Fri. Jun 18th, 2021

On April Fools Day, 2016 I had my first mammogram. 

The mammography nurse looked at me, said “everything looks good” and left the room.

My imaging was up on the screen. 

My training as a physician afforded me the ability to see that everything did not look good. In front of me was a 4cm spiculated lesion (fancy doctor-speak for cancer) in the middle of my right breast.

Two years prior to my breast cancer diagnosis, I left my job with the same healthcare system in an effort to liberate myself from progressively worsening corporatized healthcare. My youthful idealism and genuine joy at caring for others was overrun by burdensome hours of unnecessary documentation, a rotating door of unsupervised managerial staff, supplies thrown away without reordering ‘to remain complaint’, departing clinical colleagues, more boxes to check and more and more of me saying to the people I was trying to serve, “I am sorry.”  

I couldn’t do it anymore.

With $200,000 in medical school debt and one patient who stated he would follow me anywhere, I opened my own, simple, small direct pay practice. 

While I pride myself on being a fierce patient advocate, I started this practice to save myself. 

To survive professionally as a physician and personally as a kind human, I had to do something different.

Two very long years later, in the start-up phase of entrepreneurship, I was swept back. 

Back into the healthcare juggernaut ..this time as a patient.

There is a lot more to this story- to why I became a doctor, why I left the system, what it’s like being diagnosed with breast cancer at the age of 40 as a physician on the medical staff of a hospital that sends a nurse in to photograph you incase you “sue them” for the process of trying to not lose your hair. 

Those are all other stories I will tell.

But today, I want to explain, as a physician and as a patient, why healthcare is not ONE thing. 

If we want to reinvent our healthcare system, if we want things to be better, be more transparent–if we want a system that serves people in a time of need –we need to think about healthcare as two entirely different institutions: 

  • that which cares for the innumerable things that will not kill you in the immediate term 
  • and that which cares for the things that threaten your life now.

To do this, we must not only re-think, but we must demand a change in how we pay for healthcare.

Insurance is designed to bear risk. 

We purchase insurance as an umbrella, a parachute, a protection against things we *hope* won’t happen but, in anticipation of the possibility, we invest resources now to protect ourselves in the event of a personally and financially catastrophic event.

To explain this role of insurance conceptually, let’s talk about home-owners insurance. Generally, homeowners insurance is affordable enough that we do not have to rearrange our financial lives to have it. If we ruin or nearly ruin our ‘investment’- aka our home, the purpose of homeowners insurance is to come through and restitute our damaged or lost investment without us having to spend $300,000 or $500,000 or whatever the full ‘replacement price’ of our home is to get bac what has been damaged or lost. 

In the middle of chemotherapy, my father-in-law was visiting us. He inadvertandntly left our outdated shower pull partially engaged. This led to a few days (weeks?) of dripping between the shower wall and pull, resulting in flooding in the wall of our upstairs bathroom. We learned this when the ceiling of the living room bloated then fell into the downstairs. This was unexpected, disruptive and jeopardized not only the structure and function of parts of our home, but also our comfort within it. Kind of like my cancer and my body and life plans. Unexpected. Disruptive. Jeopardizing. 

With our house, after paying our deductible ($500), homeowners insurance kicked in. Drying out the carpet? Check. Ceiling repairs? Check. Bathroom tear apart, new floor, new shower, new plumbing, new paint? Check. 

We pay for insurance so that we may be insured. The whole point of being insured is that we are paying for the ability to KNOW, with certainty, that if an accident or an unforeseen event happens we won’t go broke and be left high and dry… or in my case.. Ruined and wet!

We have home-owners insurance for a fire or flood or other catastrophe. We do not rely on this insurance for simple issues like when the dog pees on the carpet, or the towel bar falls out of the wall or the dishwasher stops working. We try to make sure these things don’t happen through routine maintenance, basic handy-person skills and periodic cleaning/periodic home care. If we expected insurance to be involved in these matters, insurance would be extremely costly and inefficient. Not to mention, we would spend more time on hold and doing paperwork than we would spend just training the dog to pee in the yard in the first place. 

It’s not overtly difficult to extrapolate the above examples to self-care. How often do we hear about eating a reasonable diet, not smoking, getting enough sleep, the fundamentals of daily exercise and on and on as manners in which we are to care for ourselves?  These are the routine maintenance activities of being human. Why do we engage insurance in these matters? 

It is also NOT the purpose of insurance to regulate. We don’t rely on our insurance company to tell us what car we can buy or what home is the best fit for us. Can you imagine if your homeowners insurance said, “here is a list of pre-approved homes from which you can purchase?”… or if you had to call your insurance company and ask for a list of pre approved vehicles you could buy and which car dealers you could go buy them from? And what if,  to further justify their overreach they added in marketing that informed you that if you went with their pre-approved homes or pre-approved dealers you would be safer? This analogy stretches even then to notions that perhaps your insurance could work with specific builders, could negotiate lower cost building supplies, could lobby to regulate home-materials manufacturing… and on and on. Seem far fetched? This is precisely what has become of health insurance.

I do not understand why we, as patients, as providers, and consumers of healthcare tolerate this business model.

In the United States, medical bills are the number one cause of bankruptcy. Most of these bankruptcies occur in families who have health insurance. What the what?? How is that even happening? Insurance is not only not insuring anything, it’s not bearing risk AND it is the number one reason the cost of care is catastrophic!

Insurance, in healthcare, is the root source of our systemic healthcare problems.

Now, before you get all crazy on me, let me be clear. We need insurance for SOME of our healthcare. Just like with homeowners insurance. But we do NOT need insurance for the vast majority of our healthcare. 

In the US we tolerate, in fact we pay for a healthcare construct that bundles the entirety of our life health events under the umbrella of a business structure (insurance) that at its origins existed only to protect us from the catastrophic. But because we now utilize insurance as a normative payment model for ALL of our healthcare, the routine and simple events are bundled into the same business structure as the catastrophic. 

And that, in and of itself, is the fundamental structural problem of our healthcare ‘system’.

As a physician, when I worked under the structure of insurance-based payments, my outpatient care of patient’s warts, ingrown toenails, urinary tract infections, arthritis, you name it, was procedurally handled, documented and billed the same way that the consent, documentation and billing was done for my hospitalized patients. A matter that I could address at home with basic first aid occupied at least 40 minutes of my patient’s time to sign in, wait, be roomed, etc and then 7 minutes of face to face time with me, 10 minutes to document the procedure after their departure, then check out, more paperwork, coding and 4-6 months later, would cost my patients upwards of $150. My compensation would be about $30. And why? The justification was always that this documentation and extensive box clicking, in both settings, resulted in the ability not only to maximally bill for care but to capture ‘core quality metrics’ and thereby insure better patient care.

As a patient, I have spent hours registering, re-registering, spelling my full name, logging in, waiting, repeatedly answering questions unrelated to my circumstance all to meet ‘core metrics.’ I have received care within a hospital system that provided my chemotherapy and radiation and has 5 years of cancer treatment records where I have to inform the medical assistant of the moment that I have had breast cancer. (what?  What are they looking at in that fancy high-tech box with all the words? Shouldn’t it say… like… EVERYWHERE… ‘this chick has had CANCER and we cut off her boobs and gave her medicine that almost killed her and… )  What on earth are they looking at and documenting if not the really big important stuff? 

The intended purpose of layer upon layer of diligent patient care protocol is to keep me safe. However, the unintended consequence of our enormously complex healthcare system is that our care providers answer not to us but to boxes. 

I can tell you, singlehandedly as a doctor and patient- what keeps a human safe is a human. A human brain, human energy, human intuition, human compassion, human problem solving. 

What keeps me the safest is that my doctor (and her nurse) know my name. They know my history. They know me. 

That is the beauty of healthCARE. No matter how much science we have, how much data we review, how many boxes we check– only humans can provide authentic healthCARE.

We have allowed the product that should exist for rare use in times of catastrophe to create the rules for our entire care system. And we have been boondoggled that it is that product, insurance, that creates ‘good care’. When any business answers repeatedly to an unpresent third party, that business cannot reliably be predictable, transparent, timely nor flexible. All of these qualities are necessary for any industry that, at its core, provides service to the most unpredictable ‘end product’ possible…people.

I’m happy to attest, however, there is a better way.

And it’s simple.

Remove the routine from insurance constructs. Insure our healthcare the way we insure our homes.

What if the patient I saw in the system saw me now? She would call our clinic, my nurse would answer, triage, have her send in a picture, review it, call her back and tell her about first aid at home. Two hours of human capital saved, minimum, not to mention everyone involved could get on with more serious matters. Or, what if that patient was known to me well, called in, my nurse said “just come on in and Dr. G will see you when you’re here” and that patient came in, I popped in, I dressed the bandage with supplies available to me (not locked up in a cabinet for ‘safety’), wrote a simple note, didn’t code, didn’t bill and I charged the patient…nothing? What if I drove to the patient’s home and looked at the wound myself. What if she was billed a total of $30 instead of $150 at the time of care– she saves $120, I get the same and we both save a ton of hassle. Could we transform routine healthcare to be delivered in THIS way?

And the answer is, yes. Yes. Yes. Yes! 

This incredible simplification of primary care- our most basic, routine, maintenance type healthcare, is precisely what is happening with the grass-roots movement known as direct primary care. We can provide simple, accessible, transparent, routine primary care in a dramatically affordable manner. Without insurance.

If we want to change the US healthcare system… really, really change the system for the better we must begin to talk about TWO systems. The places where we get care for the innumerable things that occur slowly, as a part of the fundamental imperfections of day-to-day life. And the place where we get care when that very existence is rapidly threatened.

Insurance matters, and is in fact essential when there is a fire, a flood, a hurricane. Insurance matters when we see the 4 cm tumor in our breast and know we have years ahead of us with surgery, hospitalization, chemotherapy, radiation, and ongoing imaging. But for the mundane, the routine, the chronic– insurance is catastrophically burdensome and costly. It is time for us to ask insurance to step back and to be what it is most ideally designed to be. It is time for us to enthusiastically empower physician-driven direct primary care to step forward.

Dr. Julie Gunther is a dual-Board Certified Family Physician who founded sparkMD in 2013 and currently serves as President of the DPC Alliance. At the age of 40, Dr. Julie was diagnosed with breast cancer which led her to re-frame her personal goals and goals for sparkMD, seeking to build a robust, compassionate, diligent and capable team that delivers urgent care services, wellness services and aesthetic services, focusing across the board on mental and physical well being.A graduate of Harvard University and the University of Washington School of Medicine, Dr. Julie has been featured in Forbes, NPR, Bloomberg News, Medical Economics, Physician Practice, Reason TV, KevinMD, Greenbelt Magazine among many other forums.

11590cookie-checkApril Fools’ Day 2016, What Health Insurance Really Does, and Why I Now Do Direct Primary Care by Julie Gunther, MD
3 thoughts on “April Fools’ Day 2016, What Health Insurance Really Does, and Why I Now Do Direct Primary Care by Julie Gunther, MD”
  1. Wonderful article. Agree with everything, but if we are on a mission to articulate a solution to the entire problem, then we must acknowledge that there are really three systems. Yes, there is the catastrophic, life threatening system that insurance was designed for and the routine maintenance for healthy people that insurance has no place in. However, there is a third system or issue which is a fly in this ointment which is chronic care. In your amazing article, you discuss your cancer diagnosis as being in the catastrophic system. However, that’s really not true. Cancer is the second leading cause of death in the US, with 1 in 10 women will have breast cancer. In addition, breast cancer treatment is expensive, so actuarial models that work for home and car insurance, won’t work for cancer when it is so prevalent and so expensive. About 10 % of the population also has Type 2 diabetes. Yes, we have an obesity problem, and there are low cost ways that should be employed to help, but as physicians we know that we can give 110% effort to promote this and it doesn’t solve the problem. We have excellent medicines to treat patients with Type 2 diabetes and save their lives, but these medicines are not generic. The problem with DPC + health shares like Sedara (which doesn’t cover prescriptions) is chronic disease. If you don’t have cancer (or I should say didn’t have cancer, since new cancer is covered but old cancer is not) or diabetes, Sedara + DPC is a great solution. However, too many people fall through this gap. We need to continue to argue that actuarial insurance model for healthcare is a key factor in our dysfunction system and DPC can be part of the solution, but if we really want to fix the whole picture we need to acknowledge and figure out what to do with chronic disease.

  2. Dr. Mintz! Great points. My first thought is: is chronic care expensive? And… why? And…is the management of chronic medical conditions, the result and/or full responsibility of our health care ‘system’ and providers or, in fact, a result of social determinants of health (and much more). Cancer is catastrophic- or can be. Surgery, hospitalization, chemo, radiation- these things require sophisticated centers, sophisticated machinery and for innumerable reasons are expensive, eventful and extreme-expertise driven health events. Same goes with major joint revision or organ transplant or sepsis etc… But cancer thereafter? The 10 years on an estrogen inhibitor and the surveillence imaging, follow up visits, surveillence labs? When I think about my own experience here is what I see: My now ‘chronic’ issue of keeping my estrogen low and keeping track of cancer things in the event it comes back has involved imaging every 6 months. If I was allowed to pay cash for that imaging it would be less than $1000/year. Labs every 6 months– cash price they are $50. And my. meds? This is the best part. Last month I went to fill 90 days of exemestane (my estrogen inhibitor/keep the cancer away drug). The pharmacy said that will be “$600” and they were going to bill my insurer $2200 for their ‘portion’ of these meds. There are a HUGE number of issues with this: 1) I have an ACA compliant plan so these medications should, technically, be ‘free’. 2) Last year exemestane (which I’ve been on now for 4 years) was $90 for 3 months. This year, evidently, it is ‘not on the list of approved medications for my condition’. Of interest- the approved drugs for my condition caused anaphylaxis and a pulmonary embolus so exemestane is what I have to take (and my insurer knows this because, well, they paid for the hospitalization for anaphylaxis and for my pulmonary embolus AND my doctor has not written them annual letters saying why I need exemestane over other medications. But here’s the real kicker: 3) Wholsale pricing on exemestane is $45/month. Or $135/3 months. And ONE pharmacy in town honors goodrx coupons for $125 for 90 days. So, using this very specific (and yet not so specific example), I would contend we DO have the ability to triage healthcare into 1) the expensive and urgent and 2) the mundane/maintenence/chronic and therefore non urgent. And the vast majority of non urgent medical conditions- the chronic care conditions- when managed with insurance are catastrophically expensive. When chronic matters are managed with cash, advocacy AND investment in education and social change (big things beyond the ability of any one doctor but certainly an important part of our social conversation) they are much, much more affordable. Love the dialogue. Thanks for the kind words!!

  3. Thanks for your reply. I think the complexity of your response highlights my point. To be clear, I think it is extremely important to do what you did in the original article, which is to highlight are country’s insane addiction to health insurance which is not only inefficient in covering most needs, but also (as you point out) in doing not doing what it’s supposed to do (covering emergencies) since health care costs are the number one cause of bankruptcies. My point is that while using the indemnity model (car insurance, home owner’s insurance) to explain why health insurance isn’t working is very helpful. However, by limiting the discussion to two systems, the argument may be met with skepticism because I don’t think it accounts for expensive chronic conditions which are commonplace. In other words, car insurance or homeowners insurance works well since most homes or cars function pretty well within a warranty or normal use period. The problem is that many Americans (due to SES, personal choices, as well as factors beyond their control) are going to get sick quite often, and this is expensive. Thus, if as you suggest, we insure our healthcare like we insure our homes and cars, this won’t work for many Americans with chronic illness, as their premiums will be too high. All I am suggesting that as part of the conversation in educating the public we recognize that chronic disease is unique to healthcare/insurance and needs to be addressed if we are really going to fix the problem. Solutions include government negotiating prices with drug companies and elimination of prior authorizations, putting some limitations on coverage for unproven therapies (every meniscal tear doesn’t need to be scoped, every coronary artery doesn’t need to be stented), and meaningful tort reform (so we can avoid MRI’s for every headache).

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