Concierge medicine versus traditional insurance based care

Several of you have asked some really fantastic questions about this topic, so I wanted to do a breakdown of the who/what/why to these two different types of healthcare payment options.

First: traditional insurance.  This is the type of healthcare most of us receive.  We pay a monthly fee for health insurance, we find a doctor in our insurance network, and you see them for care.  As a patient, you may or may not have to pay a copay.  You may or may not have a deductible to meet.  Some plans require you to pay the first $500/1000/2000 deductible to pay out of pocket each year, then you pay nothing for care the rest of the year for healthcare.  It depends on the various 100’s of plans out there.  Most are offered by Blue Cross/Blue Shield, Humana, United, Cigna, Tricare if you are military, Medicare if you are retired or disabled.

For a provider to take insurance, it is a process!!!  First, you have to submit an application to the insurance company asking them to “panel” you to take their insurance.  This can take 30-180 days for a response.  The insurance company decides whether or not they want to panel you.  There is no algorithm or rhyme or reason to this decision, they look at your provider profile and just make a decision.  That profile is done and maintained through a clearinghouse called CAQH.  Every provider has to keep copies of all their state licenses, DEA, malpractice, practice locations, education, etc updated with CAQH.  They require updates or “reattestation” every 90 days.  Insurance companies require a “reauthorization” at various intervals as well.  Sometimes it is yearly, sometimes it is longer.  You have to re-apply to stay paneled with that insurance company.  Usually they will continue to panel you, but sometimes they decide not to, and any patients you see with that insurance you are no longer covered to see.  So if you have ever had a provider who “no longer takes your insurance”, that is one reason for it: the insurance company decided not to renew the contract with that provider.  That is super frustrating for the provider and for patients.

Then we have this difficulty.  Most people have insurance tied to their job.  It is an employee benefit offered to employees.  When you change jobs, you lose that insurance and take the new insurance from your new job.  Sometimes, the new job you take does not panel with the provider you were seeing, and you have to find a new provider just due to your insurance changing.  Or, your company decided that they were going to switch from one insurance carrier to another one during the re-enrollment period.  And the new company insurance does not panel the providers you have been seeing previously.  Also very frustrating for patients.

Our country has been sort of “brain washed” into believing that health insurance is gold, and that all healthcare should go through insurance.  For example, you pay $300 per month for your health insurance plan at work.  It covers your medical needs.  Until it doesn’t.  Your insurance dictates who you see, what meds you get, and what tests they will pay for.  The prices for healthcare are inflated beyond belief, because of health insurance.  Providers increase the price they charge in order to get a reasonable reimbursement from insurance.  For example, in my office if you are uninsured you can cash pay.  It is $200 for a new psych eval, and $100 for a med follow up visit.  For insurance, as a hypothetical example here, we may have to submit that new eval as a $285 charge in order to get $180 from the insurance company.  Every insurance company has a percentage and negotiable rate they will pay.  Insurance does make shit more expensive. They require prior authorization for meds and procedures, and if they say no, then the patient either has to pay out of pocket, or forego the procedure or med.  Your insurance company pretty much dictates who you see, what they will pay for, what treatment you can get.  Also, insurance now decides who can and cannot receive telehealth in psychiatry.  Blue Cross/Blue Shield has made telehealth impossible in psychiatry.  So those patients have to come in office.  Prior to covid, telehealth for psychiatry was not offered as insurance did not pay for it.

Second: Concierge or cash pay healthcare.  This is the alternative to the health insurance model.  In my office, we do not do concierge care.  We either take your insurance, or you can opt to cash pay for your care.  As stated above, a new patient eval is $200 and a med visit is $100.  You pay that at the time of your service, and you don’t have insurance to deal with.  Most of my cash pay patients I see them every 12 weeks to make it cost effective, we send meds to cheaper pharmacies who offer GoodRX discounts, and at the end of the year they pay the same or usually less than an insured patient does.  **FYI, CVS and Walgreens are THE MOST expensive pharmacies.  Walmart, grocery store chains, and independent pharmacies are cheaper***.  Patients can be seen in person, via telehealth, whatever they choose.  Patients on certain controlled substances do have to be seen in person at least once per year or more per DEA laws.  Pros to concierge/self pay is that it is not corporate ran mandated care.  It is a true relationship between you and your provider.  Need a vax or mask exemption?  Concierge/cash pay private care can do those.  Corporate healthcare won’t touch that with a 10 foot pole.

Concierge is the same, but different.  I have mixed feelings towards concierge care.  It is done a few different ways, and some I think are great while others seem a little “cash grabby”.  One option is that patients pay a monthly fee and sign a 12 month contract.  They are obligated to have that fee auto debited each month and in return, you have full access to your provider.  You can get same day appointments, seen as often as you like or as infrequently as you wish.  Each year you re-up your contract and the monthly fee continues.  Other options are you pay a yearly fee for care, and then all your visits for the year are “free” after that yearly fee is paid.  Others (who seem a little cash grabby to me) make you pay a yearly fee, but they also charge you a small fee for each visit.

Some examples:

1. Provider charges you $40 per month for care, it is a 12 month contract with auto debit each month.  With that contract you can call for an appt when needed, get your meds refilled, current issue addressed, and on you go.

2. Provider charges you $500 for 1 year of healthcare.  That is paid once per year for each patient (and usually offer a discount for other family members to be added).  This is the same as above, you just pay the entire chunk at once instead of monthly.

3. Yearly fee + appointment fee.  This is the one that I have some concerns with.  There is one clinic I know of in Dallas, they are primary care, and they charge $2000 PER YEAR plus there is a fee for each visit.

I think a happy medium is where I would settle if the decision were solely up to me.  It is what my husband and I are considering for our family.  Our health insurance sucks.  We have a $10k deductible.  My insurance does not cover my chiropractor so I cash pay.  We will never meet our deductible unless something catastrophic happens.  So we are looking at a hybrid.  We already spend almost $400 per month for crappy health insurance with United.  We are looking at a catastrophic policy that would cover us in the event something bad bad bad happened (heart attack, stroke, hospitalization needed, etc) but doing concierge/self pay for our basic well-care.  It would end up being cheaper for us.

My challenge to all of you is that healthcare is evolving and to keep an open mind.  The crap corporate model we have been stuck with has convinced most people that health insurance is needed.  Which, it kind of is in serious medical situations or else it will bankrupt you.  But for the day to day stuff, it can be done without insurance.  Some providers who are the “good guys” and they want to just help people, it is way easier to launch a practice as a concierge provider.  It avoids the 6 month wait to get insurance to credential and panel you just to see patients.  It also eliminates the ICD 10 codes that have to be sent to insurance and we get to just “take care of you”.  The switch to doing cash pay/concierge type of healthcare is hard to wrap your brain around, because our entire lives we have been ingrained to use health insurance.  Also, when you already spend $200-$600 per month for health insurance, adding the cost for cash pay concierge to the budget seems counterintuitive and expensive.  The next few years will bring change, and the ending of health insurance as we know it is not necessarily a bad thing if it happens.  My best advice is to find whatever ways you can to extricate yourself from corporate driven healthcare, utilize independent providers and pharmacies when you can, and create a healthcare plan that works for you both financially and personally.