Is Insurance Killing Medicine? A Panel Discussion

In this episode of From Print to Pod, we host a discussion based on the article Why I Don’t Accept Health Insurance in My Practice, Or Carry It Personally.

In the ever-evolving landscape of healthcare, one question has emerged as both provocative and essential: Is it time to rethink our reliance on health insurance? In a recent panel discussion, experts shared their perspectives on this contentious topic, highlighting the challenges of traditional insurance and exploring alternative models. This post breaks down their insights, offering a comprehensive view of why some physicians choose to step outside the conventional insurance system.

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Participants:

https://doctorsonsocialmedia.com/stefani-lafrenierre-md/

https://doctorsonsocialmedia.com/ronen-elefant-md-mba-mseng/

https://doctorsonsocialmedia.com/donya-imanirad-md/

Takeaways:

- The Need for Change: The panelists unanimously agree that the current healthcare insurance model requires reevaluation. Many physicians express frustration over its complexities and the impact on patient care.
- Direct Care as an Alternative: Direct care models are emerging as a viable alternative, offering personalized attention and improved access for patients.
- Burnout and Bureaucracy: The bureaucratic nature of insurance contributes significantly to physician burnout, suggesting a need for systems that prioritize clinical care over administrative tasks.

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Transcript

Dana Corriel: Welcome everyone to From Print to Pod, the SoMe Docs series where we take articles from our magazine and bring them into conversation. Think of it as an article club where the ideas on the page become a starting point for deeper discussion. I'm Dr. Dana Corriel I'm the founder of SoMe Docs and today's piece tackles a topic that tends to make both physicians and patients a little uncomfortable and that's health insurance.

Ronen Elefant: Thank

Dana Corriel: The article is titled Why I Don't Accept Health Insurance in My Practice or Carry It Personally. In it, an orthopedic surgeon argues that traditional health care insurance has evolved into a product that drains time, autonomy and resources from both physicians and patients, and that stepping outside of it can sometimes create a simpler, more transparent system. It's a perspective that challenges one of the most entrenched assumptions in modern medicine that healthcare insurance and healthcare are essentially the same thing. So today we're unpacking that idea, what it means for physicians, for patients, and for the future of how healthcare is financed. All right. So we are, we have here with us a panel of three experts and I will throw out the first question. And as you answer it, if you could also introduce yourself, that would be great. We have Drs. LaFrenierre Dr. Imanirad and Dr. Elefant So again, I apologize if I mispronounced anyone's name. All right, so the author opens with a statement that immediately makes people uncomfortable. And I'm quoting, not only do I not take health insurance in my orthopedic practice, I also don't carry traditional health insurance for myself or my family. What was your immediate reaction when you read that sentence? Responsible, radical, or reckless?

Let's start with Dr. LaFrenierre.

Stefani LaFrenierre: Yeah, thank you. Hi, I'm Dr. Stephanie LaFrenierre. I'm a double board certified psychiatrist and addiction medicine specialist, and I own an insurance driven practice in Southern California with two locations and growing. I think it's a very interesting topic. When I first read the article, I think it makes a lot of sense. I take insurance. I hate insurance. There's so much admin burden with it. So a lot of that resonated very strongly with me in the article. But that being said, I think there are some specialties where it makes sense to take insurance. And I think there's a lot of specialties where it's a lot easier and doable to exit the system. And I think physicians have to choose and decide what makes sense for them because we do have this system in place. And as much as I love to be a rebel and want to fight outside of it, what I learned in mental health especially, there's supreme access barriers when you just take cash. So that was a driving factor for me in my practice.

Dana Corriel: Thank you so much for that. And by the way, we welcome differences in opinion. So I truly appreciate that aspect of your response. Okay, Dr. Iman irad, your turn.

Donya Imanirad: Hi, I'm Donya Imanirad I'm an allergist in Florida and I have very recently moved from an insurance-based practice where I was an employee to starting my own direct care allergy clinic. that, you know, this article resonates with me very well because I do...

I do see the struggles that he is referring to firsthand as an employee when I was seeing multiple patients during the day and I was asked by the administration to see even more. Why the reason being is that the overhead was going up and the reimbursement by the insurance was going low. As an employee, I was forced to see more patients where in allergy immunology patients come in with various complexities and it's not a 15 minute encounter if you really want to care and not be just like a cookie cutter response. So I can allergy test you, but do they really need allergy testing? So I can totally see where he's coming from. The question is, people that will get rid of insurance in their practices and also not carry insurance. And for me that is definitely something to think about and it is the future. The only thing and I really think is a fear factor for people is for situations that are life-threatening or God forbid like malignancies that the treatment requires so much thousands of dollars and that is where people are like whether carrying insurance is appropriate or not. Otherwise not carrying insurance and going in a model where the cost is not that much to me is actually more responsible, more cost effective, and also more personalized for the patients.

Dana Corriel: Thank you so much for that reply. Dr. Elefant, let's hear your take.

Ronen Elefant: So this is a topic that's very near and dear to my heart. The first line obviously resonated with me. I'm very similar in that I don't carry traditional insurance. I do have a health share for the exact same reasons that the author pointed out. And I do want to say actually to what Dr. Imanirad was saying that

I think we've been conditioned to think that insurance is like all or none and it's binary. And the reason why this hasn't... kind of taken off just yet, but I think it will eventually is that people have to think of insurance as traditional insurance. Health insurance is not really insurance. It's just a redistribution scheme, right? So somebody else is paying for your care when it's routine and insurance is really supposed to be a product that doesn't bankrupt you when something big and unexpected happens. So I'm not anti-insurance and I think you need to carry insurance for those things, but for routine things we should be paying out of pocket and we will actually see that that's the way to get costs down in healthcare. Everybody talks about how expensive healthcare is, but it's because we use insurance for things that we could probably afford if they were out of pocket, but if we also knew what they cost. And one of the things is if you go to many doctors and you ask them like, what does it cost to see you? Most people will not even know what that is. And so,

You know, for me, I kind of live in this dual world. guess I didn't even introduce myself, but I'm a trauma surgeon and I also have a business where I do general surgery without insurance. So I kind of live in this dual world where obviously in the trauma world, you can't really afford the trauma costs without insurance. But I also know that for elective surgeries, many people can afford it. And at the end of the day, when you look at what your employer is contributing, what you're contributing from your paycheck and what you pay out of pocket. You're deductible. All that stuff adds up to actual real costs. And at the end of the day, things aren't cheaper because you're using insurance. It's just being masked that it looks like it's cheaper, but really you end up paying a lot more. in other, medical specialties, for example, that have been traditionally cash-based like plastic surgery or LASIK eye surgery, we've seen the quality go up and costs go down because of the mechanism of paying out of pocket. And I think that most physicians will see that that is the way to reduce costs and for patients to have better access in the long run.

Dana Corriel: Thank you for that. And I will interject here to say that if any of these experts are interesting to you or you want to send a note to them saying what a great job they did in the recording, when we do publish this, each person's digital business card is going to show there. And so you can, as an audience, you could click in and read more about them, see where they practice, see maybe they're on social media and where they are and follow them. All right, let's move on to the next question.

We've all been trained inside of a system where health insurance is considered essential. Is opting out of insurance actually bold innovation or is it a luxury that only certain physicians or patients can actually afford? Let's start with you, Dr. LaFrenierre.

Stefani LaFrenierre: Yeah, I think that's a great question. Again, because I'm in mental health, I definitely see different side, right? Like our practice takes California's version of Medicaid, which is in Southern California, Cal Optima, which 33 % of the population is on. And it's a government-based program, but there's no fees. Patients don't pay for their care. They don't have copays. If they have a mis-visit, we can't charge them mis-visit which is kind of unfortunate for us. But I think there are extreme barriers when you're dealing with somebody who has chronic severe mental illness, which is a lot of the population that we treat because I'm an interventional psychiatrist, so we do ketamine and trans-cranial magnetic stimulation. So we're doing procedural psychiatry, which again, a lot of these patients, there's no way they'd be able to afford a $10,000 treatment. But again, I see both sides. I think there's certainly access points, sliding skills, things like that that are reasonable and doable in the mental health field.

It's not necessarily a population that I personally work with.

Dana Corriel: Thank you for that reply. Dr. Imanirad, same question.

Donya Imanirad: In the world of allergy immunology, will say that based on experience, you can see patients that don't carry insurance. They're either from another country, they've come in, they don't have insurance yet, they haven't signed up with Medicare or Medicaid, so it's, they will have to pay cash anyway, whether they would go to insurance-based practice or like somebody, if they know about direct care, it's very hard to educate people about this. It's very fresh. They will go to direct care or a setting cash based because they get a lot more time for the money that they pay as opposed to that same amount or just sometimes a little bit higher in traditional insurance based. So you will see a combination of populations. There are those that are overwhelmed with the wait time and lack of personalized care or they're not getting the responses they want when they go to traditional insurance. They might be just in the middle. It's not a luxury. I really don't find that as a luxury. Neither is somebody who's going to the direct care. They're not expecting to make millions of dollars. They're just going to set a limit and they're just going to say, is how many number of patients I'm going to see a year.

So they just want a better quality of life for themselves and for their patients. That is my mindset on that. And so yes, you will see people that for them, paying that amount is nothing, but there are those that are choosing to go that route and there are those that they may not have the money for it, but they see the value and that will creep up more as one makes more reputation and also as they become more educated about it.

Dana Corriel: Thank you for that. Dr. Elefant, same question.

Ronen Elefant: Yeah, so, you know, the author recognizes that traditional insurance might work better for people that have chronic conditions. But, you know, going back to the access issue, you do see more and more people paying out of pocket for seeing even specialists because it gives them more access, right? So the reality is that when you're in insurance network, you have a very narrow set of options, right? You're only allowed to go to certain physicians. You're only allowed a certain number of visits. And you know that a lot of people have been very frustrated with that. And a lot of people that I know have just chosen to not even use insurance, even if they have it and pay out of pocket so they can choose what they want to do. And that's why I'm a firm believer of this model to pay out of pocket, because that gives you the most choice, like insurance actually restricts you. Quite a lot. And the reality is that most people would be able to afford it if this was ubiquitous. Again, I think prices are not as unreasonable as most people think. If you look at hospital charges, that's outrageous, but you know, that's the insurance game that they're playing. But the reality is to see a doctor for a single visit or even a couple times a year, it's affordable. Look around, many people spend $1,000 on a new iPhone every two years, right? It's just the choices that people make, they have to decide, hey, am I gonna buy that new iPhone or see the specialist that I wanna see? And it's not even gonna be $2,000, but the reality is people probably would prefer to have the choice that's for the patients. And I wanted to say this before, but you know, maybe we can go into it a little bit further. I believe that the reason why most physicians are unhappy with health care the way it is, any problem that you pick in health care that bothers physicians can be traced back to the to the fact that we use insurance, you know, from from the EMR, which is really not about the patient, but it's about the insurance, right, and how to bill maximally. To the notes, to pre-authorizations. Physicians are not burnt out because they're working hard. All physicians that I know have worked their asses off to get to where they are. They don't mind working hard. They just want to work hard for themselves and for the patients and not for the insurance company.

Dana Corriel: It's interesting that you say that because it partly answers or even fully answers the next question that I'm going to ask. So maybe you can think through what else you want to add on that topic. And the next question is that the author in this case, it's Dr. Daniel Paul describes insurance as creating quote, a constant administrative tax on your expertise. How much of modern physician burnout you can call it moral injury, whatever it is that we want to call the frustration of the physician, to some degree not being in control, but how much of modern physician burnout is actually tied to insurance bureaucracy rather than to medicine itself. Dr. LaFrenierre, let's start with you.

Stefani LaFrenierre: I mean, I think that's, I would agree that's the primary driver for those who are employees of systems. I think I have the luxury in that I own my own practice. And so I do get a lot of autonomy and freedom within an insurance model. And I have a lot of clinicians that I've hired to work with me in this model. So I think there's ways you can take insurance and beat the system and beat the burnout, but a hundred percent.

I think any physician in a system and a corporate organization and hospital, 1000%. The insurance, the productivity metrics, the documentation requirements, the prior authorizations, all of that is definitely a huge contributor.

Dana Corriel: Thank you, Dr. Imanirad, what about you?

Donya Imanirad: I do agree it is one of the, if not the number one cause of burnout for physicians and patient frustration is it's it's very important matter and prior authorization and documentation. Many times you document something, they come backand say you document this and that for this medication. or you think this is the right medication for your patient, but the insurance doesn't wanna cover it, or you have to have failed this, this and that, and you know for sure that's not gonna help the patient. Meanwhile, your patient is very miserable with their symptoms. So it is one of the things that causes moral injury and also burnout for physicians.

Dana Corriel: Thank you for that, Dr. Elefant.

Ronen Elefant: I think you'd know my answer, but I think 100 % it's all the insurance. you know, you have to think of this as like the insurance company getting in the way of the patient and physician relationship. And what happens with insurance the way we have it is that the physician answers to the insurance company and the patient answers to the insurance company or everybody's beholden to the insurance company and they've they've sort of created a wedge in between the patient and physician and I've seen this firsthand, you know how you can fix it because I've created a company exactly around this model where You get surgery, without any insurance barriers and the physicians are happier and the patients love it because again, they don't have the access issues that they see with, with traditional insurance and physicians get to practice medicine the way they thought they would practice medicine when they were in med school or when they wanted to go into it. It's funny. Like I, I saw on LinkedIn a couple months ago, there was this physician who created like an exoskeleton to like help alleviate, some of the pain of like standing in the OR all day and all that. And I said like, this is not the problem with burnout, know, like burnout is not the physician standing in the OR all day. They'll do that all day long. They love it. The real problem is the charting afterwards or, you know, like, like we were saying before, getting an email saying, can you fix this word so we can, you know, they're not, they're not going to say it explicitly, but you have to use this language in order for us to get paid more. and it'll capture, know, if we got an infection, if you use this word, we won't be dinged for it. Like, we'll get the money we deserve. Like, when did we become employees of either the hospital or the insurance where we beg to get paid for the work that we do? Like, we're the ones holding the intellectual property, and I think it's time for us to, you know, reclaim our profession.

Dana Corriel: I have so many thoughts going on in my head, but I definitely want all of you highlighted for your thoughts on this. with that, let's move on to the next question. So indirect pay environments, prices are often much lower because third-party billing disappears. If that's true, why hasn't price transparency taken off more broadly in healthcare? And let's start with Dr. LaFrenierre.

Stefani LaFrenierre: Yeah, another good question. think I don't have a finger on the pulse, honestly, of the price transparency issues. I know when you work with insurance companies, there's just a lot of stipulations in the contracts that they kind of enforce rate in terms of like your rates, in terms of reporting, in terms of like regional rate negotiations, things like that. It's a hard question for me because

To Dr. Elefant's points, I don't disagree at all, but I think part of my vision when making my practice was to take insurance, but do it as best as I could within the system. So we have like high accessibility points. We have cash-based services. We have price transparency. Like I know exactly how much it costs to see me, to see my clinicians, to do an out-of-pocket, you know, ketamine treatment rate. So I think there's hybrid models and there's ways that it can be done, and be done well for both the providers and the patients. But again, you're not going to see that in the big hospital organizations. But I do think there's a lot of, yeah, it's a corporate run show, right? And so you're not going to get them to do anything, show transparency, unless they're forced to.

Dana Corriel: Thank you for that. Dr. Imanirad.

Donya Imanirad: Yes, I agree and I really think it's a matter of what contract you have in each insurance is different So what you charge is not necessarily what comes comes out to your bank account at the end of the day so I think again, I haven't been an administrative on the administrative side of an insurance based model but we have to charge a certain amount and whatever the insurance doesn't carry is going to fall on the patient because you did charge that amount and the insurance only wants to pay you know 20 to 30 percent of that and a patient has this out of pocket that they will never meet by the end of the year so it is going to fall on them and it's going to be a lot higher however a lot of physicians or lot of lot of corporates have to overshoot based on the fact that the reimbursement is not going to be sufficient for them to meet their overheads.

Donya Imanirad: Your voice.

Dana Corriel: Dr. Elefant..

Ronen Elefant: Yeah, so I think the reason why price transparency is not working is because we're not really working in a true free market. So price transparency works when you're dealing with a regular market. But the problem is the people shopping around for the best prices are not the people who are looking for the service, right? The patients are not looking around for what the prices are. They're not shopping by price. They're going around based on what the insurance company is telling them, you know, who to go to based on who they have contracts with. And the truth is, is the prices that they're paying have nothing to do with the prices that are advertised, right? even though the, again, like most hospitals, you can go on their website and check out a procedure and they'll give you the price and then they'll say 50 % discount for cash, which is still gonna be an outrageous number. But the people that are gonna be affected who are getting the procedure are not the ones looking at those prices. So it's sort of a sham fix, if you will, right? They made it sound like it's going to work and that'll reduce prices, but even still, you can see wide variations in prices when different hospitals, even across the street from each other, advertise their prices, because it doesn't really matter, right? At the end of the day, you're still going through insurance with our current model.

Dana Corriel: Thank you for that. And I'm actually going to base the follow-up question on an extremely short story that I'm going to share with you just about a friend locally that went to the local hospital to get some radiology imaging done. And she has insurance. And there was a certain price that she had to pay out of pocket. And she had a high deductible. So that was a high amount. But the hospital, the cash pay price was much cheaper than what she paid. For example, with the insurance, she would have to pay $2,000 for the imaging, whereas without the insurance, she would have to pay $800. So my friend wanted to pay the $800 and the hospital told her that she couldn't. If she had insurance, that she had to use the insurance and therefore she was out the $2,000 instead of the $800. The reason I'm sharing the story is because of the following question.

Physicians often blame insurance companies for the dysfunction in healthcare, but insurers didn't design the entire system alone. Are insurers actually the villain here or are they just responding to incentives created by hospitals, physicians and policy makers? Let's go backwards. Let's start with Dr. Elefant.

Ronen Elefant: So this actually goes back to an excellent book that I recommend everybody read and it's called Who Killed Healthcare by Regina Hertzlinger. I think it was written in the late 2000s, so it's a pretty old book, but it's very relevant to this discussion and the answer. And that is that the three organizations that are responsible for where we are right now is yes, the insurance, but it's also government, which this goes back to World War II and why we use insurance the way we do and why employers are the sponsors. Really, employers are ones who are shopping around for healthcare and the hospitals, they're all in cahoots with each other. I don't think that this is the physicians. The physicians... sort of just let things be and didn't take a stand. And you see this with a lot of physicians nowadays still not really being interested in the finances of medicine, right? We just want to practice medicine. We don't want to deal with it. But at the end of the day, you know, it's such a big moneymaker for everybody that everybody wanted a hand in the pot. So, yes, I think the government is absolutely part of the problem in that they solidified that insurance is tied to your employer.

Ronen Elefant: The insurance model is completely out of whack because it's not true insurance. We shouldn't even be saying insurance because like I said at the beginning, insurance is there to cover you from getting bankrupt from a catastrophic problem, not for day-to-day things. And the hospitals are part of the problem, right? If you look, you've all seen that graph of administrative bloat even within the hospital, right? How many administrators are there for every single physician in the hospital?

And what are they doing? They're not revenue generators. Like they're not bringing in any money. They're just telling us what to do to fit within the insurance scheme, right? To use the right words and, you know, to squeeze everything out of what would normally be denied. So I think they're all part of the problem.

Dana Corriel: Thank you for that, Dr. Imanirad.

Donya Imanirad: I think the answer that Dr. Elefant gave is the most informed or the more informed compared to what I'm going to say. But I do see the corporate and a back and forth between what corporate requires and the insurance companies taking advantage of. getting the rates higher on patients where the price raises are coming from the corporate side. And of course, the government's probably playing a role here.

But I don't have anything else to add. do agree with the statements he made.

Dana Corriel: Thanks for that, Dr. LaFrenierre.

Stefani LaFrenierre: Yeah, I mean, I agree with what everybody's been saying. I don't think physicians get a seat at the table during these formations and corporations, CMS formations, things like that. A lot of the times, the physicians who are on these panels are already government sponsored anyway when they're setting rates and things like that, even when it comes down to specialties and EMN codes and RVUs and all that fun stuff. I'm a big fan of independent physician practice. Whether you take insurance, whether you don't, I do think.

Physicians are, we're not taught to care about the finances. We're not taught the business of medicine. And I think that that definitely needs to change so that as a whole, you know, we're more empowered. And I think physicians need to do a better job of lobbying and grouping together. You know, we see so many people with direct care models, even myself with my psychiatry practice, you know, there's so much more purchasing power, negotiating power when, you know, physicians come together, whether that's under a combined physician-owned MSO, things like that. So there's a lot of ways that physicians can begin to group and advocate and fight back, so to speak. But yeah, I think to your point.

Ronen Elefant: Thank

Stefani LaFrenierre: A lot of the policies and procedures and reimbursement schedules were not and are not driven by physicians. mean, how many physicians, CEOs of hospital or corporations even exist? Like, I have no idea. Probably like zero. But it's very rare, right? People at the top making their $30 million cuts aren't the physicians, right? They're usually the administrators.

Dana Corriel: Thank you for that. We have just a few minutes left, so I'm going to ask a final question and ask that you answer succinctly. Everything has been really great so far. This discussion is so very important as we see the field of healthcare evolve. So let's imagine a world where a large percentage of physicians stop taking insurance. Would that force the healthcare system to reform or would it create chaos and widen the divide between patients who can pay and those who can't. We kind of alluded to it earlier, but let's just imagine that world and ask ourselves that difficult question. Let's start with the middle, Dr. Imanirad.

Donya Imanirad: I think that there is a long way to that day. There's so many things that need to change and there are always going to be patients that are still not going to be able to afford, well, the government, the patients that are relying on the government to pay for their expenses are... probably not going to be able to afford a cash-based model. Another issue is educating patients about this. Right now, a lot of people, when they hear your cash-based, they just get scared off. They walk away. So there will be chaos, as in every change that we ever want to make, whether it's good or bad. There will initially be a lot of chaos. And so the reforms, I can see that there could be reforms if everybody comes together and decides not to take insurances. However, I don't know what the outcome of that would be.

Dana Corriel: remains to be seen. Dr. Elefant.

Ronen Elefant: So I think it would be very hard to do. I'd love to see it done, but I think that, you know, Washington and the insurance companies are so entrenched and there's so many, you know, special interest groups and lobbyists that will not make it, not allow that to happen.

I think there's also lot of physicians who would be scared to leave a traditional model, right, because it does take risk and in order to make change there will be a lot of uncertainty. So I don't see it really changing but I think it's going to be fragmented and we see this in other countries that, you know, there's almost like a two-tiered system unfortunately. It shouldn't be that way but I think that that's going to be what will happen.

Dana Corriel: Okay, and last but not least, Dr. LaFrenierre.

Stefani LaFrenierre: Thank you. I think the purchasing power honestly is more in the pants of the patients than the physicians at this point in the system, right? It's running a pyramid scheme, right? All the patients who are buying into the system feed the machine. I saw a great analogy the other day of like, imagine you pay for your Netflix subscription. And then when you watch a movie, you have to pay a fee to watch that movie. And then three weeks later, you get a bill in the mail because one of the actors didn't sign with Netflix. Now I have to pay them. And it's like, that'd be ridiculous, right? But that's health care, right? That's our system. And so I think physicians will, there's already severe shortages of access with physicians, which is why we're seeing the rise in mid-levels and such too, which is a whole other topic.

I really think it's on the part of educating our society and educating patients to withdraw from the system that would probably create the most impact versus the physician side.

Dana Corriel: Okay, well, that was a really great conversation. We appreciate each and every one of you for joining us for this panel of From Print to Pod. Tune in for the next episode for the next viral article to be dissected. Thank you.