Submitted June 23, 2005
Suggested title:  Insurance-free medicine for retiring ER docs
Word count: 750

Four and a half years ago I left emergency medicine to start an insurance-free urgent care.  My original plan was to taper slowly from ER work to see whether a clinic not accepting insurance could be financially viable. While preparing for my gradual entry into uncharted waters, the hospital administrator had my contract terminated abruptly.  Rather than trying to find another ER position, I decided to make the plunge – for better or for worse – into a full-time, cash-only practice.

The impetus for this radical departure had been growing for several years as I came to know many of the patients living in our small rural town in northeast Tennessee.  Some were designated “self-pay” on the ER chart, and contrary to my initial assumptions about uninsured patients I came to realize that most were neither destitute nor derelict.  They were farmers, carpenters, mechanics, restaurant owners, beauticians and other hard working folk, many from whom I had received goods and services at fair and honest prices. 

Unfortunately, I could not say the same about what I charged them for non-emergency care such as laceration repairs or treating simple infections.  The bill they received for professional services might have come from PhyAmerica, but it was the full “rack rate” – far higher than our discounted fees to third party payers – and there was no escaping the fact that I was still the one responsible.  The idea of the clinic, therefore, took shape in the context of answering for myself the age-old questions, “Who is my neighbor?” and “How should I treat him?”  

I figured that by avoiding the costs associated with billing third party payers I could still make a decent living charging much less than what the local ER’s and urgent care do.  If Americans could pay at the time of service for oil changes and brake jobs, I reasoned that they could pay directly for primary medical care in the same price range.  Rather than concealing my fees as do hospitals, ER management firms, and other physicians, I publicized them in the local newspaper, on billboards, flyers, and on the sign in the front of our clinic – poison ivy $25, simple infections $35, simple lacerations $95. 

Even though many colleagues and other health care professionals have dismissed the clinic as just one man’s quixotic quest, other Americans are genuinely interested in ways to make healthcare more affordable.  In November 2003, The Wall Street Journal featured our clinic on the center of its front page.  I subsequently was asked to testify before Congress on the topic, “Consumer-Directed Doctoring.”  SimpleCare, a network of about 2000 cash clinics, has been the cover story for US News & World Report and has appeared on other national media. 

While the medical community here has not supported the clinic, other locals have.  With nearly 6000 patient charts, approximately one-tenth of the population of our county has visited the clinic since its inception.  Roughly 60% of those have been uninsured.  Thus far this year at an average of 3.7 patients per hour, my net hourly income has been higher than the current hourly rate at the ER where I last worked.  Our clinic has demonstrated the financial viability of practicing insurance-free medicine while providing timely, quality medical care to the uninsured.   

While ER medicine offers the professional satisfaction of caring for critically ill and injured patients, most of us can’t do it forever.  The wear and tear of night shifts eventually forces most of us to find other professional challenges and sources of income.  When contemplating retirement from ER work, emergency physicians would do well to consider the option of starting insurance-free medical clinics like ours.

They are simple to establish.  There are no Byzantine 50 page insurance contracts to scrutinize and sign, and no expensive computer systems and billing software to evaluate and purchase.  Since we don’t do any billing, we are exempt from having to comply with HIPAA regulations.  While other similar clinics usually have more than four employees, ours needs only one. 

Besides simplicity, insurance-free clinics offer just that – freedom.  We are free to set our own fees.  Free from arbitrary documentation requirements and other coercive and wasteful mandates from dehumanizing bureaucracies.  Free to refuse care to the disruptive and unappreciative who have come to believe they are entitled to our services. 

We are free, now, to reconnect with the pure, spiritual purpose for which we entered medicine – to attend to the medical care of people who in turn value and appreciate our knowledge and skill. 

Robert S. Berry, M.D. is board certified in emergency and internal medicine and practices at PATMOS EmergiClinic in Greeneville, TN.  He can be reached online at rsberry@xtn.net.
A Healthcare Solution That Works
This might sound shocking to Mr. Stern coming from a private, non-unionized physician, but I agree with his analysis that “the employer-based system of healthcare is over…crushed by out-of-control costs…and masses of uninsured.” 

His plan, sketchy as it was, involves a “universal system” of “coverage” – similar, I suspect, to the one recently mandated in Massachusetts or to the less coercive “Cover Tennessee” enacted in my own state. 

I, for one, will not sign contracts with any third party payers Mr. Stern or Tennessee Governor Bredesen might decide to employ.  My primary care practice, which was featured on your front page in November 2003, universally refuses all forms of third party payment and thus prevents anyone from intruding into the sanctity of the doctor-patient relationship. 

It is also far more cost effective than “horse-and-buggy” family practices still filing small claims for routine medical care.  It requires three fewer employees and one-third the cost or roughly $200,000 less per physician in annual operating expenses. 

In five and a half years, it has grown to nearly 7000 patients in a rural county of 65,000.  Four thousand of these have been uninsured and could have chosen instead to receive care at one of four State-subsidized clinics located within fifteen miles of our office.  How about that, Mr. Stern and Mr. Bredesen, for a health care solution that works, simultaneously controlling costs and caring for the uninsured while not presuming upon employers or any other taxpayers to foot the bill?

If all routine health care in this country were paid directly at the time of service, Americans would save hundreds of billions of dollars per year.  In addition, the 2 million or so jobs dedicated to settling small medical claims could be redeployed to more productive tasks, such as direct patient care – not a trivial issue considering the Monthly Labor Review prediction that more than 1.2 million new and replacement nurses will be needed by 2014.  

The vast majority of Americans can afford to pay out-of-pocket for everyday medical care which at my insurance-free clinic costs anywhere from an oil change to a brake job. (The small percentage of truly indigent, of course, still needs a public safety net).  Practices such as mine that have applied this page’s faith in “free peoples and free markets” have demonstrated that Americans neither need nor can afford third party payment for primary medical care.

Mr. Stern’s plan also requires that this “universal system” serve our increasingly “self-managed work lives.”  At direct-payment primary care practices, patients manage their own routine medical care, purchasing it on cell phones, laptops, and (if necessary) in person with their physician on terms acceptable to both.  No third party payment system can produce this level of innovation, flexibility, and mass customization to keep up with what Mr. Stern calls a “revolutionary global economy.” 

Theoretically, direct payment through health savings accounts should work in tandem with low overhead clinics like mine.  However, in my area HSA’s haven’t caught on yet.  They are more difficult for my uninsured patients to understand and are currently more expensive than traditional high deductible indemnity policies.  They also require physicians to sign contracts with PPO’s (with all their attendant hassles, costs, and intrusions into the doctor-patient relationship). 

A far more effective and fundamental reform that will liberate us from our tax-exempt, and thus self-imposed, oppressive third party payment system for everyday health care is to eliminate the tax exemption for health insurance entirely. This would effectively cut the Gordian knot that has attached health insurance to employers since World War II.  Employee “income” at that time was declared “non-income” as a concession to companies for a war time federally mandated wage freeze, a lie we have perpetuated to this day, strangling American enterprise and costing us a fortune.

Eliminating the employer tax deduction for health insurance might sound naively simplistic to Mr. Stern, Mr. Bredesen, or others far removed from the street level realities of the health care marketplace.  So what? Ronald Reagan ignored the contrived convolutions of policy elites and cut straight to the core of seemingly intractable problems.  “Solutions are never easy.  Just simple,” he once remarked. They work, elegantly practical in their simplicity. 

Robert S. Berry, MD
1231 Tusculum Blvd.
Greeneville, TN  37745
(423) 639-9970