Healthcare is falling apart. We all know it, we can feel it, but it’s hard to say why it’s happening or even what is happening, we just know that it is true. And as bad as it is for patients, it’s even worse for providers. We know that there is something wrong. We want to help people. We are busy all day long seeing patients. Why doesn’t it feel like we are helping people?

I blame physicians. I hate to do it, because I am one, but it’s true. The healthcare crises that we are faced with today started years ago with good intentions, but the consequences have all but destroyed our profession.

I’ve talked to the old physicians, the ones who had cash practices. They would charge $11 for an office visit that could take just a few minutes. They didn’t have an EMR, they didn’t have to worry about documenting 10/10 ROS just to get paid. They wrote a quick SOAP note and saw the next patient. Their patient’s loved and respected them, and because they could afford the $11, they paid every time that they came. The physicians didn’t have to spend any time worrying about pre-approvals, denials or unpaid accounts. The physicians were happy. They were busy, but at the end of the day, they knew they had helped their patients. The nice thing was that their overhead was so low that they were very comfortable even though they only charged $11 per visit.

Then the government froze salaries, and businesses offered health insurance to attract good employees. At first, patients would pay their bills, and then they would submit their receipts for reimbursement. The doctors wanted to be nice and make it easier for their patients, so they started submitting to insurance companies directly. This led to agreements between physicians and insurance companies, offering specified payments for either managing their patients (HMO’s), or for procedures/visits. That’s when we started to lose control. Since then, we have watched as our payments have been decreased, the requirements for payment have steadily increased, and at first insurance companies, and now the government have slowly taken away our freedom to practice medicine in the way we feel appropriate.

We need pre-approval for an MRI, for surgery, for medicines that we consider appropriate for our patients. We get denials for care that was completely appropriate because we didn’t dot the right “i” or cross the appropriate “t” (really checking the right box). Why? Aren’t we qualified to make these decisions? It feels wrong that a high school graduate who is looking at an algorithm can tell you that your patient can’t have something that you have ordered. What gives them the right? We now have 14 paper pushers for every practicing physician, not a single one of them improves the care of our patients. And it always seems to happen to the “good” patients, the hard workers who are just trying to get the care they need. So we take care of them for free, or spend hours fighting for that approval, but it feels wrong when other patients who barely have anything wrong with them seem to easily get approvals for anything they desire. And if we actually try to collect on a large bill, we know that it is unlikely that we will get paid in the end.

Now, with Obamacare, we’ve added 37 million people to the insurance roles. Many of them don’t have a job and don’t pay a dime for their insurance, but they do know how to use health care for their personal gain. Since then, our schedules have become full for weeks to months in advance with patients who don’t need to be there, and we can’t seem to get the patients who actually need to be seen in quickly. Just as frustrating is that it is not uncommon for up to half of the patients to either cancel late or no show if they have ANYTHING better to do that day, leaving open spots that can’t be filled. Why would they care? You can’t charge them for a missed visit. They’ll just schedule again later, and possibly miss again.

I’m hearing of orthopedic surgeons who are leaving practice because the patients they are seeing don’t have anything wrong with them. They go to their PCP complaining of pain, but the PCP can’t find any reason for their pain, so they send them to ortho for a consult. Ortho will send them to PT, still with only a complaint of vague pain. I’ve actually had more than one PT tell me that their patients have admitted to them that they don’t really have pain, they just want to file a disability claim. Orthopedic Surgeons pay their bills by doing surgery. If their patients have nothing wrong with them, then they can’t do surgery, and their practices will not survive.

Believe it or not, there is a simple solution for all of these problems. Cash! If we, as physicians and other providers, decided that we do not want to be beholden to other entities, we could just stop taking insurance. Instead, we would charge the patients for our time and skills. We would need to provide valuable services, and we would need to be able to explain to the patients why they were valuable, and why we were the best people to provide those services. Auto mechanics do it, why can’t we? Mechanics have even convinced people to do preventative maintenance, like changing their oil and getting alignments, because they know it will cost more in the future if they don’t do them. We should be able to convince them to get physicals and take their blood pressure medications to prevent bigger problems in the future, especially if they will be responsible for paying for their bad choices. Right now, people do not feel the financial effects of poor health habits. They smoke, eat bad food and don’t exercise; but when they have their heart attack, their insurance picks up the bill. We might see them change their habits if they had to pay for their future care themselves.

But I’m not heartless either. I think the university hospitals and government clinics should stay open and provide free care to those who cannot afford it on their own. This would include most trauma care, emergent cardiac catheterizations and a lot of the cancer care. Patients would be triaged, and emergent care would be delivered immediately, but many of the non-emergent patients that we now see in our ER’s would be referred to the free clinics for care at a later date. I also think that those institutions should be staffed with residents and students from all the healthcare fields, and they should be immune from litigation. Patients should not be able to sue for care that they receive for free. Patients who could not afford care in the private sector might have to wait weeks to months for appointments at these places, but I’m sure that the no-show rate would decrease substantially. It would correct one of the great injustices of our current system – that the people who contribute the least to our society, have the best healthcare benefits, at the lowest cost. I actually believe that we would see more people looking for jobs just so that they would not have to go through that system.

Imagine seeing a patient and documenting just the important findings on a SOAP note, and not worrying if the insurance company will pay. The patient will have paid in advance for your time, preferably by credit card when they schedule their appointment. My daughter just scheduled a haircut and had to give a credit card to hold her appointment, and that’s for a haircut! We provide healthcare for them and they expect it to be free, no wonder they don’t respect us!

This would actually lead to more educated patients and true informed consent and refusal. They would come in with shoulder pain, and we could give them their options. An MRI? When it’s being paid for by a third party, they always want the MRI. But if they have to pay for it out of pocket, I bet they would try Ibuprofen first, then maybe some Physical Therapy.

And the price of an MRI would come down if they were competing for cash payments. Lasik started off as a $3,000 per eye procedure. Since then, the cost has decreased to $250-$500 per eye while the quality has increased because of the competition for patients. That happens in a capitalistic system, but not in a system of 3^rd party payers and “benefits”.

Physicians would need to learn how to justify their tests and treatments in simple, easy to understand language, so that they could convince their patients that their care was needed and appropriate. And people would learn to shop around for the quality and price that they desired for their care. Physicians would start to advertise their prices for basic care, and we would see internet based reviews that compared physician’s prices with the quality of their reviews. You would see surgeons and hospitals offering bundled flat pricing for elective surgeries, including covering most complications. A total knee replacement might have the option to include all follow up care including Physical Therapy, or the patient could choose which services they wanted to purchase if they want to use their own Physical Therapist. Each hospital and provider would be competing for business, as a result, the prices would fall and quality would improve as people were more careful with where they spent their healthcare dollars.

I would love to pair this with a mandatory Health Savings Account Program, but that is a topic for a later discussion.

In the end, I believe that we, as healthcare providers, have the power to save our healthcare system, improve the quality of care, decrease the cost by 50-75%, and improve our job satisfaction; all by going back to our roots and trusting in the capitalistic structure that made our country great in the first place. Why would we continue to allow the government and insurance companies to control us when everything they do seems to make it worse?