Sunday, April 20, 2014
You can walk into Dr. Michael A. Ciampi’s South Portland office with your medical insurance policy in hand, but you might as well be holding a blank sheet of paper.
Which is to say, you will be politely told, “That’s nice, but the only things you can use here are cash, checks or credit cards.”
Dr. Ciampi decided last April – and got substantial coverage for it at the time – to convert his family practice into a “no-third-party-payer” purveyor of cash-on-the-barrelhead medicine.
He posts the prices for his services online, and if you don’t know what the bill will be before you get examined and treated, all you have to do is ask.
I called him this week to get a six-month update on how his experiment in avoiding both government and private insurance is going, and discovered he’s pretty happy with it.
He says he lost some patients at the beginning, but the recent trend is up, and he (and, he says, his patients) are more than satisfied with the way things are going.
Like a growing number of doctors, he’s not pleased that Medicare and Medicaid intentionally are structured to keep expenditures low and don’t reimburse doctors for the full cost of treating patients (let alone leaving them anything as income).
But he’s no fan of private insurance, either, which he sees as demanding “more and more from doctors – information, audits, rates. It was dramatically affecting the time I was spending with patients and decreasing the income I was making from my practice.”
“The last straw,” he said, was the accountable care organizations contained within the Affordable Care Act (aka Obamacare) that were “reminiscent of the health maintenance organizations that we all hated in the ’80s and ’90s.”
HMOs were designed to keep expenses down, Ciampi says, at the expense of providing good patient care. And he sees that trend being exacerbated by both the ACA and private firms as time goes on.
If an accountable care organization and its doctors spend more than was allocated for X number of patients, he says, “They have to write a check to the feds. That makes the bottom line the goal, not patient care.”
That means doctors “lose autonomy, because the desire to make money is set against patient well-being. It is a major ethical dilemma.”
And he gave this example: “My Canadian grandmother needed a hip replacement before socialized medicine, and she got it. Then she needed the other one done after socialized medicine, and she was put on anti-inflammatories for years in a waiting line. She ended up with life-threatening internal bleeding, and that didn’t move her up the list one single place.
“When people say we need Canadian-style medicine here, I think of her. And I think of President Obama saying, maybe you don’t need that operation, just take a pill.”
Thus, he says, “We decided to go back to the cash model that worked from the days of Hippocrates to 1965 (the birth of Medicare).”
He makes referrals, of course, but tries to steer patients to doctors and labs that are independent of large groups or hospitals, as he believes their fees are lower on average.
His patients, mostly “working-class people,” tend to have either high-deductible policies or no insurance at all. “They are thrilled with our policies,” he says, “saying they pay less at our office than at the dentist or the auto repair shop.”
And he’s turned his back on electronic medical records, which were supposed to save tons of money.
“We know our system and we can find stuff faster here than on a computer,” he says. “And I can look at my patients when I talk to them, rather than a computer screen. Those notes aren’t really for the doctor, they’re to establish a reason to bill the third-party payers. And electronic records will destroy patient privacy.”
Finally, no matter how Obamacare works out, he sees his style of medicine succeeding. “The ACA, remember, says it will give 30 million or 40 million people more coverage – but it doesn’t add one doctor in one clinic. That means it offers insurance, but not access – you’ll get coverage, but not necessarily care.”
So people who choose to pay the ACA’s penalty instead of buying coverage will find his model attractive, as will those who buy coverage but encounter “delays, lines and rationing.”
He didn’t say it, but there’s something more: His model of coverage would dovetail well with conservative proposals to let all Americans create tax-favored health savings accounts supplemented with personal catastrophic coverage policies (with high-risk pools covering truly needy special cases).
And it would forestall the threat that current programs offer to patients who want good, affordable care while still maintaining their privacy.
M.D. Harmon, a retired journalist and military officer, is a freelance writer and speaker. He can be contacted at: firstname.lastname@example.org.