“Why don’t you accept insurance?”
I get this question every day. My answer requires background context about the healthcare and insurance systems as they presently exist, and the impact on both providers and patients.
Specifically, the impact of taking insurance on me, the provider – and the quality of care I am able to provide to you, my client.
The fact is, I’ve tried delivering care under the insurance model. It wasn’t the experience either I or my patients deserve. Here is some of the recent data that describes the landscape of healthcare in general, and the impact of the insurance model on care in particular.
“… today, I provided quick follow-up notes to the referring providers on what we are working on so that they can be involved in the process. I know few other practitioners who can take the time to do this…”
Structural Problems = Provider Burnout
A recent opinion piece in the New York Times discussed a very real epidemic that is affecting health care providers—and in turn, everyone who needs them. The malady: “moral hazard” – and the result is provider burnout.
So what is moral hazard? It is when you are forced to do things in direct opposition to your morality, your core values. Increasingly, for-profit health care institutions are taking the humanity out of how much time a physician or other provider can spend with a patient – instead placing the emphasis on volume-based efficiencies. How many patients can be seen, how many tests can be provided, how many procedures can be done in shorter and shorter times frames with fewer and fewer staff? Providers are increasingly being put in situations where they cannot do the best thing for the patient, due to short staffing, insurance restrictions, legal barriers, etc.
The article notes that many providers are “anguished and distraught, caught between the Hippocratic oath and ‘the realities of making a profit from people at their sickest and most vulnerable.’” The article notes that nearly “one in five health care workers quit their jobs since the start of the pandemic and that an additional 31% had considered leaving.” [bold mine]
Medscape, a website for physicians and healthcare professionals worldwide, does an annual survey of burnout in physicians. The 2023 survey of 9175 physicians from multiple specialties shows an astonishing 57% burnout rate in physicians and 23% reporting depression. Forty-four percent of the physicians reported that the burnout had a severe impact on their lives and that the major contributing factor was “overload.”
The problems are not affecting only physicians. NPR reported in May that almost a third of nurses were thinking about leaving the profession, with 94% reporting severe staffing shortages in their area. Nurses are constantly pushed to the breaking point in hospitals, dealing with the sickest of the sick and with 5-6 patients each, that’s less than ten minutes per patient per hour to do everything.
Anguished, distraught and stressed providers cannot deliver adequate care. What’s more, when providers burnout and leave, it increases wait times to get care for every patient, and in fact may make care unavailable to a great many simply because there are no longer enough practitioners to treat the number of patients who need care.
“… I spent an hour on the phone with the pharmacy, trying to get a patient medication released for them… “
Healthcare Insurance Hurdles & Their Impact
If a patient comes in my office with insurance, what I can provide to them is greatly constrained by a maze of limitations, deductibles, co-insurance exceptions, discounted rates, refusals, and re-submission problems. This process of submitting to insurance for care is time-consuming - the process plays out over weeks and months of back-and-forth bureaucracy. The administrative staff to navigate a different set of hurdles for every insurer is incredibly costly, and the cruel truth is frequently lack of coverage means that I must return to you, the patient, to request additional owed money.
“I had to send the prior authorization through three times to try to get them to approve the medication.”
What may be the worst is most insurers devalue the follow up visits (where the more intensive, ongoing work of checking in, adjusting medications, understanding and dealing with side effects, and closely tracking your progress really happens). Typically insurers pay providers significantly less for the follow up visits, which is a disincentive to the provider to find out how you are really doing, what your life is really like and if the medication is really working. And, provider tasks and efforts that do not take place within the appointments are not paid by insurance. Speaking to the pharmacies, updating other members of each patient’s care team, dealing with medication insurance issues – which can take hours – all go unreimbursed.
So instead of seeing 1-2 patients per hour, providers are seeing as many 4-6 patients per hour. How is a rushed, harried provider to give you the attention and care you deserve – in a 10-15 minute timeslot?
“Calls and texts were returned today to my patients…I talked several of them through side effects or changed their medications when necessary…”
Self-Pay Allows Me to Deliver the Care You Deserve
Patients wonder why I don’t take insurance. It’s simple. If I took insurance, I would be caught up in bureaucracy rather than taking care of you. I would have to see 20-30 patients a day, instead of 8-12. I’d be caught up in trying to figure out how many diagnoses and codes I can give your appointment, instead of focusing on taking care of you.
As many of you know, mental health isn’t a number, an X-ray, something to be stitched. Your mental health is not only the receptors in your brain, but also your mind, your soul, your emotional heart that we’re touching. Medications are simplistic interventions in the most complicated systems there are. Do you really have ADHD, or was it trauma – or is overexposure to social media? Do you really have unipolar depression – or bipolar depression – or just grief? What is the root of your anxiety? And will any given medication do what we want without unsustainable side effects?
Most importantly, what does your relationship with me reveal about how you are in the world? How we behave with one person tells a lot about how we behave with everyone. But if I don’t spend any time with you, how can I begin to glimpse that?
And then there is trust. Whatever our emotions and behaviors are – whatever troubles they cause us, at least they are the devil we know. If I help you step away from these troublesome emotions and behaviors, what will we build there in their place? If you don’t know me, how can you possibly trust that I mean for you the very best?
So that’s our practice fundamental model. It’s simple. I spend time with you. I hold your hand through new medication challenges (if you let me). We try to find solutions that are meaningful in your terms. The basic units of time are 75-90 minutes when we meet, 45 minutes for a follow-up. Everything else is by the quarter hour. There’s no games with price. It’s not the most expensive, and it is fair for the time we spend together, as well as the time I put in outside each of our appointments. And, you get treated by someone who has your best interests at heart – not the dictates of a breaking healthcare system, not the profits-first model of an insurance company.
You also get a provider who is not constantly overwhelmed and burned out. Someone who is glad to work with you when you’re not doing well, as well as when you are sailing smoothly.
“Today, I met someone who is hurting and now we’re on a good path. And I saw other patients really doing well! It was a good day.”