[faangFar]

Side note on billing. My wife's practice is finally hitting it's celing. She needs to either charge more or hire more doctors + get a bigger space.

She is her brand, so we probably won't get more doctors. But we have slowly raised prices from 50$ to 75$ per hour.

Next we are going to stop accepting some government health insurance because they only pay $60/hr. Long term I can see 125$-200$/hr private pay only.

The alternative to her 1 on 1 care is a hospital/clinic where you get 37 minute visits shared with multiple other clients, and have a new doctor every few weeks due to high turnover.

Word of mouth is more powerful than ads.

[gen220]

This is kind of a deep question, and not meant to cast aspersions on what you're doing, because it's perfectly rational. The world of private doctors who don't accept patients paying with insurance (government or otherwise) is very interesting to me.

Do you think there's a major difference in expected outcome for the average patient, between your wife's practice and a hospital/clinic?

I can totally grok how a patient would find her services valuable enough to pay a much higher rate, out of pocket; but I'm trying to figure out if the payer's arbitrary cut-offs are rational.

Maybe 60/hr is close to the price-point of exponentially-diminishing returns, from the risk-carrier's perspective?

Obviously, institutional payers are way more conservative with risk than financially-well-off individuals, so maybe they're making mistakes on the margin.

Anyways, hope I'm making sense. It's a fascinating topic.

[thoraway1010]

No insurance hassles - I did medical billing for a bit. The insurance co's basically just run around doctors because they KNOW folks give up. You could absolutely force the $40 extra payment if dr + patient etc proved it out / appealed it - but often not worth it. Also govt billing into central county system for the poor - ugh - the bureaucracy / overhead was a nightmare (always having to recertify to financial need / paperwork this and that - 50% of time was on stuff I'd consider no value add).

For a while I had individual insurance (prior to obamacare). Because it had pretty high deductibles, I would just do a private pay / cash doctor for primary care etc.

Some big wins:

NO discussion about whether something was covered or not! You want to get service, just call.

No crazy surprise bills - yes - I once tried to go to urgent care for something at the main hospital, but NO ONE would tell me what I would be charged as a cash pay client. Yes, it can be expensive to do cash pay, but with a doctor billing by the time you can basically predict / know your cost.

Service - you are paying by the hour. I never felt pressured out the door (no surprise). The service is good to great.

Convenience - I got someone close who used his downstairs as his office. Have a problem, go in and get checked out. Because you don't need the huge billing infrastructure I think you can get away with smaller office sizes. To pay for a full time biller you need a few doctors, who then need a receptionist etc etc.

[gen220]

Yep! There are a large number of benefits for both the provider and the patient, for purchasing elective procedures without involving insurance. It's kind of like how when you get a minor fender bender, it can be easier to settle things directly than to go through insurance. No overhead, like you suggest.

However, it's hard to replace insurance for nonelective/emergency procedures (heart attack, stroke, aggressive cancers).

Insurance-tailored billing systems are really geared towards non-elective procedures (that's where all the money is). When they encroach on the "normal" stuff, it feels invasive.

Advocating for the insurance infrastructure, there is a preponderance of medical waste out there. Doctors prescribe blood tests, urine samples, or MRI scans even though they aren't medically-necessary, just because the hospital group needs to make some money. When the patient is paying, they are on the lookout for medical waste, because they don't want to pay.

Of course, this means that there will be false negatives from the insurance carrier, when they try to clamp down on medical waste. The only loser in this game is the patient.

[faangFar]

There seems to be a lot to unpack, so sorry if this is jumping around but I tried to provide lots of details.

My wife has worked at those places and the difference in patient outcomes is night and day. Sure some people will get better regardless, but there's something special about people saying a 3 year old injury has 0/10 pain. At a big name company, they get people "good enough".

She's one of those people that would prefer to be a Physical Therapist rather than a business owner.

As a side note, many of her patients came from that 60$/hr insurance because most places don't accept it. It seems like it's a stepping stone. Knowing her, they will be grandfathered in.

Something I didn't mention is how often she does free work/eat the cost because insurance will deny payment for services that were approved but later deemed "not necessary". (Despite the person being unable to work) It's complicated because a phone call, or Physician, or patient can sometimes fix this.

[gen220]

I think there is a lot to unpack here, yes! Thank you for responding :)

I wonder how much of the outcome difference is due to selection bias, so to speak.

For example, your patients are more likely to have better outcomes, because the fact that they are willing to pay OOP for your services implies that they are bullish regarding the valuation of their physical health, which means they are likely proactive in seeking preventative care, solving health problems earlier rather than letting them fester, etc.

Similarly, I'd imagine that the better doctors probably self-select into your wife's situation, because they want to work with active patients and they want to capitalize on their skills and passions. It's a feedback loop where good-follows-good.

Good income -> good outcome, if you will.

But tragically, this implies that good doctors are less likely to be found in the big hospitals, where the people who need healthcare "most" are in need of them. "Most" used here in a marginal sense, where the needy, insurance-using patient receiving 1 hour of your wife's attention provides 10x value in terms of QoL-adjusted life expectancy, than the average proactive OOP patient.

So, we're kind of bound to have a two tier system, with this set of incentives.

In your wife's case, it seems that the price cap of insurance will prevent 10x patients from seeking her out, exacerbating the tiers. But, you can't really blame any of the individual actors in this equation (payer, patient, or provider), it's the incentives that are wacky.

I know of some doctors who "volunteer" some of their time working at a hospital/clinic, in addition to their private practice. Like, one day a week or something like that. If your wife feels guilty about her role in this dance, she might consider doing this, in addition to grandfathering-in the insured folk.

Anyways, I don't really have a point, just thinking out loud. Thank you for your perspective, curious to hear anything more on this topic you'd like to share.

[faangFar]

Just to clarify, all patients currently are accepted. There's no selection yet.

There is a difference between hands on care for 1 hour, and 1 hour being divided between 9 people (seriously, there are some clinics that do that).

[clairity]

if she's maxed out, why does she need to make more money? is the point not to help people?

[tootahe45]

no?

[faangFar]

You can only help 40 people per week without cutting down on the care. Another benefit for private pay is that you don't have to spend time on insurances or calling physicians for a prescription.

I talk a big game about raising prices but I know my wife has done free services for disabled children. She's a sucker, and we claim it's advertising/marketing.

Hospitals and big name clinics would never do this.

[clairity]

> "She's a sucker, and we claim it's advertising/marketing."

sounds like she's a regular compassionate human, rather than a sucker. far better than those hospitals and big name clinics.