The following are excerpts from the monthly newsletter AAPS News issued by the Association of American Physicians and Surgeons – the only physician organization dedicated to private medicine and the sanctity of the doctor-patient relationship.
The motto for the Patmos Clinic in Greeneville, TN, founded by Robert Berry, M.D., is “Serving the uninsured. Leading consumer-driven healthcare.” There is a tremendous entitlement mentality to overcome, and some patients go elsewhere rather than pay $15 more than their copayment. The usual reason for inability to pay is misplaced priorities, such as a smoking habit. Dr. Berry distributes information on medical savings accounts, and 15 patients have opened one. For may physicians he writes, “I don’t think the water has gotten hot enough for them to jump out of the system yet. HIPAA compliance may change that.”
Physicians Do Not Need to Organize
They don’t have to call their buddies to see what they are doing. They can do it without consulting anyone, in the privacy of their own office, in accordance with their own conscience. They can just say no to all insurance contracts.
Just say no to HIPPAcratic medicine. Just say no to 40-page contracts with lots of fine print. Just say no to hiring an army of billers to settle patient accounts. Just say no to serving as the fall guy for faceless insurers, informing patients that their insurance won’t cover a needed procedure or test.
It is time to go on the offensive and not cower with every new twist managed care throws at us. Physicians will be much happier for breaking their addiction to managed-care contracts and resuming their position serving only the interests of their patients.
Taxpayers Buy Cigarettes
I once did a survey of all TennCare patients admitted to the emergency room: 85% of them admitted to the triage nurse that they smoked. I asked them how much they smoked and told them how much it cost. One pack per day cost $1,000 per year, 2 packs $2,000. They had never done the math. I really would have no problem with their smoking or drinking-if it weren’t on the taxpayers’ tab.
1. As Robert S. Berry, M.D., described the 2003 Cover the Uninsured public relations campaign, “[RWJF] appealed to one of the most base of human appetites-the urge to feel charitable and just without actually doing charity and justice. Issuing invitations to indulge in town meetings and other photo ops, it offered participants the chance to change the world in a single sound bite, “Health Coverage for All.”
2. To survive, physicians stack their schedules with patients with simple chronic problems, explains Dr. Berry. “So much is wasted in the petty political game of ‘you pretend to pay us and we pretend to care’ that there is little left for the truly sick.”
3. On Cash-Based Practice
You have a choice. All you have to do is not sign the contracts, or give the insurers notice that you are canceling the contracts. If you don’t, some other physician in your community might get a jump on you in starting a practice like mine. You run the risk of encountering a buzz saw by what Harvard Business School Professor Clay Christensen would call a disruptive innovation- a cheaper, more efficient way of doing something directed at the low-end user that eventually catches on in the mainstream and comes to dominate the market. If consumer-driven products achieve a 75% market share in the next 5 years as some policy experts are predicting, cash-based clinics will be strategically placed. Do you want to be left behind?
Neighbors, or Villagers?
Auschwitz, once a village, should dispel Sen. Clinton’s quaint ideas about villages. Had more Germans taken to heart what it really means to be a neighbor, there might have been the critical mass of resistance to prevent the genocide carried out by the “Village.”
As medicine is a very personal endeavor-one doctor and one patient at a time-you can’t squeeze the village into it. Instead, I am trying to answer the age-old question: “Who is my neighbor?” Can American physicians rise to meet challenges from our own Village, by helping our neighbor?
An inscription on Union Station, across from the Capitol, reads: “Be noble and the nobleness that lies in other men, sleeping yet never dead, will rise in majesty to meet thine own.”
Let the Customer Choose
I have no problem with kiosk medicine even though it does compete with my practice. A kiosk manned by a nurse practitioner in a grocery store in a nearby city charges $5 less than I do. Let the patient decide whether, in a particular situation, board certification in emergency medicine and internal medicine is worth the additional $5. No need to protect the producers.
Let Patients Decide
The market has a way of sorting things out when the customer is king. Sure, some people might get hurt. But people also might get hurt with regulations. Who is one person or group to decide? Let the person who owns his or her own body decide. There is no reason to protect producers. The same group that issues licenses to physicians can restrict them for any reason they want-such as our clinic’s refusal to take third-party payment. A medical license could become contingent on my practice billing and accepting Medicare and Medicaid and treating everyone who comes to my door. That is not acceptable to me. Therefore, I say abolish the boards that protect physicians before they make political correctness a requirement for practicing medicine.
Cost of Third-Party Payment
Billing overhead probably doubles the cost of providing service. The best way to determine cost is to look at a practice like mine in which I can charge about half the going price and make as much net income. I don’t play games to get paid; I tell the patient the price up front (simple throat infection, $35; pneumonia or kidney stones, $50). Here in northeast Tennessee we have to keep everything simple. Otherwise I would get confused and think I was treating the third party, not the patient.
The Hazard of Tax Subsidies
The sick and the infirmed we shall always have with us. We therefore need to find a sustainable way to meet this need. Wedding an organization's existence to the tax policies of one administration might well make it a widow in the next - and where would the patients be when the nonprofit shuts down? The physician who depends on his patients for his income could survive - if the "free" clinic hasn't driven him away.
I got a good view of this principle while working in Haiti. The U.S. had extra rice, and what could be more generous than giving food to the starving? Unfortunately, many rice farmers were forced out of business, so when the temporary generosity was exhausted, there were no rice farmers to meet the demand.
It is very dangerous to disrupt natural exchange between individuals. In Haiti, it caused more starvation. In the U.S., it will eventually deplete the supply of medical services to those in greatest need.
Private Care for All
Between May 21 and Sept. 21, our clinic obtained prospective data on all 262 new patients. Of these, 157 (60%) were uninsured, 75 (29% had commercial insurance, 12 (5%) had TennCare, 9 (3%) had Medicare, 6 (2%) had TriCare, 2 (1%) had an HSA, and 1 had a Christian Medical Cost Sharing Plan. Our clinic accepts no insurance of any kind, but only direct payment. It has existed for more than 42 months, and income is up 25% compared with this time last year.
EMRs Not a Panacea
Politicos and other members of the chattering classes seem to think that all physicians need is more information. If I don't already know something about a patient with a chronic illness, I know where in the chart to find it. If I refer a patient, I give the receiving physician a distillation of relevant information. For physicians in mid-career, much of diagnosis is intuitive, from information gleaned from looking at the patient, not a computer screen. Newt needs to coat-tail a physician who has not been squeezed into a bureaucratic ball.
Lower Policy Limits Desirable. The lowest limit my liability insurer will provide is $1 million/$3 million. I doubt any lawyer would take a case with a $250,000 policy limit and a physician without assets. But why would anyone want to become a physician if he had to be asset-free to have peace of mind? And if we do not wish to accumulate assets for attorneys to seize, why work more than 20 hours per week?
Americans are beginning to view physicians as the scum of the earth, judging by sources such as The New York Times. They will not appreciate us as long as we are available.
The Only Answer. If the tax exemption for health insurance were eliminated, HMOs would evaporate into thin air just as Sauron did when the ring landed in the fires of Mount Doom. We must throw away that ring of power. All it does is shift money around (the taxes lost from the exemption must be made up somehow) at the expense of the uninsured and the small businessman. Alternately, physicians could refuse to sign contracts with the devil (HMOs). But as long as the desire to get something for nothing exists in the human heart and as long as physicians fear destitution for standing up for what is right no number of laws will make the situation just.
Who Needs/Gets Expensive Medicines? I was with some doctors last night at a dinner meeting. I had almost forgotten their bravado in gaming insurers. One knew exactly which health plans did and didn't pay for the new drug Ketek (telithromycin). The whole attitude was, who cares about what medications cost when someone else has to pay? I suggested that they might get concerned if the HSA idea catches on. They rolled their eyes. They may not realize that I'm receiving about five new patients from their practices weekly, with few if any going the other way. Those who don't learn to practice cost-effective medicine will be in the "patient-flight zone."
From page 1 As Robert Berry, M.D., points out, that's comparable to Columbus's method of keeping his men from returning home: he burned their boats. Preventing escape is a necessary feature of "a vision that weaves the individual parts into a functional system" as in the failed HSA (Clinton's Health Security Act, the antithesis of the new HSAs, Health Savings Accounts) (JAMA 2004;292:2000-2006). Or as in Canada.
Hidden Costs. The tax breaks for low-copayment, low- deductible insurance should be listed among the Extraordinary Popular Delusions and the Madness of Crowds by Charles McKay, originally published in 1841. The indirect costs are incredible: $200 billion in tax revenues that has to be raised elsewhere, skewed incentives, administrative costs of insurers and doctors, delays, etc. All costs are factored into the final cost of goods and services, and global markets are not fooled. These hidden costs contribute to the outsourcing of labor.
Why Work and Save? For doctors especially, the possibility of retaining personal wealth is so remote that it makes little sense to save. We are easy prey for personal injury lawyers, DEA agents, and federal prosecutors, never mind the IRS. Why should I work any more than necessary to meet current expenses when my savings will probably be plundered by the time I am 65? One thing they can't steal from me is my time in the present. The most reliable thing I can take with me into my 70s is my medical skills, available 25 hours per week.
Medicare Adds $200,000 to Overhead. In order for me to accept Medicare, I would have to add three full-time employee equivalents, and a total of $200,000 to my costs. There is no way that I can provide affordable care to the uninsured (now 60% of my practice) and take Medicare. Medicare-eligible patients, paying privately, make up 3% of my practice. Instead of opting out, it might have been a better business decision to refuse Medicare patients entirely in my practice, considering the paltry number willing to pay. Then I could work part-time in the ER to maintain my ER skills. However, I would make less money per hour working in the ER than in my clinic and would still have the fixed costs of the clinic.
From page 1 "The third-party payment system in primary care is going down," writes Robert Berry, M.D. "It will vaporize like the chief Nazgul, the Witch King, did in The Lord of the Rings after Eowyn stabbed him through the hole in his helmet. And we will be free of their coercion and terror."
Surviving on TennCare. Participating doctors learned the art of the "churn." This involves stacking the practice with relatively healthy patients and bringing them back every few months for 5-minute checks. The system sets up disincentives to caring for the truly sick and incentives for providing a lot of unnecessary care.
From page 1 Dr. Robert Berry of Tennessee estimates that he saves $200,000 annually as a result of opting out of Medicare and forgoing all third-party payments. "If all primary care physicians went insurance free, the country would save approximately $60 billion in physician overhead alone."
Productive Use of Money. I estimate it would take about $50,000 to $75,000 to get started in a third-party-free clinic like mine which would be made up within a couple of years.
Imagine that all the money that has been invested in studying the problem had been given as low or no-interest loans to help start clinics. With $10 to $15 million, we could have had 200 direct-payment clinics actually caring for the uninsured, as opposed to talking about covering them. And the money would be coming back to be reinvested in more clinics.
It's about power, not caring. Agitate, agitate for ordinary Americans not people with powerful desk jobs to control the money. Expose the true motives of the "reformers." There is no policy panacea or great macrosolution that will usher in a medical utopia only a bunch of microsolutions, of which every direct-payment clinic is an example.
Trust in Government. When I spent a summer in Brazil, a friend told me she had been saving up and almost had enough money to buy a car. One day the government suddenly froze all bank assets and devalued the currency. When she once again had access to her assets, she had only enough to buy a set of tires. Maybe it couldn't happen in America. But what if there's a crisis used to justify a "one-time tax," as on retirement funds?
Price Transparency. My fees are published on two large billboards, on a sign in front of my office, in my waiting room, and on the internet (www.cashdoctor.com). I charge everyone the same. For someone who is truly down on his luck, I will discount my already discounted fees; charity is more effective above the AGI line than below it. I do not "reprice" to keep the business of someone who doesn't mind waiting three hours in the ER because my quoted fee of $135 to suture his laceration is more than the copayment on his insurance.
Who Determines Value? It appears that one can't improve on the natural exchange of values between individual persons. Many call this the free market. Politicians who think their wisdom exceeds that of many such counterbalancing exchanges tread very close to hubris which the ancient Greeks considered the worst of character defects.
Know When to Fold It. The vast majority of physicians have agreed to play the game set by third-party payers. But they don't have to pick up the hand the third parties have dealt them or even sit at their gambling table. In the quiet of their conscience, they can just say no. They will enter a much better world. No need to scrutinize 50-page contracts, or hire three billing clerks, or worry about not getting paid.
Tax Subsidies. If medical insurance were not tax deductible, there would be no insurance for small claims. Why should there be insurance for services that cost the same as an oil change or a brake job? Third-party payers are not evil; they just exploit the subsidies our politicians have given them. The subsidy favors some people (employees of large companies) over others (cleaning ladies, general contractors, small retailers, etc.). It is a sophisticated form of theft, and if theft is evil, the subsidy is evil. It creates encounters like one in our parking lot: a Lexus pulled up, a teenage boy jumped out and asked what our clinic charges for a sore throat. After hearing the reply ($35), he told his mom, and the Lexus screeched off.
Rationing by Waiting. The process is gradual. Doctor time per visit decreases gradually, and delays increase until the wait is unacceptable and there are no quick fixes. But it seems less painful to employees that an sudden switch to a Health Savings Account and they can't blame the employer. It's the greedy doctors, or the greedy insurance executives, or "the economy."
Unaffordable. Americans neither need nor can afford third-party payment for noncatastrophic medical care. The tax break for health insurance amounts to a subsidy to everyone in the medical industry at the expense of all others. This is not only unjust, but inefficient. It creates the need for perhaps 2 to 3 million people to settle small claims. Every expense that is not involved in direct patient care unnecessarily increases the cost of all goods and services. Returning the human capital involved in insuring routine medical costs to productive use would be a tremendous boon to the economy.
Diversification. The ill and the injured we will always have with us. Government programs come and go. You can't depend on them to pay the bills. Besides, putting too many eggs in one payer's basket is a prescription for disaster. I now have 7,000 payers in my practice this should be adequate diversification.
A couple who came to see me two years ago may actually go into solo practice. Their office manager said they'd be jumping off a cliff. But with TennCare disenrollment, it's getting harder to make ends meet. I'd say the water is starting to boil, and the frog is about to jump out.
VA Electronic Medical Records. The VA's vaunted EMR system may be wonderful, but the VA won't allow anyone on the outside to verify this claim. The VA never provides medical information on its patients when we fax a signed release-of-information request. Never. When I need records from the VA, I have the patient collect them, and many times it is very difficult for him to do so. Because of the VA's secrecy, I do not believe the glowing reports on its chronic disease management system even though published in reputable journals. Also, what the VA will care for, based on the veteran's service- connectedness, is ever diminishing and longer delayed.
The New Standard. The "standard of care" is becoming whatever is reimbursed. So physicians bring insured patients back to their office more often than is warranted to churn their insurance. One of my patients sees her cardiologist every 3 months to check her cholesterol, even though her level is good on no treatment. Medicare pays, so why not? If the patient had to pay, I suspect she would never have it checked again the course that I recommended to her.
But lots of insured patients don't get the kind of care they want, or can't get it in a timely fashion so they come to see me. I think that as long as it is still legal to serve patients and not sign contracts with the Beast, physicians will always have work. No country with universal health coverage has ever been able to guarantee prompt, high quality care.
A Solution that Works. In five and a half years, my third-party-free practice in a rural county of 65,000 has grown to 7,000 patients. Of these, 4,000 have been uninsured and could have chosen instead to receive care at one of the four state- subsidized clinics located within 15 miles of my office.
Eliminating the tax exemption for health insurance would cut the Gordian knot that has attached health insurance to employers since World War II. This would liberate us from the oppressive system of third-party payment for routine medical care. As Ronald Reagan said, "Solutions are never easy. Just simple." He ignored the contrived convolutions of policy elites and cut straight to the core of seemingly intractable problems.
Safety Valve. More Medicare beneficiaries are showing up at my clinic, telling me they can't get into a doctor who accepts Medicare for 2 to 3 months. I am seeing only those who have Medicare Part A, but not Part B, on their cards. The waits to see a doctor are getting longer, so that some are resorting to my clinic even though (as they tell me) I am not a "real doctor" because I don't accept third-party payment even though I am boarded in both internal and emergency medicine.
It's simple economics: if you don't pay doctors to provide medical care, they won't provide it, regardless of demand.
I might now be called the "overflow doctor" or the "doctor to the uninsured." I refuse to participate in an irrational, wasteful, impersonal system. If the government does not reach the ultimate coercion level, requiring doctors to accept public insurance as a condition of licensure, I will always have work to do. Eventually, I will probably be able to charge whatever I want for my time and skills, as retiring baby boomers choose to transfer their wealth to good doctors, rather than allowing it to be confiscated by government after they die.