Q: Why don’t you accept health insurance?
A: If you think about it for a moment, the purpose of insurance – any kind of insurance – is to lessen the impact of those big life disasters that would otherwise leave us reeling when they hit. Insurance is all about sharing risk. For some of life’s problems, having insurance makes a lot of sense. When we try to use it to take care of our everyday expenses like primary care, however, we are ignoring the function of insurance. Instead, we’re buying into the idea that insurance can get us something for nothing.

When it comes to primary care, at best, the health insurers act more as purchasing clubs than true insurance. Health insurance companies know this, and they also know that they need to make a profit to stay in business even though they don’t contribute any real value. In fact, health insurance industry involvement in primary care contributes negative value because it causes significant damage to both patients and doctors.

How so? It goes far beyond the wasted health dollars that insurers pull out of the system to maintain their bottom line. The real problem is that about 40%–50% of a typical physician’s overhead comes from the costs of doing business with insurance companies. These costs arise from the need to employ specialized coding and billing staff to navigate the arcane rules that insurers come up with to control their payouts to doctors. To pay for those extra staff members, doctors need to see several extra patients per day, leading to many overly rushed visits. Beyond physician burnout and depression (which are very real problems), rushed visits also lead to significant problems for patients.

Lack of time for adequate communication leads to misunderstandings, missed information, and forgotten or overlooked problems. Chronic health problems are rarely being reversed or prevented by addressing the underlying causes; that takes too much of a doctor’s precious time. Instead, problems are treated first with pills — increasingly expensive pills. Rushed visits also lead to inadequate exams, unseen/unchecked medication interactions, delayed access to care, increased specialty referrals, increased hospitalization rates, and ultimately a higher disease burden and higher death rate. Those woes and several more are directly linked to doctors not spending enough time with their patients — time that is exceedingly difficult to come by when one works for the cut-rate fees offered by the insurance industry.

Q: If it’s that bad, how do health care insurers continue to make this scheme work?
A: In a word, fear. Unless they are particularly specialized, most doctors are afraid that they won’t have enough patients if they don’t accept whatever deals the insurance companies offer them. In markets where there aren’t many doctors, those doctors have more negotiating power, so the insurance companies may be more reasonable in order to guarantee that “their” patients will have somebody to see. In other places insurers are ruthless in their demands, except where doctors have banded together in groups that are large enough to fight back. This is why so many private practices have disappeared — they don’t have enough negotiating power to remain profitable, so they either sell out to hospital systems or simply go under.

Doctors who sign insurance company contracts are actually forced to help create artificial value for the insurers they work for. How? The contracts require medical practices to significantly raise their charges if they want to be fully reimbursed for their services by insurers. (For example, an insurer may allow a maximum payment of $60 for a particular type of visit, but they will also only pay, at most, 60% of the charge. In this case, the practice will almost certainly raise their rates to charge at least $100 for that type of visit.) The intended side effect of such policies is to punish uninsured patients (the very people who are often already in financially desperate situations), thereby creating the perception that the medical insurance is offering additional value.

If you’ve ever seen an explanation of benefits from an insurance company, you probably noticed that there is a huge difference between the bloated charges on the doctor’s bill and the amounts that the insurance company actually allowed (paid). Despite appearances, that difference isn’t usually there because of overly greedy doctors; it’s there because the insurance companies want it that way. Sound like a racket? It is. Particularly when you consider that the health insurance companies use any and every excuse and technicality they can to reject claims for payment, forcing doctors to hire expert billers and coders in order to fight back.

Q: Egads. What can be done about this?
A: A growing number of doctors are joining the Direct Primary Care movement to simply obviate the problem, at least on our level. We don’t accept health insurance ourselves, although we do recommend that our patients have at least a high-deductible catastrophic coverage plan to help cope with major health expenses when they come along. Opting out of bad relationships with insurers allows us to concentrate on caring for our patients instead of focusing our visits on how we’re going to get paid.

Q: I have insurance.  Will I be able to use it to cover the costs of my medications, labs, imaging studies, and referrals? 
A: Generally speaking, yes — at least once you’ve met your deductible. I don’t bill insurers for my services, but they’re still on the hook to pay what they owe for the rest of your care. That said, the low negotiated prepaid/cash prices I can get for you on many of these services may make your insurance coverage moot anyway — particularly if you’re not going to meet your annual deductible.

Q: I don’t have insurance.  Will I be able to afford the costs of my medications, labs, imaging studies, and referrals?
A: Generally speaking, yes.  🙂  There are a few things (e.g. MRIs and such) that simply aren’t cheap in this country, and sometimes a specialist is needed who doesn’t offer cash-discounted services.  That said, I don’t need to refer to specialists very often, and you can expect to save substantial amounts of money through a combination of greatly discounted lab services, discounted imaging services, discounted medications, and very cost-effective prescribing practices.

Q: What about the poor? Don’t they deserve/need health insurance, even for primary care?
A: Our country has a significant number of poor and indigent people who need assistance to afford even basic primary medical care. Rather than demanding “Cadillac-level” insurance for all, however, a more appropriate response to that problem would be a combination of societal contributions (i.e. welfare) to health care spending accounts and perhaps some volunteerism on the part of primary care providers to allow the poor to be treated along with everybody else. Doing it that way avoids the need to burden doctors everywhere with enormous amounts of extra paperwork and also gives the poor additional autonomy by allowing them to participate in the same health care markets as everybody else.

The only option for many poor people is to go to Medicaid clinics where the quality of care is often abysmal due to extreme pressure on Medicaid providers to see an enormous number of patients every day. Poor-quality care ultimately costs our State and Federal governments ridiculous amounts of money every year because undertreated problems become very expensive once they get bad enough to warrant emergency room visits and hospitalizations.

Q: Why don’t you work with Medicare?
A: I’d love to, but frankly, it’s both too onerous and too dangerous for Direct Primary Care providers to accept Medicare. Fear of burdensome audits and financial ruin from the False Claims Act is a particular concern.

Q: Can I still use Medicare for other things?
A: Yes. Medicare patients who join my practice must sign an “opt-out” agreement acknowledging that Medicare cannot be billed for my services.  That said, imaging studies, lab fees, medical equipment, home care services, and specialist referrals can all still be charged to Medicare. Prescription drugs are still partially covered for those participating in Medicare part D.

Q: Do you offer any discounts for financial hardship?
A: Yes, up to a point — although my rates are already extremely low, so there are limits to what I can offer. It doesn’t hurt to ask if you might qualify for a discount, particularly if you are older, have limited assets, and are on a limited or fixed income. Please contact me to discuss the particulars of your situation.

Q: How does an FSA or HSA plan work with Direct Primary Care?
A: As of June 2019, the IRS has been directed by President Trump to consider payments to a DPC practice as eligible medical expenses (i.e. they can be paid with an FSA or an HSA), but to NOT consider a DPC membership as a “health plan.” It is possible that future legislation may change this, but under this interpretation, it is legal to make contributions to an HSA plan while also being a member of a DPC practice.

Q: Do lab fees, imaging study costs, and co-pays still qualify as FSA/HSA deductible expenses?
A: Yes.

Q: What happens if I decide to cancel my monthly membership?
A: I stop billing you and you stop being my patient at the end of the month that you have paid for. Legally speaking, you have up to 30 days to find another physician after one of us gives the other notice. If you choose to use my services during this period, then you will be charged for that month’s membership if you have not already paid for it.

Q: I like most of what I see, but I noticed it said you’re into holistic and functional medicine. Those are things I think of as “woo woo,” and I don’t do “woo woo.”
A: Neither do I. Please allow me to explain. ‘Holistic’ means a focus on and understanding of the patient as a whole being (including mind-body connections), and not trying to treat disease processes as somehow being separate from the patient they occur in. I know that sounds a little bit ‘out there’ to some people, but there is a great deal of hard evidence supporting all manner of connections between mood and stresses and physical health (among other things).

‘Functional medicine‘ refers to thinking systematically about deeper mechanisms and interactions in the body and being able to piece together an understanding of what’s out of balance that would lead to the symptoms/problems that someone might present with. For example, if I meet somebody with high blood pressure, I don’t just want to figure out which pill works best for them with the fewest side effects (although that’s important, too — at least until their blood pressure problem can be understood and addressed in other ways). I want to know why this person has high blood pressure. What’s their diet like? Do they have an elevated uric acid level, which might suggest excessive fructose or meat consumption? Do they smoke? Do they get enough exercise? Do they have other risk factors for the metabolic syndrome? Are they getting enough sleep? Might they have sleep apnea? Is their job stressful? How long has high blood pressure been an issue for them? Are there genetic issues in play? Do they have heart problems or kidney problems which could both cause and be caused by their blood pressure problems? When you look at things this way, functional and holistic approaches don’t seem so “woo woo” at all — they’re just common sense.

Q: What’s your take on alternative medicine practices like acupuncture, massage, meditation, Reiki, and homeopathy? 
A: I respect that some people are helped by these things. To be pragmatic about it, it’s not really very important to me whether someone is actually helped by something or by their belief in that something. As to my own biases, I believe the evidence for massage for relief from stress (and improvement in problems caused by stress) is compelling, as is the evidence for its effectiveness in helping with many muscular complaints and vascular and lymphatic drainage. The evidence in support of the health and mental benefits of mindful practice (meditation) is huge and very real, and I’m happy to recommend it freely.

The evidence for acupuncture is mixed; I wouldn’t recommend it to everybody, but it does seem to benefit some people some of the time. I don’t claim to understand it (which makes me less comfortable when recommending it), but it can be helpful enough that it’s in my toolkit as a backup option. I’m not aware of any scientific evidence to support Reiki or homeopathy, which seems to be okay with people who are believers in those things. I don’t recommend those modalities to my patients, but I respect that some people feel helped by them and it’s absolutely fine by me when they do — particularly when their beliefs don’t lead them to reject approaches I have a better understanding of and evidence for. It’s a complex and interesting world and I don’t claim to have all of the answers for everybody.

Q: Are there any things you particularly question about modern “Western” medical practice?
A: Absolutely. I question many things, particularly when profit motives appear to be influencing commonly accepted standards of care. That said, I still try to keep good track of the official ‘right answers’ (which even the most orthodox of doctors will admit frequently change over time) so that when I feel the need to go ‘off road’ I can let my patients know how and why my thoughts deviate from the conventional. I take a collaborative approach; if I fail to make a convincing enough case to change your mind on something you have opinions about, I can often be persuaded to go along with doing things your way — especially if you’ll let me monitor the situation over time.

Q: What are your weak spots? What sorts of things don’t you do or cover that some other primary care doctors might?
A: Here are the things that I can think of:

• I am an Internist (specialist in adult medicine), so unlike a Pediatrician or a Family Practitioner (who is cross-trained in pediatrics) I don’t treat anyone under 18 years of age.
• I don’t carry vaccines in my office. This isn’t actually much of a problem because in most cases I can send you to a local pharmacy to get them.
• I consider myself relatively weak when it comes to sports medicine and orthopedic issues. I know the basics and can address most of the minor injuries that a weekend warrior may present with, but I know my limitations and tend to refer to physical therapists or orthopedists fairly quickly.
• While I can and do provide what I consider to be basic gynecologic care (Pap smears, STD testing, HRT, wart freezing, etc.) I don’t offer some of the more comprehensive services (colposcopy, cone biopsy, IUD placement, etc.) that some other providers might.
• I refuse to do disability evaluations in most cases (I loathe them!). In cases where there is overwhelming objective evidence (pain and weakness do not count) and thus no danger of corruption of the doctor-physician relationship, then I MAY make rare exceptions to this policy at my sole discretion.
• I do not currently prescribe buprenorphine/suboxone or other narcotics for the treatment of opiate addiction. In fact, I am reluctant to prescribe controlled substances for most chronic problems. (Properly documented ADD and properly documented testosterone deficiency are two notable exceptions that I can think of.)
• I am not certified to do certain specialty physical exams (e.g. for pilots or commercial truck drivers).

Q: What about nutritional supplements and herbs? Are you a believer?
A: Probably more so than most internists. I take several supplements myself and commonly recommend a variety of them when scientific evidence is reasonably compelling. Some other supplements appear to be a waste of money, but again, I have a collaborative approach. If something isn’t actually dangerous, I won’t get bent out of shape if you want to go on doing it if it seems to be working for you. As to herbs, I consider many of them to be very real medicines, so I like to know what my patients are taking and why. I don’t consider myself knowledgeable enough about them to prescribe very many of them (with a few important exceptions), but I respect that trained herbalists have their own pharmacopoeia and that it’s important for me to consider the potential effects of herbs as part of the overall picture.

With regard to supplements, I offer my patients significant discounts through the Slower Medicine Fullscript site. Click the button below to sign-in or create a patient account. (NOTE: Active discounts are only available to Slower Medicine members. Once membership has been established, discounts will apply to all purchases from that point on.)