Doctors keep it simple, ditch insurance


Millions of Americans are eligible for health insurance for the first time through the Affordable Care Act, but a small segment of doctors say they want out of the third-party payer system.

The practice models vary considerably, from low-overhead cash practices to direct primary care. But the reasons for parting ways with insurance companies are pretty much the same. Physicians say they are fed up with declining payments, stacks of preauthorization forms, and the hamster wheel of 8-minute patient visits.

So they’re taking a leap of faith, tearing up their insurance contracts, and in some cases, opting out of Medicare.

"I was really scared that I wouldn’t have patients," said Dr. Juliette Madrigal-Dersch of Marble Falls, Tex., who started her own cash-only practice about 11 years ago.

Dr. Juliette Madrigal-Dersch

For the first 6 years, Dr. Madrigal-Dersch’s internal medicine–pediatrics practice was cash only but accepted Medicare patients. But she soon realized she wanted out of Medicare too. That was the scary part for her. She said she worried that she wouldn’t have any patients over age 65 once she made the switch.

Her fears turned out to be unfounded. Although many of her Medicare patients did leave the practice, some stayed and then some returned. The ones who came back told her that they missed the long visits – typically 20 minutes to an hour – and felt like they couldn’t always get the care they wanted from other doctors who participated in Medicare.

Leaving Medicare

Dr. Madrigal-Dersch, who is a past president of the Association of American Physicians and Surgeons (AAPS), is part of a growing and vocal minority of physicians who are opting out of Medicare.

The AAPS, which is outspokenly critical of the Affordable Care Act (ACA), has been hosting a series of workshops providing tips to physicians on how to move to cash-only practice and how to drop Medicare. The sessions are in high demand, said Dr. Jane Orient, AAPS executive director.

Dropping insurance and going cash only is a model that works not just for primary care physicians, but for lots of specialists too, she said, including surgeons. It can be harder to do in fields like neurology where most of the patients are older and the procedures are expensive, she added.

Although the number of physicians who are opting out of Medicare is still small, the momentum is growing, Dr. Orient said. "I think some of the physicians who do it want to stay under the radar, particularly with Medicare."

Federal officials have acknowledged the trend, but said it is not impacting access to care. A recent analysis from the Health and Human Services department shows that about 650,000 physicians participate in the Medicare program nationwide. In 2012, 90.7% of physicians were accepting new Medicare patients, up 87.9% in 2005, according to the report.

Dr. Lee H. Beecher, a psychiatrist and addiction specialist in St. Louis Park, Minn., said he also maintains a cash-only practice. He stopped accepting all insurance, including Medicare, about 8 years ago.

The problem, he said, is that he started to feel like an employee of the insurance companies.

"I felt that the quality and nature of my practice was being challenged and actually subverted in many ways by the third-party payer system," said Dr. Beecher, who is also the president of the Minnesota Physician-Patient Alliance, a nonprofit think tank.

The transition was pretty straightforward for him, Dr. Beecher said, because psychiatrists are paid basically for their time. Despite this, he said that it is difficult for patients to learn what psychiatric services cost. When patients asked around to find out the cost of psychiatric consultations and care at Minnesota’s large clinics, they were told that no one knew the actual cost and that the charge was determined by the patient’s insurance.

"Unless psychiatrists have direct pay practices, their fees are not visible to patients," Dr. Beecher said.

Prices on display

Price transparency is a big part of the appeal of the cash-only model, said Dr. Brian R. Forrest, a family physician in Apex, N.C., who started a direct primary care practice called Access Healthcare.

At Access, the prices for each type of office visit are displayed on a large menu in the waiting room. The most expensive visit is $59.

Patients who don’t want to pay a la carte can join the practice as "members." For a monthly membership fee of $39, a patient can come in for any reason and pay a $20 per visit fee. That fee includes most lab work.


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