When George Lai of Portland, Oregon, took his toddler son to a pediatrician last summer for a checkup, the doctor noticed a little splinter in the child’s palm. “He must have gotten it between the front door and the car,” Lai later recalled, and the child wasn’t complaining. The doctor grabbed a pair of forceps — aka tweezers — and pulled out the splinter in “a second,” Lai said. That brief tug was transformed into a surgical billing code: Current Procedural Terminology (CPT) code 10120, “incision and removal of a foreign body, subcutaneous” — at a cost of $414.
Have you investigated direct primary care programs as a “subscription” model to the services you provide? Like what’s described here:
https://www.aafp.org/about/policies/all/direct-primary-care.html
I’m not a physician or in medicine at all, so this is genuine curiosity on my part for an idea that was recently described to me. I’m looking for feedback from someone that lives inside the system on if they even think something like this is feasible or has potential to succeed.
I’ve investigated this in that I’ve polled some of clientele on the idea and the general feedback I’ve gotten is some interest but generally rejection
I think the issue is twofold:
One: I’m mental health, and for any specialization a subscription model potentially doesn’t make sense. You may utilize our services heavily for a period then suddenly not at all or minimally.
Two, and the bigger one: most people polled did not have an interest in paying for such a thing when they already had insurance benefits via their workplace. This is understandable and gets into a great deal of complexity. Decoupling insurance from jobs is often cited as a huge need and that obviously necessary. But additionally the current system only allowing changes to insurance annually really hampers this too.
Finally, one frustrating point on this topic is contractual obligations with insurers. If I implement a system like this and continue to take insurance as well I run into issues because of the above situations. If you have insurance and decide to subscribe instead, planning to potentially cancel your plan in 8 months when you can renew your benefits package, I can actually be penalized for billing you privately when I knew you were a subscriber of a plan I was in network for.
Not all insurances do this but a lot have this in their contractual agreements. It would jeopardize my ability to maintain network status for the clients I do take insurance for and potentially cost me tens of thousands in clawback payments if I were ever audited for being out of compliance.
Thank you for the detailed response.
I was aware that there were coverage contracts with insurance providers that could potentially get in the way of this, but I hadn’t really thought about the “I already have insurance, why buy this?” aspect, but it seems obvious in hindsight.
The sporadic usage of specialists, which I would qualify mental heath as one, also doesn’t necessarily lend itself to this model.
I think I stand with the majority of people in that all healthcare, of which mental health should be a substantial part, needs an overhaul in the U.S.
It’s the how that becomes the difficult part.
I think the ultimate problem is that it needs a collectivist solution and the people we’ve elected, who would need to architect such a thing, have consistently shown they have no interest in such a thing
Challenges all around though. People talk about “lobbyist money” and that’s certainly a major factor but there’s more to it than that. We have no social safety nets in the us. That’s why when Kamala proposed Medicare for all she proposed a two lane option that still had privatized plans (which would still enable so much administrative waste, but would at least be an incremental improvement in terms of reintroducing compulsory insurance and decoupling insurance from employment).
But to overnight create an actual socialized medicine program akin to the nhs would destroy hundreds of thousands of jobs overnight. It would also eliminate tens of billions of dollars of waste administrative spending and streamline so much stuff that I do, but it would be a nightmare to get political support for because anyone who works in medical billing, who works for Aetna, Cigna, anthem, etc, would see the writing on the wall. Some of their jobs would be recreated in whatever new system was made but the majority would be made redundant. that’s where we go back to the lack of a social safety net piece: the USA has an extremely poor track record here. And it’s not just overpaid ceos making 10 million a year, it’s thousands of administrators, claims adjusters, middle managers, etc, making 40-80k who would be thrown to the wolves