Have you gone to the doctor recently? I mean in the last couple of years or so. Think about what you saw while you were there.
My son has had two visits over the past 6 months, one to his pediatrician (PCP) and one to his psychiatrist. My son’s PCP accepts a wide variety of insurance plans (but not SCHIP) and his psychiatrist doesn’t accept any insurance. You pay her and file with your insurance company afterward for reimbursement.
Visit with the Pediatrician (Primary Care Physician)
When we got there we checked in at the reception desk where they verified all our personal information and insurance or other method of payment. We were paying cash. Some doctors or clinics require payment before you see the doctor. This one doesn’t.
As we checked in, I saw a sea of clerks behind the desk and in the file room, which they have walled off with windows. I guess that is so you can see how many people have to get paid when you use their services. We waited for about 10 minutes and were called to the back by the nurse. The doctor saw my son and we were in and out in about 25 minutes. As we left, we stopped by the payment desk and paid for the visit. We got a 25% discount off the price because we paid for the visit in full that day.
The quality of care with my son’s PCP is excellent. This PCP and the other doctors in the group have been my son’s pediatricians since he was born and I have no intention of changing doctors. My son is on SCHIP, so we have to pay the doctor visit bill, but they cover his prescriptions in full. This group doesn’t accept SCHIP.
There are 3 doctors in this group and each has one assigned nurse. There is at least one float nurse and usually there are two. That nurse handles phone calls, gives routine immunizations, fills out school health forms and covers during breaks. That staff count comes to 7-8 professionals in the practice to see and treat patients. That office area also has two other groups of pediatricians with 2-3 doctors each with the same ratio of nurses. All use the same reception desk and file room.
There are at least 15-20 clerks behind the reception desk and in the file room at any given time at that clinic office. These clerks don’t handle the actual billing. They handle collecting the required information, calling insurance companies for pre-authorizations when needed, and taking co-payments or deductible payments from patients. Each area of medicine has groups of doctors and there own clerks and file rooms. The more doctors in an area of medicine in the clinic, the more clerks required.
There is an entire department in the clinic that does all the actual billing and insurance payment collection. There are about 50 employees there. All they do all day is fill out insurance claim forms from the information collected by the clerks in the doctors’ offices and send them to insurance companies for reimbursement. Forms go out by postal mail or by computer. Payments take on average 4 months to come back. Medicare is the only exception. They pay in about 45-60 days.
The clinic has more administrative employees related to insurance billing than patient care employees and doctors. Dealing with getting insurance companies to pay requires an entire department of its own. The cost to run such a department is staggering, but less expensive than for a smaller group of doctors to handle it themselves. Certain administrators specialize with a few insurance providers so they can put claims through 2-3 times faster than if they didn’t specialize or have a large staff.
When our doctors’ group joined the clinic after being independent for decades, I asked why. They said it was because of the increasing administrative overhead. The clinic offered the entire administrative staff they needed at a more affordable and predictable price than they were paying. It comes with renting the office space, too. They moved so they could have predictable expenses every month and get out from under the pile of insurance issues they had to deal with before they moved.
The doctors each take a day off a week now that they moved to the clinic. They can afford for each doctor to work 4 days a week. All the pediatricians in town associated with certain hospitals rotate 24 hour on-call duty, so each doctor is only on call once or twice a month.
They also use the hospital’s nurses exchange to screen after hours calls. The nurses are able to authorize trips to the emergency room for non-life-threatening emergencies, prescribe certain medications, forward calls to the on-call physician and give advice. They report all calls to the patients’ doctors daily. It’s an excellent way to triage patients and make the most efficient use of all available services while getting each patient the care they need quickly. The hospital provides the service with little or no charge to doctors who use it to reduce the number of unnecessary ER visits.
The bottom line is with large clinics that have a large administrative staff to handle insurance claims, doctors make more money and may get more days off during the week than if they remain in independent practices if they accept insurance as payment.
Visit with the Psychiatrist
There is a stark contrast between the PCP visit and the visit to the psychiatrist.
We walked into her office, checked in with her receptionist and paid our bill. This psychiatrist requires payment before you see her. If you need a payment alteration, it will be handled after you see the doctor. They accept cash, checks, credit and debit cards, and money orders. They do not accept insurance.
We saw the doctor, got my son’s prescriptions and were on our way in about 40 minutes total.
There is no sea of clerks, just one receptionist. The office has two nurse practitioners and a few mental health counselors along with the doctor. This doctor has her own building which is paid off. She only sees patients 4 days a week, and that extra day is usually a day off that she spends with her family.
She used to belong to a small clinic, but didn’t like dealing with insurance and paying ever-increasing rent. She felt it interfered with the quality of care she was giving her patients. Our check-up visits are 20 minutes now instead of the 15 minutes they used to be. When I need to get my son in on short notice, she has 30 minute or longer appointment times available. If I have to call her after hours, she calls back within about 15 minutes, and she is the one on the phone.
This pediatric/adolescent psychiatrist can demand up-front payment and get it because she is one of the best psychiatrists for kids and teens within 100 miles. She is worth every penny and then some.
There is a huge difference in quality of care provided by pediatric psychiatrists who take insurance and the 1-2 who don’t. Most of our experience with psychiatrists who took our insurance didn’t seem interested in talking with me or my son. One only spent 5 minutes with us and handed us prescriptions without even asking how he was doing. We changed doctors when we were assigned that one by our insurance company. We went through 3 doctors before going out on our own and paying cash.
I haven’t found quality of care issues to be the case with psychiatrists who treat adults. I still see the same doctor my insurance assigned me to even though I no longer have insurance. Pediatric psychiatry takes special people with special talents who can relate to children and teens, and diagnose them properly.
Since our terrific pediatric psychiatrist wasn’t on the provider list of the insurance company, they wouldn’t reimburse us anything for visits with her. They did cover prescriptions with co-pays.
Now that my son is on SCHIP, they don’t pay for visits, but they do pay for his medications in full–no co-pays. That’s very important to us because he must have his medications and they cost about $200/month. Now that his condition is under control, we only have to see the doctor every 4-6 months.
I don’t have any insurance at all and I have to pay for my doctor bills and medications out of pocket. My medications cost about $280/month. It’s often cheaper than that if my doctor has samples of the name brand drug I take. Then they only cost $150/month. I have to pay for the generics I take. Pharmaceutical companies don’t give samples of generic drugs to doctors. One of my generics is $10, the other is $140. Generic drugs shouldn’t cost that much.
It is becoming very clear to me that private health insurance companies and the price of prescription medications are a large part of the health care cost problem. Insurance companies already ration health care by denying and approving payment for medications, doctors, tests, procedures, and surgeries. You’re free to have whatever treatment you desire, but they may or may not pay for it. If you can’t afford to pay for expensive services that you need on which coverage has been denied, your health care has been rationed.
What value do private health insurance companies bring to the health care table? What value do they add? I’ll discuss this question in a future post.
What have your recent experiences been with your doctors? What have you noticed about the way the office operates? Do you have insurance and if so, what do they cover? Have you had to fight with your insurance company? If you don’t have insurance how are you managing? Let us know in the comments.
\\ tags: health care costs, health care quality, private medical insurance realities, public option, single payer health insurance
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