3 ms·

A couple years back I started seeing a "hippy" doctor in my town (Boulder). He's a licensed MD and doesn't accept insurance; cash only at $300 an hour. Totally

A couple years back I started seeing a "hippy" doctor in my town (Boulder). He's a licensed MD and doesn't accept insurance; cash only at $300 an hour. Totally worth every penny. He actually listens, and is willing to get creative with things. If you're not satisfied with your PC provider, find a cash only doctor. I think you'll find they care more.

arkades 10y ago
IME, it's not that they care more - it's that they have the time to pause and think. A buddy of mine is a world-renowned specialist, but in a niche too small to allow him to go all-cash. He gets a patient a couple of years back who came with literally boxes of medical records, years of failed doctor visits, and in excess of 100k$ in worth of tests and interventions. He spent two days poring over her records, and got her the diagnosis no one else did - got her on the right tx, and gave her her life back. Insurance reimbursed him precisely the same (<$300 gross) that it would have for an ordinary visit of ordinary length, more or less. (Fine, he billed a level 5 eval and management instead of a level 3; difference of nearly peanuts). How often do you think he sets aside the time to pause and really think deeply on a problem? If he was charging cash and had the chance to charge people for his time and expertise, knowing him, he'd be happy to do nothing but spend days at a time tackling the hardest problems available.
- csydas 10y ago
  >He spent two days poring over her records, and got her the diagnosis no one else did - got her on the right tx, and gave her her life back. Well, quite frankly, this is part of the problem and it's a social adjustment we need to make as well. We see this with virtually any position where you need to diagnose; 99% of the time it's a simple issue from column A, but occasionally you get a symptom that looks like the issue is from column A but it's actually in column B. In technology, we fly through column A solutions because they're cheap, fast to test, and often done without cost, and column B solutions are more drastic, more expensive, and sometimes more dangerous. The difficulty in translating this to medicine is that a lot of times column B solutions are dangerous to the point of no return. Combine this with the fact that there really aren't rollbacks when it comes to health, you have actual life or death decisions to be made. Taking the time to review the whole history can really help with this and to get a full timeline of events, but even then it's hard to get past the column A/B thinking. I've been dealing with a very annoying sinus issue for 3 years across about 8 doctors from across the planet (due to moving because of work). Every time I've started anew with a doctor, they go down the exact same treatment list as the previous, and when they're told that I've done that already, they just want a repeat. I understand this thought process (what if I'm lying, what if they bungled the test, what if something changed, etc), but I've done this 8 times now. I've been told each time it's an allergy, but every time we see an allergist, they can't get me to react to any allergen they have available to test for and are left scratching their heads as to why antihistamines don't have any effect. They also can't find a common cause that fits with allergies, but in their minds, it just looks so much like allergies they're not sure what else to test. I secretly suspect that if I could just get a doctor to spend more than 20 minutes in a consult to review the case and what I've done so far we could try something else, but regardless of where I've been, I just can't get a doctor to look too much longer. They either don't believe the symptoms as I report them, don't believe the steps I've already tried to resolve it, or they just don't have the time to care past the initial look at the symptoms. I appreciate the difficulty in having to do this: when column A fails, it looks great if you pick the right item from column B, but it also gets really expensive while you shop around to find the right item from column B. They make it look so easy on House, but no place is willing to really do that sort of patient history and testing, and if the condition is not life threatening, then it's just a "deal with it" situation, we're gonna keep throwing the easy stuff at the symptoms until the person stops complaining. I don't know what the problem is or how to embolden doctors to take a little more time, but some change would be nice. Though, hearing stories from my mother who has been a nurse for 20+ years, sometimes emboldened doctors look for problems that aren't there so they can look like heroes. It's a crazy thing with health and unfortunately the value of such emboldened decisions tends to be a very ad-hoc assessment. If it worked well, it was a gutsy but necessary maneuver. If it did nothing, it was reckless. If it caused harm, it was malpractice.
kkielhofner 10y ago
You're describing (in a way) concierge medicine. Wikipedia has a rough description: https://en.wikipedia.org/wiki/Concierge_medicine https://en.wikipedia.org/wiki/Concierge_medicine Annual fees can run in the 10s of thousands of dollars but quality and access to care is top notch. An appropriate comparison would be flying Spirit vs private. It's such a different experience (and in the case of medicine - outcome) that it can hardly be called the same thing.
- arkades 10y ago
  Concierge access is a business model largely dependent on the SES of the community the doctor is located in, and his personal charisma/following. It's very, very poorly correlated to physician quality. Access tends to be a lot better, but only in those practices that are 100% cash. Those practices that try to "transition" or do a mixed customer base tend to be the same as all-insurance practices, since they fail to transition operations/processes towards the cash-based context.
  - kkielhofner 10y ago
    I should have mentioned that my experience is highly anecdotal - a handful of patients across a couple of doctors. Yes, these practices are 100% cash. I noted several key differences: - Top-tier education. Medical school and residency at top 5 programs in the United States. - Availability. They have total patient rosters in the low-hundreds, and many of these patients are seasonal. Response was always same day and more often than not immediate (phone, text, e-mail). I got the sense I maintained this consistent level of ready access because I am a relatively "simple", "low maintenance" patient. - Time. Full labs and blood draws were done quarterly. Results were tracked and compared over time. Each draw was accompanied by a follow-up that could last as long as an hour, depending on how long you wanted it to (for whatever reasons). I never saw anyone look at a watch or a clock. Making informed decisions regarding diet, cholesterol, and lifestyle (for example) is much easier when your doctor can spend 30 minutes discussing your lipoprotein trends over the past five years against 30 years of varying data, trends in medicine, and studies of actual impact on mortality and quality of life. - Network and peer credibility. Their "med school buddies" were often in nationally recognized programs and specialties. Made an incredible difference in access at least once for me personally. Any referrals were met with similar levels of access, even in all-insurance or mixed practices. I've often said the single most important benefit of concierge medicine (for whatever underlying reasons) was that your physician actually LISTENS to you and treats you like a real person, a whole person. Not only does that make substantial differences in your perception of care (and overall experience) it made definite and substantial differences in outcomes in my experience.

arkades 10y ago

IME, it's not that they care more - it's that they have the time to pause and think. A buddy of mine is a world-renowned specialist, but in a niche too small to allow him to go all-cash. He gets a patient a couple of years back who came with literally boxes of medical records, years of failed doctor visits, and in excess of 100k$ in worth of tests and interventions. He spent two days poring over her records, and got her the diagnosis no one else did - got her on the right tx, and gave her her life back. Insurance reimbursed him precisely the same (<$300 gross) that it would have for an ordinary visit of ordinary length, more or less. (Fine, he billed a level 5 eval and management instead of a level 3; difference of nearly peanuts). How often do you think he sets aside the time to pause and really think deeply on a problem? If he was charging cash and had the chance to charge people for his time and expertise, knowing him, he'd be happy to do nothing but spend days at a time tackling the hardest problems available.

csydas 10y ago
>He spent two days poring over her records, and got her the diagnosis no one else did - got her on the right tx, and gave her her life back. Well, quite frankly, this is part of the problem and it's a social adjustment we need to make as well. We see this with virtually any position where you need to diagnose; 99% of the time it's a simple issue from column A, but occasionally you get a symptom that looks like the issue is from column A but it's actually in column B. In technology, we fly through column A solutions because they're cheap, fast to test, and often done without cost, and column B solutions are more drastic, more expensive, and sometimes more dangerous. The difficulty in translating this to medicine is that a lot of times column B solutions are dangerous to the point of no return. Combine this with the fact that there really aren't rollbacks when it comes to health, you have actual life or death decisions to be made. Taking the time to review the whole history can really help with this and to get a full timeline of events, but even then it's hard to get past the column A/B thinking. I've been dealing with a very annoying sinus issue for 3 years across about 8 doctors from across the planet (due to moving because of work). Every time I've started anew with a doctor, they go down the exact same treatment list as the previous, and when they're told that I've done that already, they just want a repeat. I understand this thought process (what if I'm lying, what if they bungled the test, what if something changed, etc), but I've done this 8 times now. I've been told each time it's an allergy, but every time we see an allergist, they can't get me to react to any allergen they have available to test for and are left scratching their heads as to why antihistamines don't have any effect. They also can't find a common cause that fits with allergies, but in their minds, it just looks so much like allergies they're not sure what else to test. I secretly suspect that if I could just get a doctor to spend more than 20 minutes in a consult to review the case and what I've done so far we could try something else, but regardless of where I've been, I just can't get a doctor to look too much longer. They either don't believe the symptoms as I report them, don't believe the steps I've already tried to resolve it, or they just don't have the time to care past the initial look at the symptoms. I appreciate the difficulty in having to do this: when column A fails, it looks great if you pick the right item from column B, but it also gets really expensive while you shop around to find the right item from column B. They make it look so easy on House, but no place is willing to really do that sort of patient history and testing, and if the condition is not life threatening, then it's just a "deal with it" situation, we're gonna keep throwing the easy stuff at the symptoms until the person stops complaining. I don't know what the problem is or how to embolden doctors to take a little more time, but some change would be nice. Though, hearing stories from my mother who has been a nurse for 20+ years, sometimes emboldened doctors look for problems that aren't there so they can look like heroes. It's a crazy thing with health and unfortunately the value of such emboldened decisions tends to be a very ad-hoc assessment. If it worked well, it was a gutsy but necessary maneuver. If it did nothing, it was reckless. If it caused harm, it was malpractice.

kkielhofner 10y ago

You're describing (in a way) concierge medicine. Wikipedia has a rough description: https://en.wikipedia.org/wiki/Concierge_medicine https://en.wikipedia.org/wiki/Concierge_medicine Annual fees can run in the 10s of thousands of dollars but quality and access to care is top notch. An appropriate comparison would be flying Spirit vs private. It's such a different experience (and in the case of medicine - outcome) that it can hardly be called the same thing.

arkades 10y ago
Concierge access is a business model largely dependent on the SES of the community the doctor is located in, and his personal charisma/following. It's very, very poorly correlated to physician quality. Access tends to be a lot better, but only in those practices that are 100% cash. Those practices that try to "transition" or do a mixed customer base tend to be the same as all-insurance practices, since they fail to transition operations/processes towards the cash-based context.
- kkielhofner 10y ago
  I should have mentioned that my experience is highly anecdotal - a handful of patients across a couple of doctors. Yes, these practices are 100% cash. I noted several key differences: - Top-tier education. Medical school and residency at top 5 programs in the United States. - Availability. They have total patient rosters in the low-hundreds, and many of these patients are seasonal. Response was always same day and more often than not immediate (phone, text, e-mail). I got the sense I maintained this consistent level of ready access because I am a relatively "simple", "low maintenance" patient. - Time. Full labs and blood draws were done quarterly. Results were tracked and compared over time. Each draw was accompanied by a follow-up that could last as long as an hour, depending on how long you wanted it to (for whatever reasons). I never saw anyone look at a watch or a clock. Making informed decisions regarding diet, cholesterol, and lifestyle (for example) is much easier when your doctor can spend 30 minutes discussing your lipoprotein trends over the past five years against 30 years of varying data, trends in medicine, and studies of actual impact on mortality and quality of life. - Network and peer credibility. Their "med school buddies" were often in nationally recognized programs and specialties. Made an incredible difference in access at least once for me personally. Any referrals were met with similar levels of access, even in all-insurance or mixed practices. I've often said the single most important benefit of concierge medicine (for whatever underlying reasons) was that your physician actually LISTENS to you and treats you like a real person, a whole person. Not only does that make substantial differences in your perception of care (and overall experience) it made definite and substantial differences in outcomes in my experience.