KANSAS CITY, Mo. - You go to the doctor. You pay the doctor.
What could be simpler?
Following a practice that would have been typical in the 1960s, some doctors have decided not to accept health insurance.
Patients of these doctors pay the whole charge — at the time of the visit or after the doctor sends them a bill. For patients who have health insurance, it is up to them to get reimbursed by their health plans.
Doctors who go this route — an estimated 35,000 or so across the country — say they gain autonomy and independence by opting out of an increasingly dysfunctional health-insurance system.
"It keeps me working for the patient. I don't have to answer to the insurance company first," said John Dunlap, an Overland Park, Kan., internal-medicine physician who has never worked through insurance companies since beginning his practice in 1980.
Despite the allure, those deciding to work outside the health-insurance system are more of a trickle than a flood. Health care industry studies suggest that roughly 90 percent of doctors are affiliated with a managed-care plan, and those numbers have not moved much in recent years.
"Our physician-turnover rate in our networks is significantly less than 1 percent," said Susan Johnson, a spokeswoman for Blue Cross and Blue Shield of Kansas City. "We just don't see many physicians leaving our networks."
Patients have their own reasons for agreeing to such cash-and-carry arrangements — but it is generally not about saving money.
It is the "quality of care, the personalized attention," said Jari Holland Buck, a patient of Jane Murray, a Mission, Kan., doctor who does not accept insurance payments.
Murray is medical director of the Sastun Center of Integrative Health Care. She practices what she describes as "open-minded" family medicine — conventional treatments with a heavy emphasis on nutrition, lifestyle and other nonpharmacological treatments.
Murray stresses the importance of the doctor-patient relationship.
"I don't want to be the intermediary between the payer and the patient," she said. "When the person has a direct financial covenant with me, it's clear that they're my boss."
Why do this?
Going to a doctor who does not accept insurance may actually cost patients more money because the doctors work outside of any insurance network.
"I establish my own fees, based on reasonable charges," Dunlap said.
Chuck Wiedenhoft, who had an appointment in March with Dunlap for a physical, said he would probably save money if he went to a doctor in his health-plan network.
The 56-year-old Overland Park resident chooses to go to Dunlap for peace of mind.
"It's the confidence in the quality of the service I get, and the confidence I have in him as a doctor," he said.
Longer visits with the doctor are a draw for patients like Mike Palmer, who has been going to Dunlap for three years. The 60-year-old Leawood, Kan., resident is retired but still does consulting for his former employer, which provides him with health coverage.
Palmer said his physical in March with Dunlap took about an hour.
"Besides going over my test results, he asked about my family and how I was doing emotionally, how I was doing exercisewise," Palmer said.
Dunlap mails him a bill, Palmer said, and a standard insurance form that lists services and charges. Palmer pays the bill, then signs the insurance form before sending it to his insurer. The insurer reimburses Palmer or the amount goes toward his out-of-pocket deductible.
Murray also has a set fee schedule "based on what I feel is a reasonable compensation also might pay more than if they went to doctors in their insurance networks.
While Murray said she normally does not negotiate charges with patients, she sometimes lowers fees for patients going through tough financial times, especially if she has treated them for an extended period.
"I couldn't do that if I had signed contracts with insurance companies," she said.
More time with patientsMurray said working outside the insurance system enabled her to spend more time with patients, which leads to better outcomes and fewer visits.
The Leawood, Kan.-based American Academy of Family Physicians said that the typical family doctor sees about 85 patients in an average week, or about 17 a day.
Dunlap and Murray said not dealing with insurance companies enabled them to operate with smaller clerical staffs, which saves money.
For some doctors, that savings has translated into a reduction in fees.
Vern Cherewatenko, a family-practice physician in Renton, Wash., said he was able to cut his fees by 30 percent to 50 percent when he stopped dealing with health insurance companies.
Less record keeping"We don't have to bill and keep track of accounts receivable," said Cherewatenko, the founder of SimpleCare, which advises doctors on how to operate a practice this way. "It's just like eating a meal at Denny's."
In 2002, the Center for Studying Health System Change, a nonpartisan research group, reported that nine out of 10 U.S. physicians contracted with at least one managed-care plan between 1997 and 2001. That, of course, means that one out of 10 — or about 35,000 doctors — did not.
Alwyn Cassil, a spokeswoman for the Washington-based group said a new study, expected to come out in early May, would show a small increase in the proportion of practicing physicians who did not contract with managed-care plans.
No big exodus"There is no exodus of large numbers of physicians from managed-care contracting," she said.
According to the American Medical Association, 88.1 percent of U.S. physicians participated in managed-care plans in 2001, the latest year for which it has data.
That percentage probably has not changed much, said Texas physician James Rohack, immediate past chairman of the AMA's board of trustees.
Most doctors who practice without insurance company involvement care for relatively well-off patients or, at the other extreme, provide care mostly to indigent patients who lack insurance, Rohack said.
Other variablesThere are a number of other variables that come into play, such as the kind of physician.
For example, Cassil said about one in three psychiatrists practices without managed-care contracts, about three times the rate of other doctors. Cassil said many psychiatrists feel constrained by low reimbursement rates from health insurers.
One development that may encourage this type of practice is health savings accounts, which the Bush administration is promoting as a way to lower health-care costs and expand health coverage.
Big trend or not, practicing medicine without insurance has strong appeal for some doctors.
"Collecting money from third-party payers has become very complex and expensive," said James E. Allen, a Kansas City internal-medicine doctor. "If I could find an adequate clientele that could pay for visits as we went, then I'd probably drop a lot of the insurers I'm with."
Source: http://www.chron.com/disp/story.mpl/business/3813864.html
