within the plan, to someone who was great. Is that not an option?

toofache32
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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Fri Feb 14, 2020 11:25 pm

Dottie57 wrote:
Fri Feb 14, 2020 9:36 pm
Sandtrap wrote:
Fri Feb 14, 2020 9:13 pm
DW and I have always gone where the best medical care is available regardless of insurance coverage.
At times, it has been costly but well worth it.
It is in our best interest to be our own advocates when it comes to quality medical support and care.

When we were in ACA coverage (dismal and expensive) for several years before Medicare, we really bit the bullet paying for outside insurance quality care, yet having the ACA Coverage policy expense (just in case).

At present, not all medical clinics and specialists take Medicare.

* There's a danger in limiting one's medical care and treatment, etc, to only what is covered by insurance.

**It is well worth it to be sure one has more than adequate financial resources in retirement to cover all insured and uninsured quality medical services.

j :happy
Unfortunately most people will never have the resources you are talking about. I don’t have any idea how much would be needed to cover uninsured quality medical services.
It must not be that much because my private practice is cash pay. And most of my patients are regular working class, not the wealthy you would think.

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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Fri Feb 14, 2020 11:27 pm

mega317 wrote:
Fri Feb 14, 2020 9:40 pm
Why don't you give your cell phone to your hospital clinic patients?
Why would I? They have a nurse who gets paid for that while I don't. This is the insurance business model. Cheapest care possible. Nurses are cheaper then doctors.

mega317
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Re: Does anyone bypass insurance for primary care?

Post by mega317 » Fri Feb 14, 2020 11:56 pm

I suppose I'm making some inference, but your longer post seemed to imply that the patients who get your cell phone are getting better care in part because of that. I'd think you'd want all your patients to get good care. I realize you can't control the length of a visit or the clinic hours, but surely you control your phone number.
https://www.bogleheads.org/forum/viewtopic.php?t=6212

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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Sat Feb 15, 2020 12:14 am

mega317 wrote:
Fri Feb 14, 2020 11:56 pm
I suppose I'm making some inference, but your longer post seemed to imply that the patients who get your cell phone are getting better care in part because of that. I'd think you'd want all your patients to get good care. I realize you can't control the length of a visit or the clinic hours, but surely you control your phone number.
Don't confuse better service with better healthcare. All my patients get "good care" which meets or exceeds the minimum standard of care in an accredited TJC/JHACO accredited institution following guidelines set by the government. But....some patients get better service which is also more efficient and more convenient. Insurance doesn't pay for this and only rewards me for higher volume (less time per patient) and penalizes me by making it more expensive to get insurance to pay. To pay their discounted rates. If they actually paid my fees (at market rates which my cash patients are happy to pay, evident by the fact I stay in business) then it might be worth it to have the extra expense to hire a room full of people to sit on the phone and argue with insurance companies and fight denials. I don't have that expense in my private practice and I pass the cost savings on to the patient. Insurance is a bloated middle man that increases costs.
Do you give your cell phone to clients to call you in the middle of the night? Do you go in to your place of business nights and weekends without compensation? Don't you want all your clients to get good care?
Last edited by toofache32 on Sat Feb 15, 2020 12:39 am, edited 5 times in total.

TigerNest
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Re: Does anyone bypass insurance for primary care?

Post by TigerNest » Sat Feb 15, 2020 12:24 am

My solution (as a mostly healthy guy in my 30s) has basically been to just to stop getting physicals. It's been so difficult over the last 5+ years to find a PCP that takes my insurance in pretty much every city I've lived.

This year, though, after two visits to Urgent care for an ear infection, I joined One Medical: https://www.onemedical.com/

It's absolutely fabulous so far. $199/year membership fee, for same day appointments, no rush visits, digital everything... I can hardly believe it.

toofache32
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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Sat Feb 15, 2020 12:27 am

TigerNest wrote:
Sat Feb 15, 2020 12:24 am
My solution (as a mostly healthy guy in my 30s) has basically been to just to stop getting physicals. It's been so difficult over the last 5+ years to find a PCP that takes my insurance in pretty much every city I've lived.

This year, though, after two visits to Urgent care for an ear infection, I joined One Medical: https://www.onemedical.com/

It's absolutely fabulous so far. $199/year membership fee, for same day appointments, no rush visits, digital everything... I can hardly believe it.
Amazing how prices come down and market forces come into play after you remove the bloated insurance middle man.

Insurance should not pay for routine office visits. This is why medical insurance is so expensive...because we want it to pay for everything and anything related to health. Can you imagine how expensive your auto insurance would be if they had to pay for your oil changes and to fill up your gas tank?? Insurance should be something you hope you never need, not a debit card to use whenever you can. This is the fatal flaw of our cultural entitlement.
Last edited by toofache32 on Sat Feb 15, 2020 12:35 am, edited 1 time in total.

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tooluser
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Re: Does anyone bypass insurance for primary care?

Post by tooluser » Sat Feb 15, 2020 12:33 am

Keep looking. I used to have the same rushed, uncaring experience with a large medical practice near me.

Then I changed doctors to a single physician practice that takes my insurance. The choice was semi-random, based on sparse internet reviews, his age, the medical schools he graduated from, and hospitals residenced at.

For routine appointments I always make it the first of the day, 7am. Yet very often I have to wait because the doctor is seeing someone else. I could get annoyed, but he is taking his time to do the job right with every patient. We are never rushed once he sees me. He is well-read, up to date on medical issues, thorough, suggests appropriate tests.

They are out there. Keep looking.

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Re: Does anyone bypass insurance for primary care?

Post by mega317 » Sat Feb 15, 2020 12:37 am

If it doesn't improve care, what is the benefit to the patient of better serivce?
toofache32 wrote:
Sat Feb 15, 2020 12:14 am
Insurance is a bloated middle man that increases costs.
Amen to that.
https://www.bogleheads.org/forum/viewtopic.php?t=6212

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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Sat Feb 15, 2020 12:49 am

mega317 wrote:
Sat Feb 15, 2020 12:37 am
If it doesn't improve care, what is the benefit to the patient of better serivce?
It's just better service. Indirectly I like to think it does improve care. But it doesn't mean those getting less care are getting inadequate care. Instead of calling a hotline for some nurse you never met who knows nothing about your condition and simply tells you to go to the ER, you call me directly with questions. People are surprised how doctors remember your important details even though they haven't seen you for weeks or months. I surprise myself with this. I can handle many things over the phone and triage problems more accurately than someone who doesn't know you, to see if I need to see you now or if I can see you tomorrow in my office.

As an example, I do tons of office biopsies. Instead of having patients take off work to see me a week later to review the results (like in the hospital clinic), I call them one evening to review results. I don't get paid for extra visits so it's in my best interest to be efficient. And this is more efficient for patients also.

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Re: Does anyone bypass insurance for primary care?

Post by mega317 » Sat Feb 15, 2020 1:10 am

I appreciate the conversation. You are confusing me--do you think the cell phone access does or doesn't improve care? I would agree that an ER visit that could be prevented by a phone call is not good. Clearly if two patients have the same minor complaint, one is triaged over the phone by a physician who knows them and medicine well, the other is sent to the ER where they are likely to wait a long time, may get unnecessary testing and treatment, etc, are getting different quality health care, not just service. I would also feel that's true about hospital clinic patients and concierge patients equally (not knowing anything about the respective populations). So why do some of your patients get that and not others? If my understanding of the model is correct, you wouldn't be paid extra for either phone call. And I never said any patients are getting inadequate care.
https://www.bogleheads.org/forum/viewtopic.php?t=6212

EnjoyIt
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Re: Does anyone bypass insurance for primary care?

Post by EnjoyIt » Sat Feb 15, 2020 1:11 am

mega317 wrote:
Sat Feb 15, 2020 12:37 am
If it doesn't improve care, what is the benefit to the patient of better serivce?
toofache32 wrote:
Sat Feb 15, 2020 12:14 am
Insurance is a bloated middle man that increases costs.
Amen to that.
It actually does improve care. When a physician has the time to talk to you, they have the time to get all the details and understand the situation better. Afterwards they have more time to explain what everything means, what the patient needs to do and answer questions to make sure the patient understands. This leads to better compliance as well as understanding what to look out for and what to do in certain situations.

By getting to talk to the doctor instead of a triage nurse, the patient is less likely to be sent to the ER for non emergency issues saving money and unnecessary testing. Unnecessary testing has risks.


The corporate insurance model offers very little time for such a detailed process even if it meets the definition of standard of care.

Even though toofache32 won't admit it, I am positive without a doubt that his private patients are better off and receive better overall medical care as compared to his corporate patients.

EnjoyIt
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Re: Does anyone bypass insurance for primary care?

Post by EnjoyIt » Sat Feb 15, 2020 1:16 am

mega317 wrote:
Sat Feb 15, 2020 1:10 am
I appreciate the conversation. You are confusing me--do you think the cell phone access does or doesn't improve care? I would agree that an ER visit that could be prevented by a phone call is not good. Clearly if two patients have the same minor complaint, one is triaged over the phone by a physician who knows them and medicine well, the other is sent to the ER where they are likely to wait a long time, may get unnecessary testing and treatment, etc, are getting different quality health care, not just service. I would also feel that's true about hospital clinic patients and concierge patients equally (not knowing anything about the respective populations). So why do some of your patients get that and not others? If my understanding of the model is correct, you wouldn't be paid extra for either phone call. And I never said any patients are getting inadequate care.
On the corporate side the medical providers are expected to be as efficient as possible. There is little to no time for the things you have listed. I Have experienced work on both sides, on the insurance/corporate side you bust your rear for the day and go home exhausted. On the concierge side you have lots more time, less stressed and provide a better service to the patients. I will admit it. The concierge side gets better care. Not just because they are paying for it, but because the concierge side gives you a physician who is less stressed with more time to work with the patient as opposed the rushed service that is demanded from the corporate/insurance side. I hope that makes sense.

SteveinVanvcouverWA
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Re: Does anyone bypass insurance for primary care?

Post by SteveinVanvcouverWA » Sat Feb 15, 2020 1:19 am

I am a family physician and started a Direct Primary Care practice 19 months ago. Happily, I don't take insurance, rather, my patients pay a monthly fee like a gym membership. Instead of rushed visits like in my previous 19 years of practice, I can spend 30-60 minutes with patients. Labs and prescriptions are deeply discounted. We do labs and dispense most of our patients' meds right in the office. I take off suspicious skin lesions and inject painful joints at no extra charge to patients. My patients can reach me by phone, video or text 24/7 and we do home visits. Patients have unlimited office visits. They wait less than 5 minutes and we greet them by name. I work for the patient, not the insurance companies. In my former rushed insurance-based practice, I scarcely had time to ask a patient how their fishing trip was or how their family is doing. Now I have ample time. My fees are reasonable, based on age and averaging $57/month per patient. I love practicing medicine again.

toofache32
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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Sat Feb 15, 2020 1:37 am

mega317 wrote:
Sat Feb 15, 2020 1:10 am
I appreciate the conversation. You are confusing me--do you think the cell phone access does or doesn't improve care? I would agree that an ER visit that could be prevented by a phone call is not good. Clearly if two patients have the same minor complaint, one is triaged over the phone by a physician who knows them and medicine well, the other is sent to the ER where they are likely to wait a long time, may get unnecessary testing and treatment, etc, are getting different quality health care, not just service. I would also feel that's true about hospital clinic patients and concierge patients equally (not knowing anything about the respective populations). So why do some of your patients get that and not others? If my understanding of the model is correct, you wouldn't be paid extra for either phone call. And I never said any patients are getting inadequate care.
The ER visit is less efficient and more costly but does not result in less care. Quite the opposite.... perhaps it's too much care as a result of decreased efficiency. You are correct that this decreased efficiency can result in unnecessary testing in the ER from an ER doc that doesn't fully know the patient. The patient should be upset that their insurance doesn't encourage better efficiency. If insurance would pay me to be available (in my hospital practice), then I would be. But they don't. When they pay only 1/3rd of my regular fee and make me fight and spend money just to get that 1/3rd, this is what happens. For my private practice, this added service of availability is built into the fees and business model. The economics are actually very simple.

My point is that everyone seems to want to go to Best Buy and get a 60 inch TV but some only pay for a 30 inch TV. And they wonder why they can't get the 60 inch TV for the cost of a 30 inch TV. Both will show the same movies and accomplish the same outcome, but one is obviously more desirable. But there is nothing wrong with the 30 inch TV. We have a 2-tiered healthcare system. And there is nothing wrong with that. The lower tier is still getting at least the minimal standard of care. If you want the 60 inch TV, guess what? It costs more and is available.

mega317
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Re: Does anyone bypass insurance for primary care?

Post by mega317 » Sat Feb 15, 2020 1:45 am

EnjoyIt: definitely makes sense.

Toofache32: I did not say less care.

But if the concierge patients get cell phone access, are they told not to call on hospital clinic days? Are they going to get a rushed, stressed doctor if they call those days? Do you call back in the middle of a clinic day, making the clinic patients wait? It seems like you have some very stressful days and some less stressful days, but it's hard to me to understand why some patients get better access. Some doctors see a mix of medicaid and private insurance in the same practice. Do they book different visit lengths, call some back with biopsy results but not others, etc? How is this different just because you work in two different buildings and don't have control over some logistics?

Am I understanding this wrong--do you charge for a cell call? Otherwise why do you care who is on the other end?
https://www.bogleheads.org/forum/viewtopic.php?t=6212

toofache32
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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Sat Feb 15, 2020 1:51 am

Oops, duplicate post.
Last edited by toofache32 on Sat Feb 15, 2020 12:29 pm, edited 2 times in total.

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Sandtrap
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Re: Does anyone bypass insurance for primary care?

Post by Sandtrap » Sat Feb 15, 2020 1:54 am

SteveinVanvcouverWA wrote:
Sat Feb 15, 2020 1:19 am
I am a family physician and started a Direct Primary Care practice 19 months ago. Happily, I don't take insurance, rather, my patients pay a monthly fee like a gym membership. Instead of rushed visits like in my previous 19 years of practice, I can spend 30-60 minutes with patients. Labs and prescriptions are deeply discounted. We do labs and dispense most of our patients' meds right in the office. I take off suspicious skin lesions and inject painful joints at no extra charge to patients. My patients can reach me by phone, video or text 24/7 and we do home visits. Patients have unlimited office visits. They wait less than 5 minutes and we greet them by name. I work for the patient, not the insurance companies. In my former rushed insurance-based practice, I scarcely had time to ask a patient how their fishing trip was or how their family is doing. Now I have ample time. My fees are reasonable, based on age and averaging $57/month per patient. I love practicing medicine again.
You are awesome!!!!!

I have several family member MD's burned out after 30-40 years of private practice in the insurance business model. Patients have long waits and 3-5 minute office visits at times. The docs are trying hard, everyone is trying, but things are compromised as well. Private primary care practice has changed greatly over the decades.

j :happy
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toofache32
Posts: 1962
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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Sat Feb 15, 2020 2:06 am

mega317 wrote:
Sat Feb 15, 2020 1:45 am
EnjoyIt: definitely makes sense.

Toofache32: I did not say less care.

But if the concierge patients get cell phone access, are they told not to call on hospital clinic days? Are they going to get a rushed, stressed doctor if they call those days? Do you call back in the middle of a clinic day, making the clinic patients wait? It seems like you have some very stressful days and some less stressful days, but it's hard to me to understand why some patients get better access. Some doctors see a mix of medicaid and private insurance in the same practice. Do they book different visit lengths, call some back with biopsy results but not others, etc? How is this different just because you work in two different buildings and don't have control over some logistics?

Am I understanding this wrong--do you charge for a cell call? Otherwise why do you care who is on the other end?
I'm not concierge. My private practice patients don't pay membership fees. It's simply fee for service, or "out of network". Fees are told up front with no surprises and we NEVER ask for more later. Usually I come out ahead but I have had to eat it big on a few cases. This gives me skin in the game to get it right the first time.
If someone calls on my cell phone whether it's a patient or my wife, I answer if I am available or call back as soon as I can which is usually within the hour. Doesn't matter which practice I am in. My private patients get better access because they bought it through a different business model where I am compensated for it. I have answered calls from patients while out of town at conferences, on vacation, on my little fishing boat, and at my kids baseball games. Being on call 24/7 is not free. And insurance doesn't pay for that.

I used to see Medicaid patients in my private office but that didn't last long. I treated them the same as paying patients, but they did not treat me the same. High rate of no-shows (2 out of 3 don't show up) and other issues I won't go into which makes it a difficult population to treat in a private setting. And they were the only patients I've ever had who abused my cell phone. Some handed it out to friends and family, then I would get calls at 10pm from people I never met asking for medical advice. Some were truly appreciative and I enjoyed treating them.
Last edited by toofache32 on Sat Feb 15, 2020 4:16 pm, edited 3 times in total.

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Sandtrap
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Re: Does anyone bypass insurance for primary care?

Post by Sandtrap » Sat Feb 15, 2020 2:10 am

Dottie57 wrote:
Fri Feb 14, 2020 9:36 pm
Sandtrap wrote:
Fri Feb 14, 2020 9:13 pm
DW and I have always gone where the best medical care is available regardless of insurance coverage.
At times, it has been costly but well worth it.
It is in our best interest to be our own advocates when it comes to quality medical support and care.

When we were in ACA coverage (dismal and expensive) for several years before Medicare, we really bit the bullet paying for outside insurance quality care, yet having the ACA Coverage policy expense (just in case).

At present, not all medical clinics and specialists take Medicare.

* There's a danger in limiting one's medical care and treatment, etc, to only what is covered by insurance.

**It is well worth it to be sure one has more than adequate financial resources in retirement to cover all insured and uninsured quality medical services.

j :happy
Unfortunately most people will never have the resources you are talking about. I don’t have any idea how much would be needed to cover uninsured quality medical services.
Yes. It has been a financial strain for us through the years to pay for medical care that insurance did not cover. Sometimes it is expensive but also sometimes it is far less than one expects.
The relatively recent availability of Nurse Practitioner Clinics and other medical business models that take up the slack in overloaded MD's services show a lot of promise and are already very busy. It's a good idea to be proactive to access and match one's needs to each medical professionals scope of practice and quality of care.
Folks blessed with great health and fitness likely might not have to think about these things as much as others that have to spend more time with the medical system that they'd like to.

j :happy
Wiki Bogleheads Wiki: Everything You Need to Know

smectym
Posts: 737
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Re: Does anyone bypass insurance for primary care?

Post by smectym » Sat Feb 15, 2020 2:27 am

In recent years there has been a proliferation of so-called “urgent care“ centers in major cities. They offer quick access to doctors without ER wait times. Usually they take insurance, but in cases in which they don’t or the insurance bureaucracy is an impediment to immediate care, sometimes it can make sense just to pay what they ask, and bypass insurance. Usually what these urgent care clinics charge for care without insurance is not excessively onerous, though of course if a family is hard pressed at that moment and can’t pay, there could be difficulties. Not sure how such hardship cases are handled in the urgent care clinic context

sawhorse
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Re: Does anyone bypass insurance for primary care?

Post by sawhorse » Sat Feb 15, 2020 2:34 am

With concierge primary care doctors, how do referrals work? If your plan requires specialist referrals, will the plan accept a referral from a primary care doctor not in the network for a specialist in the network?

sawhorse
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Re: Does anyone bypass insurance for primary care?

Post by sawhorse » Sat Feb 15, 2020 2:40 am

SteveinVanvcouverWA wrote:
Sat Feb 15, 2020 1:19 am
I am a family physician and started a Direct Primary Care practice 19 months ago. Happily, I don't take insurance, rather, my patients pay a monthly fee like a gym membership. Instead of rushed visits like in my previous 19 years of practice, I can spend 30-60 minutes with patients. Labs and prescriptions are deeply discounted. We do labs and dispense most of our patients' meds right in the office. I take off suspicious skin lesions and inject painful joints at no extra charge to patients. My patients can reach me by phone, video or text 24/7 and we do home visits. Patients have unlimited office visits. They wait less than 5 minutes and we greet them by name. I work for the patient, not the insurance companies. In my former rushed insurance-based practice, I scarcely had time to ask a patient how their fishing trip was or how their family is doing. Now I have ample time. My fees are reasonable, based on age and averaging $57/month per patient. I love practicing medicine again.
That's a really great rate. What does it include? I still don't think my very mediocre current primary care doctor is worth that, but I've had two excellent primary care doctors in the past who knew how to handle almost everything on their own and would definitely have been worth more than that.

There's a concierge practice around here that charges $6k, and they don't even do home visits, not even for an extra fee :shock:
Last edited by sawhorse on Sat Feb 15, 2020 2:47 am, edited 1 time in total.

toofache32
Posts: 1962
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Re: Does anyone bypass insurance for primary care?

Post by toofache32 » Sat Feb 15, 2020 2:46 am

smectym wrote:
Sat Feb 15, 2020 2:27 am
In recent years there has been a proliferation of so-called “urgent care“ centers in major cities. They offer quick access to doctors without ER wait times. Usually they take insurance, but in cases in which they don’t or the insurance bureaucracy is an impediment to immediate care, sometimes it can make sense just to pay what they ask, and bypass insurance. Usually what these urgent care clinics charge for care without insurance is not excessively onerous, though of course if a family is hard pressed at that moment and can’t pay, there could be difficulties. Not sure how such hardship cases are handled in the urgent care clinic context
Those are not for primary care, and that's a different animal from the primary care question asked by the OP. Many of these facilities actually meet the criteria for ERs (thus increasing costs enormously) although the public views them as urgent care since they are not in a hospital. The other side of this is that there are many people who go to these facilities (both ER and urgent care) for convenience when they should just be seen by their PCP, then get upset when it costs more than their PCP.

smectym
Posts: 737
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Re: Does anyone bypass insurance for primary care?

Post by smectym » Sat Feb 15, 2020 2:50 am

toofache32 wrote:
Sat Feb 15, 2020 1:37 am
mega317 wrote:
Sat Feb 15, 2020 1:10 am
I appreciate the conversation. You are confusing me--do you think the cell phone access does or doesn't improve care? I would agree that an ER visit that could be prevented by a phone call is not good. Clearly if two patients have the same minor complaint, one is triaged over the phone by a physician who knows them and medicine well, the other is sent to the ER where they are likely to wait a long time, may get unnecessary testing and treatment, etc, are getting different quality health care, not just service. I would also feel that's true about hospital clinic patients and concierge patients equally (not knowing anything about the respective populations). So why do some of your patients get that and not others? If my understanding of the model is correct, you wouldn't be paid extra for either phone call. And I never said any patients are getting inadequate care.
The ER visit is less efficient and more costly but does not result in less care. Quite the opposite.... perhaps it's too much care as a result of decreased efficiency. You are correct that this decreased efficiency can result in unnecessary testing in the ER from an ER doc that doesn't fully know the patient. The patient should be upset that their insurance doesn't encourage better efficiency. If insurance would pay me to be available (in my hospital practice), then I would be. But they don't. When they pay only 1/3rd of my regular fee and make me fight and spend money just to get that 1/3rd, this is what happens. For my private practice, this added service of availability is built into the fees and business model. The economics are actually very simple.

My point is that everyone seems to want to go to Best Buy and get a 60 inch TV but some only pay for a 30 inch TV. And they wonder why they can't get the 60 inch TV for the cost of a 30 inch TV. Both will show the same movies and accomplish the same outcome, but one is obviously more desirable. But there is nothing wrong with the 30 inch TV. We have a 2-tiered healthcare system. And there is nothing wrong with that. The lower tier is still getting at least the minimal standard of care. If you want the 60 inch TV, guess what? It costs more and is available.
My comment relates to the observation above that sometimes ER care results in too much rather than too little care. There are cases in which what’s really going on is “defensive medicine”: i.e., the MD is prescribing outlandish tests and going the extra 10 to 20 miles for fear of getting sued if any possible test is omitted, which alleged omission might then form the gravamen of some lawsuit, even if the suit is essentially frivolous.

An unfortunate consequence of our legal system, which places few or no obstacles to the filing of low-merit lawsuits, which usually end in settlement to the profit of the plaintiffs attorney—because from the standpoint of the defense, it’s often simply cheaper to settle rather than go the far more costly route of final adjudication on the merits.

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