In an environment of increasing regulation, government mandated red tape, and shrinking reimbursement, health care practitioners find themselves caught between a rock and a hard place. They are being forced to see more patients to make ends meet and both parties are poorer for the process. Not necessarily in just a monetary way. Patients are beginning to feel frustrated and disengaged from their mutually frustrated and disengaged providers. Both parties feel short changed by insurance companies who demand more of each while delivering less to both.
The whole conundrum inspires both parties to dream of an alternative universe where clinicians could concentrate only on patient care and where patients could feel they had obtained a service worthy of their hard earned cash. In this mythical land, it is the patient who would be allowed to keep charge of that most intimate of human possessions,their health and well being. Patients would more enthusiastically embrace the care and advice given to them by an unhurried professional whose only concern is what is best for their clients. In this place, patients would be seen and treated as individuals, not populations. No third party could be privy to their confidences, nor exist to place idiotic constraints on the provider while holding the payment carrot in front of their noses as incentive to substitute acts of expedience for acts of clinical judgement and commonsense.
Providers would be able to see fewer patients, spend more time with each of them and, thus, be allowed to preserve more personal enthusiasm for their professional duties by being allowed to reserve more energy for their families, friends, and personal pursuits. Everybody could go home happy. Patients would feel they’d gotten their money’s worth and leave empowered to make informed decisions regarding their health care. Providers would be able to tally their income for that particular day to the proverbial penny removing the suspense that surrounds the reimbursement game. Sound like “The Impossible Dream?” Hardly.
This, my friends, is the real life world of cost transparency as provided by “cash only” or “direct pay.” Such models are popping up with greater frequency, founded by a few of us rebels who have decided not just to think outside the box, but to kick in its walls and rebuild it altogether.
Fourteen months ago, my nurse and I made the choice to bypass third party payers and to contract directly with our clients. We have been rewarded with a thriving practice of people who are delighted to pay cash up front knowing that there are no hidden costs to worry about later. Overhead is minuscule in this model which automatically slashes costs by less than half. We provide our patients with a price list upfront and they reward us by listening to and following the care and advise they have purchased. I have noted this phenomenon in monitoring the progress of our chronic patients who exhibit marked improvement at each follow up and the small percentage of return visits for acute conditions that do not respond the first go round.
What does this tell us about direct payment for services rendered? It’s simple. People tend to be more engaged when they are in control. Up front knowledge of costs tends to do this. It removes the anxiety of watching the mailbox for a bill they must budget in order to pay. They do not have to spend their visits distracted by trying to add elusive figures in their heads while their provider is distracted by the same mental gymnastics.
Because the only contract is between me and my patient, I work directly for them. I am able to spend more time in the exam room so that when they leave they more thoroughly understand their options and are more likely to follow the treatment regimens and advice because they have received. Direct pay makes people far more likely to be compliant because they occupy the driver’s seat. When they pay up front they know that I work only for them. I do not waste their time by clicking boxes or agonizing over diagnosis codes to insure payment. I do not charge their insurance $300.00 while hoping to perhaps realize a profit of $39.99 after overhead some ninety to 120 days in the future that is, if every I is dotted and T crossed on their claim form. I do not have to pay people to beg third parties to make good on the services for which patients have already paid in premiums for the privilege of hoping a third party will see the logic of medical necessity and open their tight fisted wallets. I do not feel obligated to order unnecessary tests to satisfy a health policy’s idea of protocol. I do not lump my patients into “populations,” because this model allows me to see them as individuals with their own unique set of circumstances. Price transparency fosters mutual respect and allows me to provide holistic care that is truly “whole.” It creates productive team work between the patient and myself that is beneficial for us both.
Someone called me a visionary the other day and asked where I’d gotten my idea. I smiled and answered, “Hippocrates.” You see, when something very old is made new again, people tend to either approach it with suspicion or ponder is relevance in disbelief. After all, we are schooled to embrace progress so that any step backward into the past is considered suspect. They shouldn’t be concerned because, as I have discovered, it is sometimes the oldest and most simplistic of ideas that have the ability to provoke change, and dare I use the word? True reform.
Kim Byars is a nurse practitioner and founder, Byars Family QuikCare.
