Who does your doctor work for? by Dr. Q
On my first day in residency training, I saw a patient for their annual exam. I reviewed all their chronic problems, made adjustments to their medications, and counseled them extensively on lifestyle changes. Feeling accomplished and glad they had everything addressed during their “free” annual physical exam, I went to present the patient to my faculty. My feedback was to make sure I billed them for a sick visit in addition to a wellness visit because I had addressed their chronic conditions. I was dumbfounded because I thought the whole point of an annual visit was to help patients tune up all their issues. I also became upset because now the patient who thought they had a “free” visit was on the hook for a sick visit bill. This exploitative and confusing system underlies our medical system, and it continues because all doctors who accept insurance payment work for the insurance companies and not their patients.
When you use your insurance card to “pay” for a doctor’s visit, the doctor files a claim to the insurance company on your behalf. After your visit is finished, the doctor will pick a code based on level of complexity, use your visit note as proof of complexity, and submit both to the insurance company for payment. Usually any copay you provided doesn’t factor in at all and is a made-up number to discourage you from seeking care. While this may sound simple, the process is actually rather complicated. Each code has a dollar amount and different types of services have different codes. Office visits have several levels of code based on length and/or complexity, procedures have codes, wellness visits have their own codes, some times of day have codes. Not only does everything have a different code and dollar amount, combining codes can sometimes increase or decrease the amount of their individual codes. All this is to say, getting money from insurance companies is a big game. And just like most games, players are incentivized to get the most points. Unfortunately, when it comes to medical care, sometimes winning more points comes at the expense of the patient.
Perhaps the most obvious example of misaligned incentives is the rushed office visit. Doctors can only make so much from the insurance companies per patient, therefore, the more patients they see the more they make. For many doctors, the rush is a necessity because in many cases they have to see at least 12 patients a day just to maintain overhead. With the pressure to see more patients, many doctors are forced to make rushed decisions such as starting a medication when a discussion about lifestyle would’ve been better or making a referral when they could’ve handled it just as well. Double booking makes this problem worse. To not miss out on revenue, doctor offices will place two patients in one time slot in case someone cancels or no shows their appointment. Besides needing sheer volume to bring in revenue, doctors will also play the insurance based codes game.
Like my story at the beginning, double coding happens all the time. The physical exam is perhaps one of the biggest examples of false advertising. In your “free” physical you must have no abnormal values/vitals and the doctor should not do anything or else you will get what we call “split billed”, meaning a code for a sick visit is added to your annual physical code and you end up having to pay for the visit even if you weren’t expecting it. Sometimes double coding will decrease payment, so the doctor will have you follow up for something that can be done in one visit. A common example is joint injection. If you need both joints injected, it only takes maybe one minute extra to do so, but injecting two joints in one visit pays about 75% of injecting one joint across two visits. For this reason the doctor may make up some reason for you to come back in order to realize the other 25%. Procedures done on the same day as an office visit for chronic care management also pay less, so doctors are incentivized to have you come back when they could easily do a visit and a procedure.
COVID-19 exposed many flaws in our healthcare system and nowhere more than the flawed insurance based primary care system. Patients found themselves facing closed doors at their doctor’s offices during a global pandemic when medical guidance was needed the most. One reason telemedicine started picking up was because insurance companies started agreeing that telemedicine was work worth paying for. Prior to the pandemic, anytime a doctor would call a patient to review labs or discuss anything, they would not get paid for it. This is why many times doctor offices will have you come into the office for something simple like having a form filled, reviewing labs, or a simple medication refill- they don’t get paid otherwise. While some offices still use telemedicine, the payments have started rolling back and insurance companies will likely soon end telemedicine payments, causing doctors offices to encourage patients to go back to the office for any number of made up reasons.
I started EuDoc with Dr. Keener because we were fed up with this broken and corrupt way of “providing care”. We did not want to work for the insurance companies, we wanted to work directly for our patients. Instead of playing games with codes, we wanted to focus our attention and energy on creating the best healthcare experience we could for our patients. And we did not want to jump through hoops chasing payments while remaining oblivious to the cost which burdened our patients, we wanted to help our patients navigate the system and help them understand the true costs of the healthcare system. While our direct primary care practice is the first of its kind in Midlothian, we join thousands of doctors across the country who were also fed up with the broken way things are now and opened their own direct primary care clinics in order to work directly for their patients and begin healing this broken system.
