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Comment by bachmeier | Hacker News Reader

My primary care doctor informed me a few days ago that he's shutting down his current practice. Appears to be driven by his desire to get away from the insurance companies. He's part of a new practice where you pay a monthly fee and everything's included. You can text and email with questions, stop by for an appointment and get right in, and so on.

The advantage for him is that he never deals with insurance companies again. The disadvantage for me is that, since I have few health issues, and they're minor when I do, it would cost a lot more per year.

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The crazy part is this is how it used to work.

One of the older models for a physician went like this:

- you opened a practice

- you charged a "subscription" to be a part of your practice

- people could come as much as they wanted

What's crazy to me is that MORE doctors don't do this since I'm 100% sure there is a demand for a service like this.

When you have a market as distorted as medicine in the US, it's not just that crazy things happen, but also that normal, functioning versions of the thing are crowded out by the inescapable pull of the distortion.

Makes sense. Primary care would be better like dentists.

The monopolies formed for these health networks are bad for everyone. The staff are miserable, patients don’t heal, and half the time the companies are losing money. My primary care was bought by a hospital network, which was bought by some multi-state network that is under financial stress yet just boight another regional network to ruin.

The two shops around here charge about $175/month for a family ($80/month single adult). That's a difficult price to swallow when you have insurance through work, which almost everyone able to pay $175/month does. There's probably some value, but I need a doctor so little, I just can't see paying for it. It's competing with services like Zoomcare, which is basically an on-call online-scheduled prescription service which works very well for my purposes. I struggle to see these Direct Primary Care services getting off the ground unless they're in a very affluent neighborhood where price doesn't really matter anyway.

I would pay that without blinking if the care was good and getting appointments didn't take 3-12 months. We just waited a YEAR for a new patient appointment for my chronically I'll wife and the doctor is terrible. Told her he basically had no interest in helping figure out her problems and if he did, he wouldn't be a PCP.

I no longer support licensing primary care physicians after some of the things I've seen. I know someone that had high blood pressure (a condition that's easy to verify even if you don't have a doctor) and their doctor refused to do anything about it. As in, the patient repeatedly brought it up, and the doctor ignored the problem. That's not the worst I've seen by a long shot.

Licensing serves no purpose if you're not going to take it away in cases of incompetence and malice. This has turned me into a fan of malpractice suits with large punitive damages.

Lol so let's just not have doctors then?

Well, Mister "lol"; what does "have doctors" mean to you. Because it seems to me without needing any sort of special education that one could conceivably take the term 'have doctors' to mean one thing according to how one poster describes their experience and mean something else entirely depending on how another poster would describe their experience. So, explicitly, what exactly does " have doctors " mean to you?

Unfortunately there's very little reprocuasion for a doctor being bad at their job. As long as they don't do anything That'll revoke their license they don't care. That's the problem and naturally when people get beaten down enough they stop trying, and you get people like yourself who will just say "why go to doctors they usually don't help me anyways so might as well save myself the time."

Yep this. We travel very far for my fiancé's gp because it's the only doctor trying to help her and takes her insurance.

Finding a doctor is easy. Finding a good doctor that will try to figure things out when things go very wrong is very challenging and frustrating.

This model is doing very very well actually. Most people hate getting whatever doc their crappy work insurance offers. Once people find a doctor they like they stick around for decades.

My dad is a GP and ran a practice that at its height in the mid 00s had around 5000 patients, 4 doctors, a slew of nurses and probably 15 office staff. He worked about 50-60 house a week and was ultra stressed out. Then in the early 10s he switched to this concierge model. Now he has 1 office staff/med assistant, 300 patients, and makes literally 4x what he made with the previous model.

Insurance companies, along with declining pay and the gobbling up of private practice by giant medical corporations who treat doctors like low level employees are driving GPs away, and into specializations.

If the government wants to stem this shit tide they need to tell insurance companies to get fucked, limit the intrusion of corporate bean counters, and give incentives like the cancellation of school debt to folks who go into GP. No number of highly paid specialists will ever replace GPs

The medical industry employs about 15 to 20 percent of all active US workers [0]. Some people read that and think it's a good thing, "wow, such job creators", like measuring software accomplishment by the number of lines.

No wonder my medical costs are so high. Every high premium and medical bill is my turn to personally support 20% of the nation. I wonder how much is left over for the doctor?

This will be difficult to solve because "make the system simpler and fire lots of people" is painful and not politically popular.

[0] https://www.census.gov/library/stories/2020/10/health-care-s...

I've had a lot of family time in the hospital systems in a relatively well-managed part of the US. And, I worked in the 'back office' of a medical system a while ago. Talking to billing people, etc, I came to the conclusion that "reform" with existing vested interests is... not going to happen. I don't know what a _good_ solution is, but I can imagine the least painful way is to have a parallel universe of MDs with a wholly different billing, licensing, board-certification regime.

One interesting question is: why is one hospital's rate for procedure X different than another? how can providers work at different hospitals? The answer lies somewhere in the "it's a maze of subcontractor relationships", "it's a maze of one off insurance contracts"...

It's a very good example of why vertical integration beats subcontracting. :)

How about ending the AMA Cartel from limiting the supply of doctors, easing the requirements for foreign doctors to practice medicine in America, and far expanding the list of services that can be performed by a Nurse or trained technician?

I have several friends / acquaintances that have converted to this kind of concierge practice. At least a few years ago, $5k / patient / year was a going price for one of them, which gave you basically 24/7 more-or-less direct access to a physician. I'm not sure how it worked WRT lab and radiology costs, but it seemed that people could subsidize the expense significantly by changing to catastrophic insurance only, as simple visits (just a history and exam) were already covered, and many simple meds (eg antibiotics) available on the $4 list.

One BIG reason that my wife and I remain working in a U.S. Federal system (in which the federal government pays for all necessary care) is that I don't have to deal with insurance. It is soul-crushing to have pencil pushers hundreds of miles away díctate the care you provide.

Do you have an idea what the difference is in cost? A subscription clinic opened up by me and their price was shockingly reasonable to me after years of insurance deductibles and whatnot.

He charges $80/month. In the most common year, I only have my annual physical, and that's covered by insurance. That translates to $0 out of pocket. Other years I have visits for other reasons. With the deductible and copay, it's more than $100 for any visit. I'd need 7-8 visits a year to reach $80/month out of pocket.

On the other hand, not having to make appointments weeks in advance, and even being able to send a text message to save a visit has some value. I don't think that would be possible with my insurance (the doctor wouldn't get compensated).

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