How Did Doctors Get Into This Mess (and how do they get out?)

   I have been a practicing podiatrist for over 40 years. I began my practice when things were very, very different for doctors. We put in our years of education and training but we were remunerated very nicely. Health insurance was an indemnity model. The patient had insurance coverage for 80% of the fees and then were responsible for 20% (unless they had a secondary policy). There was no such thing as ICD codes, CPT codes or HCPCS codes. We hand wrote the diagnosis and what we did at the visit whether it was procedural or an evaluation visit on the claim form. The risks of performing surgery were considered as well as the post-operative care involved, and we were paid very well.  It was up to each doctor to do adequate marketing so the practice could grow since there was no such thing as participating with insurance. Most important, we had the respect and trust of our patients.

    Sometime in the early 1990s, things began to change. The HMO format (which already existed for certain large businesses who recruited doctors to take care of their employees) moved into the health insurance industry under the name “managed care”. Insurance companies offered “participation” status to doctors. This meant patients would find you in their manual under the list of participating providers and were only expected to pay a very small co-pay (I remember $2- $5 at the time). No more marketing! The schedule of fees was reasonable, and it seemed like a no-brainer. We could just be doctors without any of the marketing requirements to maintain our following.

    But lo and behold, in the microscopic writing of our contracts, were clauses that gave them the right to “adjust” the fees at any time. And adjust they did. It became obvious that managed care really meant managed payments to doctors. But by then, we all bit the bait and dove in. Some insurers left podiatric medicine out and we fought like crazy for inclusion. And so, we were included.

    Something very terrible happened along the way. Patients were slowly conditioned to feel that their medical care was only worth $5. If you needed to perform a procedure that wasn’t covered by their plan, they either refused it or many would ask you to put in “extra claims” to cover the cost so they wouldn’t have to pay. Additionally, I certainly recall my patients saying to me, “Why should I pay the deductible? Dr. So and So never charged me”.  I lost many patients at that time because I refused to commit fraud. But what I realized back then is that it wasn’t only the patients who became conditioned to devalue what we do. We did as well.

    Through the years, too many doctors would “operate” on the claim forms and come up with coding that got them paid because patients were refusing to pay deductibles, co-pays and non-covered services. And slowly, over time, doctors backed themselves into a corner. Insurers saw the opportunity and seized it. They wrestled the standard of care away from doctors and completely took control of health care. Unfortunately, they do not function from a health care algorithm. It is purely financial. Fees got lower and lower. Then they instituted guidelines for coverage which, over time, got stricter and stricter.

    If that wasn’t bad enough, then they instituted prior authorizations for imaging and procedures. By the time all of this happened, most doctors had built their practices on the premise that they accept insurance and that is how they attracted new patients. Even doctors that advertise always list the insurance that they accept because it makes attracting new patients much easier.

    Now, doctors work very hard. They must see a high volume of patients if they want to stay viable. They must have offices large enough to handle high volume and they must hire enough employees so the practice can run as smoothly as possible. Most offices hire employees whose only job is to call insurance companies and fight for fees that are owed. Expenses are enormous and the rigors of running this kind of practice is very stressful.  The great majority of doctors, regardless of specialty, hate what has happened. Many are so stressed they are suffering with health problems, anxiety and depression. Many are planning on quitting medicine altogether.

    Several years ago, I was giving a lecture to podiatrists. There were about 200 of them in the lecture hall. I asked, “By a show of hands, who is happy with their practice and loves being a podiatrist”? Two doctors raised their hand. I then asked, “Who hates going to work”? Almost every hand in the room went up. I asked them to tell me why they hate going to work. I called on at least 10 of them. Everyone said the same thing…insurance is destroying their autonomy and satisfaction. That was very enlightening to me. I had felt that way as well and dropped out of all insurance in 2000. I successfully developed a direct-pay practice where patients didn’t have to wait to get an appointment, were taken into the room at the exact time of their appointment, benefitted from extended stress-free visits with me, had easy access to me and enjoyed successful outcomes where many others had failed. I had the time to create deeper bonds and the potency of the doctor-patient relationships in my practice increased a thousand-fold.

    Now, when I speak with doctors who still take insurance, it is still universal. They hate it. So why do they stay in a situation that is difficult, stressful and not as lucrative as they deserve after all the years of education and training? What I am told repeatedly is, “Who would pay me out of pocket?” The conditioning is very cellular. They really believe there is no value to what they do. I find that incredibly sad. Not to mention the fact that a stressed-out doctor will not perform as well as a relaxed doctor. And, no less important, their patients do not respect them the way they respected doctors years ago.

    I have been an outspoken opponent of participating with insurance for many years now. I have been called a lot of names. I have been judged and ridiculed online by some of my peers because in addition to going direct-pay, I have been practicing holistic/functional medicine for 36 years. Yet, despite all the venom, I am happy and successful, and they are unhappy and bitter. I never retaliated. I didn’t hate anyone. I just distanced myself from mainstream podiatry because I was unable to have an impact.

    Things came to a head this past year. I started getting lots of emails from podiatrists who wanted help. Many asked me to mentor them. Too many told me they were struggling financially and were ready to quit altogether. Honestly, I was taken aback. I had been irrelevant in podiatry for a long time. I did try for quite some time to bring functional medicine to podiatry, but other than a few podiatrists, it was flat out rejected.

    But my heart opened. I knew how bad things had gotten for them. The irony for me is that although I am in the twilight of my career, I am on a mission. I am committed to helping as many podiatrists as I possibly can. I authored and created a course for them to learn how I practice and how to go direct-pay. I am supporting these docs through the transition. I am happy that at least some are embracing what I have to offer and feel confident that the legacy I leave behind will be a source of professional satisfaction for so many younger doctors.

    There is another reason why I believe it is critically important at this stage in medicine for doctors to completely opt-out of insurance. When there are no doctors giving credence to insurance company controls, they have no business. If they see their business is in jeopardy, guess what? They will have to find a way to get doctors back. That means they won’t be able to exercise complete control over health care nor will they be able to tell doctors how to practice medicine. Until that happens, it will only be the few smart and the brave doctors finding their way to a much better paradigm and practice dynamic. The rest will continue to be part of a system that has the worst medical outcomes than almost any other country, even though more money is spent on health care here in the U.S. than any other developed nation. And that is just an absolute travesty!