Last week’s Grand Rounds, hosted at Bedside Manner, included an interesting article from Dr. Alan Dappen at Get Better Health. Dr. Dappen is inviting his fellow primary care physicians to switch their practices over to a system of directly contracting with patients rather than with health insurance companies and Medicare/Medicaid. He explains that 75% of people would be able to receive their primary care services for about $300 a year in this sort of system. Their health insurance could still be used for emergencies, higher-cost specialists, and serious illnesses or injuries. The doctors would be able to focus on treating their patients rather than billing health insurance companies, and thus office overhead would be lower, resulting in doctors being able to charge less for their services and still make a reasonable income.
There’s a lot that I like about this idea. I’m a fan of high deductible health insurance coupled with HSAs, and I believe that in an ideal world, health insurance would only be used as a safety net when people needed very expensive care. Routine care and low-cost treatment would be something that people would include in their budgets, and pay for directly. They would be able to shop around, compare prices, and possibly use less care because they would be paying for it themselves. Hopefully, health insurance premiums would be lower too, as carriers wouldn’t have to pay for small, routine health care bills.
But we don’t live in an ideal world. Some people don’t have room in their budgets to add even an extra few hundred dollars a year for health care. Some are used to the idea of comprehensive health insurance that covers everything with copays, and a lot of people balk at the idea of shelling out $75 or $100 to see a doctor when they know that it “costs” $25 if they use their health insurance copay. People with HSA qualified health insurance are more likely to stop taking maintenance medications than insureds with traditional policies that cover the meds with copays. People without health insurance often just don’t get seek out health care at all. While it sounds good to say that people should be able to budget for their day-to-day health care needs and use health insurance just for the big stuff, it doesn’t work that way for a lot of people.
Personally, I would be open to the idea of seeing a family practice doctor who doesn’t contract with health insurance carriers, and paying for routine care out of pocket, if there were some way to combine that with a discount on our health insurance premiums. We have a $5000 family deductible, so we pay for all of our own care each year unless we go over that $5000 threshold. But as long as we see in-network providers, any amount that we spend gets counted towards our deductible, and preventive care is covered by our insurance policy before we meet the deductible. So if we were to start seeing a family practice doctor who billed us directly, we wouldn’t get any credit towards our deductible for money we spent at that doctor’s office (meaning that if we had an emergency or large medical bill, we’d still have to pay the full $5000, in addition to whatever we might have paid the doctor that year), and we’d have to pay for all of our own preventive care too. If we also had to continue paying the same price for our health insurance, this would amount to more out of pocket exposure for us each year, rather than less.
If the DocTalker Family Medicine idea were to become more widespread and if insurers could account for this type of care when setting premiums, I can see it making a lot of sense for healthy families who want to use health insurance for large medical bills and budget for smaller bills themselves.
