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going direct pay - I think

  • 1.  going direct pay - I think

    Posted 02-13-2018 19:33
    So, I think Jean will be the last original IMP standing.

    At the end of this year, I plan on severing my insurance contracts and going direct.
    I am tired of working 65-75 hour weeks with fully half of my time spent on the demands of insurances - documentation, billing, coding, referrals, prior authorizations, and "quality ( read - checking boxes and pasting text blocks)"
    Although in my IMP practice as it stands now,  I could continue to work and earn enough to live well ( about $120-140K per year), I asked myself: why am I working this hard to make insurance companies richer?
    After Jan 1 of this year, the 2 biggest insurers in the state began to require 100% specialist website referrals for their respective managed medicare and -caid products, and  I saw my admin work spike another 2-3 hours per week: I also saw the writing on the wall. This incessant grinding down of the primary care work force cannot end well for us (the grindees).
    For the past 3-4 years, I worked within the state's quality organizations and the health insurance commissioner's office to try to change the flawed quality measurement system towards more sensible, less burdensome quality measures based on HowsYourHealth, but at our last meeting 2 weeks ago, I realized the obvious truth:  that these bureaucrats really have no intention of changing the rules for small practices to make "quality" work less burdensome. Another pipe dream, up in smoke.
    These two realizations coming together have finally cracked my rose colored primary care lenses. This crazy health care wealth extraction system is not going to change, not one iota, until it implodes.

    The direct practice upstairs is doing quite well, due to the scarcity of quality primary care in RI.
    I'm going to charge the old IMP standard of $1/day for no holds barred primary care ( way less than the going rate of the folks upstairs, who are 25- 50- 75-100 $ per month, depending on age).  I expect I will keep around 1/4- 1/3 of my 750 patients ( we will see! )  so I will get to breathe.  Perhaps I will travel around the country a  little and visit you guys ! For every 100 paying patients, I will see 15 medicaid or medicare patients that don't have the resources to pay me ( I have the list percolating now). Going to use HintHealth for collecting money; possibly may moonlight a little at the Navy base or the University Health center if needed.

    Hurrah ! I 'm embarking on another IMP adventure !


    Lynn Ho

  • 2.  RE: going direct pay - I think

    Posted 02-14-2018 07:27
    NAh Kevin Egly is still out there   Last talked to  him maybe 1 yr ago  They struggle   And Gwen Hanson is till out there Gordon says

    In 3 yrs I hope to have the mortgage gone  Then I think I will  dump many insurances and do medicare and mediciad only and wind  down   Things are getting worse and worse and those who could speak who could do something  do nothing Except for Lynn.   Those who promote worthless complexity  speak and do alot This is  not a country that wants primary care We would have to unionize or strike


         Jean Antonucci MD
         115 Mt Blue Circle
         Farmington ME 04938
    ph 207 778 3313   fax 207 778 3544


  • 3.  RE: going direct pay - I think

    Posted 02-15-2018 20:38
    Yay for all of you and us!!
    Also see below.
    This is one solution- there's a group of benefits and corporate types who have figured out that PRIMARY CARE IS (an important part of) THE ANSWER to fixing the health care system.  These enlightened CEOs have figured out the formula:
    high quality primary care, (best as salaried or DPC, which will cost about twice as much as they're spending for primary care now)
    directed referrals to high quality/low cost centers of excellence
    (some pharmacy solution, NOT the commercial PBMs)

    Rosen hotels has cut their health care costs in HALF by doing this.  WE know it's possible, because we've been talking about it for years.
    Here's guys with big money who want to work with us.
    Dave Chase has a bunch of great articles on LinkedIn. This is his book:
    Their blurb below
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    Peter Liepmann MD FAAFP MBA
    My mission is to fix US health care
    Bakersfield CA

  • 4.  RE: going direct pay - I think

    Posted 02-14-2018 14:13
    Wow, thank you sad on one level, you, Jean, Brady, and several others were such champions of the IMP movement.  It is incredible the way that healthcare is headed, with little slowing it down.  I hope it truly does implode at some point so that we can try to rebuild it from the bottom up.

    That being said, I transitioned my half of the practice to DPC last July, it has gone very well.  Unfortunately, I am still stuck doing prior auths for medications, some specialists and much of the testing I order.  Do you have thoughts on ways that you will try to decrease that burden?

    Jennifer McConnell,MD
    Maranacook Family Health Care
    169 South Road
    Readfield, ME 04355
    (207) 620-4449 (phone)
    (207) 685-3208 (fax)

  • 5.  RE: going direct pay - I think

    Posted 02-15-2018 05:45
    Interesting Jenn
    wondering - are the priors and referrals coming from patients in the DPC part
    patients with managed medicare that require referrals I am requesting they move to straight medicare which does not require referrals or priors
    because I will be unable to do referrals if not contracted provider, as far as I can tell
    what % of people moved to DPC from your practice and what percent left, do you have a number?
    I saw Hint Health showed some person from a traditional practice, only 7% of his patients followed him . of course, he had 3000!
    I expect my percentage will be more

    Lynn Ho

  • 6.  RE: going direct pay - I think

    Posted 02-16-2018 06:06
    Hello everyone,
    I am still out here too, just don't log in and communicate as often. Congratulations Lynn on making the jump! I have limited the insurances I accept over the years, down to about 5. Fortunately, many of my patients who have plans that I do not accept, are willing to pay cash for a visit. I charge $85 for regular visits and $150 for physicals/DOT physicals. I keep talking about, but never act on, trying to get an annual fee for noncovered benefits. I feel that if I can get an extra $100/person/year to help cover my Athena EMR/Portal and the concierge type of care that I give without charging concierge prices, I would feel better. I definitely do not want to become employed again. I am making a living but do get frustrated with less reimbursement from the private insurances than the employed practices get, but am definitely happier than those docs I think.
    Margaret Coughlan
    Millbrook, NY
    Solo since 2007

    Margaret Coughlan

  • 7.  RE: going direct pay - I think

    Posted 02-17-2018 09:25
    I’m doing DPC and love it.
    One way to dramatically cut down on priors is to run an in-house pharmacy. There are lots of advantages— convenient for patients, adds a bit of revenue, confidence patients are actually getting their meds, but in my experience one of the nicest parts is the decrease in back and forth with the pharmacies and arguing with insurance over $6 medications.

    I also find I’m much less irritated by PAs etc when I have time to do them...

  • 8.  RE: going direct pay - I think

    Posted 02-21-2018 17:52
    I felt the same way, I also felt I had done everything I could at the state level to try to make them see... In the my case I thought this, if I went direct pay and lost a bunch of patients I couldn't go back and sell my practice, if I sold my practice and hated it and then decided to switch to direct pay, I still could. At any rate, while it is hard to have partners and have to have consensus on everything, I work 4 days a week (about 9-10 hours) and find it much less annoying. My patients definitely miss the lack of barriers they  had in my IMP style practice. I have to say though that while I definitely went through a period of grieving, it is all just fine now.

    Kris Oaks
    Kristin L. Oaks D.O. Inc.
    Worthington OH

  • 9.  RE: going direct pay - I think

    Posted 02-27-2018 13:43
    I am about to start a solo peds practice and this discussion is a little disheartening... Any IMP peds out there that are making a go of it either DPC or insurance based?

    Elizabeth Bird, MD
    Chester CT

  • 10.  RE: going direct pay - I think

    Posted 02-28-2018 05:12
    Yes Elizabeth doctors are like patients-one hears the negatives.
    Many  small practices are doing fine.
    States vary
    Peds is tough I thought becasue well here in MAine anyway soomany  kids are on medicaid which is often low paying

    So keep your overhead low-- vaccines will be a huge problem  in terms of time and money; and just do the math  I am doing ok
     I make more money every yr but of course my own health insurance eats it up sadly
     I encourage others on  the list serv to write in now saying they are doing ok
    If you have a working spouse you  have it made IMO   The first yrsmay be  tight

    Ask us specifics.
    Also do be a paying member of imp for at least  a couple of yrs It will save you lots of money  Ther eis JOhn Brady's business plan somewhere on the website and lots of other good stuff.Of course you can do this  Keep your space small and staff minimal are the biggest things Choose a functional cheap EMR  .Do not do your own billing- people will tell you to and give good reasons Those that do are unhappier.


         Jean Antonucci MD
         115 Mt Blue Circle
         Farmington ME 04938
    ph 207 778 3313   fax 207 778 3544


  • 11.  RE: going direct pay - I think

    Posted 03-01-2018 06:24

    We are a hybrid type of practice (small yearly fee requested) and mostly insurance based (although we opted out of medicare).  We are a little bigger than the usual IMP.  (2 FTE providers equivalents and 3.25 support staff)  Now starting our 11th year and have been following IMP over the years.  We feel the practice has been very successful clinically and financially....but we needed to be very 'picky' about which insurances we deal with and which programs (NCQA/PCMH etc) we choose (or more accurately choose not) to participate in.  We have outsourced many of the things that we feel we are not good at or do not want to deal payroll calculations, billing support, contracting.    

  • 12.  RE: going direct pay - I think

    Posted 02-28-2018 05:19
    There are some of us making money just dandy as private practices. Not direct pay. Regular insurance. We just arent the ones posting on here. It is not all disheartening. There are many variables that influence whether you can be successful...  It makes me sad to think that readers of this forum come away thinking all gloom and doom because I was quite inspired by these forums a decade ago.

    PJ Parmar

  • 13.  RE: going direct pay - I think

    Posted 02-28-2018 06:26
    Thank you; I appreciate the perspective. I did a search for John Brady's business plan and could not find it (I am a paying member so should have full access)-- anyone know where it might be?
    Many thanks!

    Elizabeth Bird, MD
    Chester CT

  • 14.  RE: going direct pay - I think

    Posted 03-01-2018 07:42
    I agree with PJ.  Things are much better now than they were 10 years ago, including those of us that take insurance.  When I started I had no access to value based reimbursement, risk sharing, shared savings, etc.  Now the bulk of my income comes from those types of contracts.  Medicare is leading the way on this, but Medicaid and commercial plans all over the country moving in the same direction.  

    I also think the debate about the value of primary care has been settled: high quality primary care = cost savings.  This should make a big difference going forward since there doesn't seem to be much resistance to doctors sharing in that savings.

    Of course, there are 2 big changes that go with getting shared savings: the increased importance of diagnosis coding and accountability for quality measures.  These add work for us, but we can't get access to the shared savings without them.  They provide some insurance for payers that we aren't gaming the system by refusing to take care of sick patients and skimping on preventive care.  I'm convinced that the time/money needed for these 2 efforts is much smaller than the potential income from cost savings.  We just have to make sure our contracts make that effort worthwhile.