Direct pay primary care and the ACA still don't mix

Lately I’ve gotten hooked on watching the reality TV show, the Deadliest Catch. It’s astounding to me what these guys go through to catch crab in the Bering Sea.

One of the recurring themes on the show is the new crop of “greenhorns” — new recruits to the profession of working crab boats — that try to show they can hack “the world’s most dangerous job” each year. They often come with bravado and brashness, thinking that they can prove to the world just how tough they are. Reality hits quickly, and most greenhorns don’t make it through the year. The more the bravado, the more quickly they seem to wilt.

Welcome to health care 2013: my reality TV show. Here is something my family just got from our insurance company:

$1200 per month? This is double what we have been paying all along. Compared to this, the $50/month that I charge (maximum $150/family) seems pretty reasonable. This plan is, after all a high-deductible insurance that doesn’t cover a whole lot of services, so a practice like mine that focuses on avoiding unnecessary tests, medications, and use of medical services would make a lot of sense, wouldn’t it?

But people are scared and confused by what has been going on with the Affordable Care Act. They are getting letters like this, and (like me) don’t know how they can afford to do this. I have to admit, the irony of this happening as a result of something labeled “affordable” is not lost on me or my patients. It’s also a tough irony to see how a practice like mine, which was built to offer access to truly affordable care, is being hurt by the ACA.

I got this from a patient who recently signed up:

I am sorry to inform you that due to our circumstances, and the ACA it is not feasible for us to use your service. We would still not qualify for appropriate coverage because we don’t have hospitalization. We will just go to prompt care or the emergency room if necessary. Actually I hope everyone drops their health insurance and goes to the emergency room, and show the socialists how we can totally decimate their ideas of forcing some to pay for others. If I didn’t have so many personal issues right now I would have stayed with you, but if I would still be penalized for not being in an exchange, it doesn’t make sense to keep going. Some months we don’t even go to the doctor, so I must say thank you, for your work with us, and I hope you are able to weather the storm, and we wish you success.

While this sentiment is fairly strong, it is fairly representative of people’s feelings on this issue. Other direct care providers have reported a significant drop in the number of people signing up.

The solution, I am told, is to combine what I am doing with a “wrap around” high-deductible plan, and that “will meet the ACA requirements” and get the person out of paying the fine. Many/most of my patients are interested in this possibility, both for themselves and for their businesses (as a very large percentage of my patients are owners of small businesses). This would benefit all parties, it would seem:

This would be a huge gain for me, as it would give my practice an inside-track to a large number of patients.
It would be good for the patients, as it would give them the ability to avoid the fines while maintaining high-quality care.
It would benefit the small businesses as they’d be able to insure their employees or at least be sure their employees weren’t getting socked with huge insurance bills (see above).
It would benefit the insurance companies, as I would be far more focused on avoiding spending up the patient’s deductible, reducing unnecessary testing, and keeping the patient out of the ER/hospital. In short, they would reduce the risk, which is speaking in a language insurance companies know well.

This is where, just like it does to a greenhorn on the Deadliest Catch, reality hits. It’s not as easy as I thought. I thought the contrast of my practice’s simplicity with the complexity and confusion of the ACA would have people seeking alternatives. Enter me stage left with heroic bravado, here to save the health care system! But I am met with the same smirks and sneers thrown at the greenhorns by the weathered deck hands.

None of my patients know what to do, and I could probably get several hundred covered lives’ worth of business for an interested insurer. I could make some employers happy and the lives of a bunch of employees happy as well. But when it gets right down to it, I am met with blank stares. How crazy, wanting to do things in a better way! How crazy, trying to improve care quality while saving money! How crazy trying to offer truly affordable care! Don’t I know that there is no cutting into line here, and that I’ll have to fill out all the proper forms and stand at the end of the line until my turn comes?

I’ll still hit the street and try to get answers for my patients. I’ll still be calling more insurance agents trying to put something together that doesn’t make a mockery of the word “affordable.” But I suspect my hopes for gaining some advantage by the provision in the ACA for pairing practices like mine with wrap-around plans is not reality.

These crab pots are coming back empty.