The Worried Well … and Worse Than Nothing

Kaiser Health News is allegedly an “editorially independent program” of the Kaiser Family Foundation and is not, apparently, affiliated with the health insurance company Kaiser Permanente, despite the similarity in name.

One of the organization’s goals is to provide “trusted information on national health issues.”

Trusted?

Two recent articles published by writers from Kaiser Health News — one by Charlotte Huff and another by Michelle Andrews — appear to bring that goal into question. Both articles deal with the topic of Direct Primary Care, and yet throughout both pieces are insidious threads of bias towards health insurance companies.

The title of Huff’s piece, “Flat-Fee Primary Care Fills Niche for Texas’ Uninsured,” appears to promise information about Direct Care filling a gap — which it does. Consider, though, the use of other phrasing and statements. Above the title, in bold red, no less, are the words A FALSE SECURITY.‘ And, below it, the italicized tagline: “It’s [Direct Care] not insurance but it’s better than nothing … “

Really, Ms. Huff? Better than nothing? Those of us actually delivering Direct Care practice and the patients in receipt of it (at least at Still Point) have a different view, and comparatively it goes something like this:

TRADITIONAL “INSURANCE” CARE

DIRECT CARE

WAIT TIME FOR APPOINTMENT

6 weeks to 3 months

Same day/next day
AVERAGE TIME SPENT WITH DOCTOR AT CONSULTATION

10 minutes

40 minutes
COST/CO-PAY AVERAGE

$30-$60

$60
TIMELY FOLLOW-UP ? Frequent
ACCESS 24/7/365 No Yes
ACCESS TO MY OWN DOCTOR During business hours Yes
HOUSE CALLS What? Yes

So, if same or next day appointments, spending 40 minutes in consultation, having access 24/7/365 to one’s own doctor — maybe even at one’s own home — is considered “better than nothing,” then traditional insurance care in comparison appears to be “worse than nothing.”

The bias continues, manifested by an indefensible untruth. Huff claims that “[p]roponents of the [Direct Care] model, which is also supported … by the American Academy of Family Physicians, say it can provide a safety net for those with limited treatment options.”

No, we don’t. We say, quite clearly, that Direct Care offers a genuine alternative to a system that is struggling to maintain even a modicum of the concept of service and efficiency. It’s not about “limited treatment options,” and everything to do with Americans finally taking charge of their own choices for health care — and, for once, leaving the insurance companies out of the equation.

Insurance companies don’t like this. They, in response, make spurious claims about Direct Care practices such as suggesting patients “worry” that “easier access to [Direct] primary care is ‘good enough’,” that such patients “won’t investigate insurance options,” or that it’s “sort of the illusion that it’s kind of like insurance.” All of these alleged statements and claims are from Huff’s piece.

Bollocks. At Still Point, as at most Direct Care practices, we’re very clear to point out that we are not offering insurance. We also encourage our patients to carry catastrophic or high-deductible insurance (thereby directing patients to investigate their options). As for Direct Care being “good enough,” isn’t what constitutes “good” treatment  up to the medical practitioner to determine for his or her patients? — that is, if the practitioner has sufficient time to fully engage and interact with the patient.

Fortunately, at most Direct Care practices, practitioners do have this time.

A similar vein of bias-towards-insurance-companies is detectable in Michelle Andrews’ article, “A Pioneer in ‘Flat-Fee Primary Care’ Had To Close Its Clinics. What Went Wrong?” Andrews’ piece breathlessly opens with a classically negative “but” conjunction: “In theory, ‘direct primary care’ should result in better health … [b]ut some analysts say that approach just encourages the worried well to get more care than they need.”

What? To begin, which analysts? The Board Members of Kaiser Permanente or Blue Cross or United, for instance? The corporate bodies of administratively-heavy corporate medical  conglomerates? Proponents of doctors seeing 25 or more patients a day and spending 10 minutes with each, most of it on a computer in order to merely comply with onerous EMR reporting burdens and insurance-driven-and-created “treatment codes”?

And … the “worried well”?  Does that mean the individual who is concerned about his or her health and wants some reassurance or to access some medical expertise? The worried well had better not want to discuss any health concerns in detail with the physician or practitioner. There’s no time. So, let’s only see the really sick. Their complicated concerns can be dealt with effectively in a 10-minute consultation, six of which is spent with a face glued to a computer screen.

Patient? What patient!

Andrews’ article goes on to point out that Direct Care practices don’t accept insurance, which is true. The rest of her statement is absolutely and cringingly false. She claims not accepting insurance “frees the doctors from having to get preapprovals from insurers on treatment and lets them skip the paperwork … .”

If only. Daily, we toil at the “pre-(un)approval game” that insurances appear to play: the “you’ve used the wrong fax number even though this is the fax number we told you to use,” or “this person is not a member, even though last week the person was a member,” or “this is the wrong ICD-10 code for this. Request denied,” or “you need a peer-to-peer and we called once and you didn’t pick up so therefore that option is now eliminated.”

All the while, the hapless patient is waiting for treatment. Then again, perhaps he or she is just among the minions of the “worried well.”

Appallingly, Andrews discusses a hypothetical patient who is referred to a specialist by a Direct Care family practitioner. “That patient,” Andrews instructs us, “who likely has a high-deductible insurance policy … will probably be on the hook financially for the entire cost of medical services provided by the specialist — rather than insurance paying a share.”

Rubbish. Plenty of our patients are referred to specialists and the care is covered by their insurance. And for those who do have a high deductible, it’s not going to matter either way whether they see a traditional family practitioner or a Direct Care practitioner: the high deductible is still the high deductible. Above all of this, though, is the fact that health insurance has become so prohibitively expensive that many times a high-deductible policy is all one can realistically afford.

Nowhere does Andrews mention the possibility of negotating cash payments, either. As a specific example (from our own experience), the cost of an antibiotic co-pay WITH an insurance plan was $17.48. The cost to pay cash WITHOUT using insurance? $3.40.

Yes, really.

Andrews’ article continues to somewhat gleefully outline the demise of a Direct Care practice called Qliance that, inexplicably (given the overarching goal of individualism of Primary Direct Care), was serving 35,000 patients. That’s not Direct Care. That’s corporate medicine, replete with all the problems of a burgeoning, administratively top-heavy gelatinous monolith that cannot respond to individuals in a timely and effective and efficient way because it’s just too damn big.

Direct primary care seeks a small, individualized, and personalized patient base. Often, it’s a bare-bones approach, without the need for a small army of “coders” and “billers” (and here we are reminded of one hospital where the number of billers and coders are higher than the actual number of patient beds).

Direct primary care, at least the way we practice it at Still Point, is very small and people — patients — matter. It’s the same as in the book by E.F. Schumacher, Small is Beautiful: Economics As If People Mattered.  Paul Hawken, in his introduction to that book, points out that Schumacher has made an edifying and heretical observation: “There are inherent thresholds in the scale of human activity that, when surpassed, produce second-or-third order effects that subtract from if not destroy the quality of all life.”

Direct Primary Care is heretical to the interests of mainstream insurance companies because it re-establishes the connection and relationship between the doctor and the patient, without a corporate interjectory to micromanage, deny, reject, and control. It puts power back in the hands of the patients: power to choose, to direct their own health care, and enhance their own quality of life.

It would be nice to see writers such as Christine Huff and Michelle Andrews, with their enormous potential power to really enact significant and lasting change through the media platform of an organization self-tasked to provide “trusted information on national health issues,” at least try to present a realistic assessment of Direct Primary Care rather than insidiously appear to align themselves with an agenda of speaking for the nameless, faceless bureaucracy that has become medicine and health insurance in  this country.

SMALL IS BEAUTIFUL

Nine Köpfer

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