tag:blogger.com,1999:blog-26666124.post3839526764669552172..comments2024-03-18T03:28:36.581-04:00Comments on Shrink Rap: Why Psychiatrists Don't Participate with Insurance NetworksUnknownnoreply@blogger.comBlogger56125tag:blogger.com,1999:blog-26666124.post-5971796023031167972018-02-14T21:54:27.278-05:002018-02-14T21:54:27.278-05:00I think someone needs a script for an antianxiety ...I think someone needs a script for an antianxiety medication sprinkled with empathy and the ability to tolerate another point of view from people in a weaker position. Traceyhttps://www.blogger.com/profile/14024684321173119883noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-61653283388280279752014-01-27T21:46:56.662-05:002014-01-27T21:46:56.662-05:00This post is up on Kevin MD at http://www.kevinmd....This post is up on Kevin MD at http://www.kevinmd.com/blog/2014/01/psychiatrists-insurance.html<br /><br />You all might like reading the comments there (the post is verbatim, so if you do surf over, go straight to the comments)Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-83349858556722066032014-01-25T17:12:26.647-05:002014-01-25T17:12:26.647-05:00@Dinah, congrats on reposting this article to Kev...@Dinah, congrats on reposting this article to KevinMD.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-6037767758885165782014-01-24T16:08:45.974-05:002014-01-24T16:08:45.974-05:00@Nathan - your comment is brilliant. As we French ...@Nathan - your comment is brilliant. As we French say, Touché.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-61816427949030344362014-01-24T09:28:47.452-05:002014-01-24T09:28:47.452-05:00This is post about why psychiatrists don't ta...This is post about why psychiatrists don't take insurance, not about involuntary commitment. Shrink Rap has many posts up on involuntary commitment, please feel free to comment on those if you're interested in that subject line.Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-82072266521159132982014-01-24T09:24:32.717-05:002014-01-24T09:24:32.717-05:00How's this for analogy:
The US military hasn&...How's this for analogy:<br /><br />The US military hasn't activated its selective service list in over 40 years (psychiatrists not involuntarily committing for a long time), but it doesn't mean that it can't or won't (pervasive power dynamic of psychiatrists/others). But if a volunteer armed forced wasn't cutting it (self-pay clients) and the Pentagon and all of their contractors still wanted government contracts (hospitals and drug companies), I would not be surprised if the Draft returned (increases in involuntary commitment). <br /><br />The US government also creates a disincentive of possible jail time and fines for people who don't register (threats of harsher treatment/diagnoses/longer stays if not compliant to treatment plan whether agreed to or not). This is to keep folks from actively protesting for fear or worse things than possible deployment (structural factors that keeps people from questioning or seeking alternative treatment).<br /><br />I'm not a big fan analogies, but thought I'd throw one out as some here like engaging with them. Nathannoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-73674827177706550762014-01-23T22:51:16.060-05:002014-01-23T22:51:16.060-05:00Je Suis,
You and everyone else might be intereste...Je Suis,<br /><br />You and everyone else might be interested in this horrific article about a woman held against her will right after her husband murdered her teenage son and then committed suicide. And her insurance company is being billed for charges that she is fighting.<br /><br />http://tinyurl.com/kqo4cbbAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-29284256168321824662014-01-23T19:34:31.572-05:002014-01-23T19:34:31.572-05:00@Dr. Reidbord
You seem to think that the potentia...@Dr. Reidbord<br /><br />You seem to think that the potential to commit an act - without consequences; i.e. sanctioned by law and thus inviolate for all intents and purposes - does not, by default, cause numerous problems. it does. I have mentioned a few, but most likely not all, and yet no mention is made of the difficulties caused to the victim (for want of a better word..) of such an action. Why is that? <br /><br />I agree that the ability to detain someone against their will is a threat, no matter who holds that ability. Police, nurses, psychiatrists, whomever holds the capacity to initiate such a hold has the potential for harm. It is a situation that is too easily abused; and before you say nay, I have seen such abuses firsthand. <br />Make light of the "fearsome threat" all you want, but I have known individuals that truly needed psychiatric intervention - and this is me saying that, remember; it's not something I say lightly - and I have heard all about their fear of just such an occurrence. That fear kept them from even attempting to access "help"; essentially, a cornerstone of psychiatry is preventing the practice of psychiatry. Ironic, huh? And sad. So very, very sad; and many times, so very, very unnecessary. <br /><br />So "holdable" patients don't generally come to you? Perhaps that's because you are in a private practice, and do not accept insurance? The worst cases are also the ones who cannot afford your fees - there, we're back on track with psychiatric reimbursements, making this post relevant to the discussion - so I would venture that you are treating mostly the 'neurotic wealthy'. That would make it a bit easier to not initiate a hold, I suppose. A win-win situation, seemingly.<br /><br />A peace activist? Really? So, in light of that comparison, do you actively demonstrate against involuntary commitment? Do you speak out against it? If not, then the correlation lacks a certain something. There is also a certain conflict of interest involved - an involuntary commitment, however initiated, inevitably leads to an encounter with psychiatry. It has the potential to be a self-sustaining system; those who benefit are also those who can initiate. Sounds more like a drug pusher, get em in and hooked on your product, then sit back and reap the benefits. I think I like that juxtaposition a little better.<br />It has a certain je ne sais quois, nest-ce pas?<br /><br />Thanks for the last word, by the way - I always wondered who held dominion over that. Now I know.Je Suisnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-39952624115570894532014-01-23T15:00:25.671-05:002014-01-23T15:00:25.671-05:00I think it all probably depends on where you live,...I think it all probably depends on where you live, but I know for certain that there is no access to mental health care for medicaid patients in my town. The nearest place is a 45 minute drive away and can take several hours by bus. There are also no 24 hours buses, and they all shut down in the evening, so you might not get home. I'm not using Medicaid but I see a pdoc who works nights and I have to get a ride back if I want to see him cuz the buses stop running. In fact wealthier folk have actually complained about the fact that there is not mental health care available for the town's mentally ill homeless.<br /><br />It's so interesting to hear Steve Reidbord write, because I have always dreamed of one day moving the San Francisco bay area because of their wonderful public transit. They have trolleys, buses that run all night, the BART (underground subway thingy)...I guess it all depends on how you look at things. I always think of San Francisco as public transportation heaven for California. I live closer to Los Angeles and I've met people who live in LA who didn't even know that LA has a subway. Now there's a major city with some public transportation issues. Still better than where I live, but remarkably worse than SF.<br /><br />What's the saying? SF was built vertically. LA was built horizontally (to accommodate all the cars).Borderlinehttps://www.blogger.com/profile/10583635462258613228noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-23735810906498024372014-01-23T03:56:58.370-05:002014-01-23T03:56:58.370-05:00@P-K: Improving mental health services for the poo...@P-K: Improving mental health services for the poor is an area of common concern for providers and patients/clients. I agree that "wraparound" services enhance access, and also supply basic necessities such as shelter and food, which can take priority over psychiatric care proper.<br /><br />@je suis: If my potential to apply a 72-hour hold, not used in decades, is a fearsome threat, it must be as well for others who can apply one. Here in California these include all sworn peace officers (e.g., police), as well as individual mental health professionals authorized by each county. This <a href="http://www.sccgov.org/sites/mhd/Providers/Documents/2012-5150TRAININGLOG(caamaann2).pdf" rel="nofollow">pdf list</a> for Santa Clara Co. shows the many nurses, clinical social workers, psychologists, and others who are authorized, generally because they work in public settings with severely disturbed clients, and they opted to receive extra training to get the authorization. A patient is far more likely to be involuntarily committed by one of these non-psychiatrists than by me in my office — because "holdable" patients don't generally come to see me, and when they do, I do my utmost to find alternatives to 5150'ing them. Using me to illustrate the fearsome threat of commitment is like using a peace activist to illustrate the inherent warlike nature of human beings. Yes, I <i>could</i> commit someone, but I'm a singularly bad example. That's why I said your concern about forced treatment doesn't apply in this discussion of out-of-network office-based psychiatrists. More precisely, it would apply as well, i.e., as little, to general discussions of psychiatric nursing, social work, clinical psychology, etc.<br /><br />Since we're veering off topic, you can have the last word if you wish.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-79035152252135176132014-01-22T19:24:47.451-05:002014-01-22T19:24:47.451-05:00@Dr. Reidbord
I am sure it must be nice to chat w...@Dr. Reidbord<br /><br />I am sure it must be nice to chat with people of a like mind (or not, I can think of a few issues with that..), but I can't say for certain - if it ever happens, I'll let you know. <br /><br />Btw, I was being generous in saying that your analysis was flawed, as a flaw is (per Merriam-Webster):<br /><br />1) a defect in physical structure or form, or<br /><br />2) an imperfection or weakness and especially one that detracts from the whole or hinders effectiveness.<br /><br />As I tried to point out, there are such fundamental differences in the two objects of your analogy that to call it flawed is disingenuous at best. It's not a "flaw" if they share merely surface similarities (i.e. both are services) but otherwise are nothing alike, it's a failed analogy that falls apart in the face of the irreconcilable differences. <br /><br />My "incessant repetition about involuntary commitment and your right to commit suicide" does indeed apply here, although I don't think you understand why that is. Let me try to explain.<br />Involuntary commitment is the elephant in the room here - basically, the gist is that psychiatry is a business, and can charge what the market will bear. However, that market is ofttimes forced to bear a cost that would otherwise be rejected via the machinations of involuntary commitment. It creates a captive audience, literally. It's like you're playing a game, but the hand you've (the mental health professional) been dealt has a joker in it that acts as a wild card; no matter what the other player (client or patient or whatever you like) holds, he or she cannot win, as your joker always trumps the hand. Always. <br />That joker is involuntary commitment. It creates a kind of fear, a fear that prevents some from even attempting to access mental health care, a fear that causes some to withhold information or downplay symptoms, a fear of the mental health professional themselves. A fear of loss. Unfortunately, especially with some of the new legislation being passed and/or considered, it's a very real and founded fear. This is why the "incessant repetition", to bring to light a very real, and very much flawed (see definition 2) aspect of psychiatry.<br /><br />So, great, you've not committed anyone in a long time - have you ever? You seem to think that the immediacy of the event is what's important, while it's the ability to initiate an involuntary commitment - acted upon or not - that's the real issue. Power restrained is still power, and still a threat. <br /><br />As for the "right" to commit suicide - there does not need to be a right, there simply needs to be the ability to say no. No to interference, should that be the decision you make. As I have mentioned, psychiatric outcomes are vague at best, and depending on ones economic abilities, care may be very much restricted, or else forced to the point of bankruptcy. The poor receive mainly medications, ones that have been getting a lot of attention lately as lacking efficacy, especially over the long haul. Therapy is mainly for the wealthy, what with the high rates psychiatrists charge and that many don't participate with insurance networks (see, well, this post). So, with outcomes in doubt, and access limited, sometimes severely, as well as the distinct losses associated with an involuntary commitment, what is the point in forcing this kind of care on someone who is unwilling? <br />Someone who is already suffering so much that their end is a relief? If you have nothing better to offer, then it is merely sadistic to force someone to endure these hardships on top on those that brought them to the brink in the first place.Je Suisnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-50435746868199983482014-01-22T18:59:46.209-05:002014-01-22T18:59:46.209-05:00Dr. Reidbord, thanks for clarifying. I understand...Dr. Reidbord, thanks for clarifying. I understand what you're saying and I agree, the services of the wealthy and the poor will never be equal. Maybe I'm just biased because services for the poor are particularly absent in my state, we rank near the bottom in spending on mental health, and I think it shows. <br /><br />I suspect things in my state may look a little different than they look in Maryland, for example, I doubt there are as many services available for the poor here, because of our lack of spending on mental health. <br /><br />There is a bright spot, though. I've seen some amazing things happen with services for the homeless in a large city in my state. They combine mental health care with primary care, assistance with food, etc. There's none of this - go to this office to get this form, or that form, etc, it's simply show up. That's more of the approach that's needed with treating the indigent with severe mental illness, at least in the beginning, it just doesn't make sense to require a buttload of obstacles to get people in the door, particularly when many people aren't too keen on seeing a psychiatrist to begin with. <br /><br />Anyway, I think things could be better. But, we have a long way to go.<br /><br />Pseudo-KristenAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-87452992903202789462014-01-22T18:14:55.717-05:002014-01-22T18:14:55.717-05:00@Dinah
No one said that the poorest and most vuln...@Dinah<br /><br />No one said that the poorest and most vulnerable members of society have no access to care - I know I didn't at least - and I am not denigrating the work done in community mental health centers. Far from it. I am saying the same thing you posted, that it's the working (or not working) poor who get screwed. This includes the people on Medicare or Medicaid; you cannot really equate the care allowed under those plans to the resources available to the wealthy (or well-off even), now, can you? Someone able to finance their own care, free of insurance restrictions (or able to finance beyond those restrictions) or Governmental oversight (in the cases of Medicaid/Medicare) is going to receive a greater slice of that health care pie. It only stands to reason, greater resources equals greater opportunities, or better access if you will. There is no secret, no mystery, here - it's basically the same reasoning used to justify charging what seems to be exorbitant prices to many. Those that can afford it, will, and those that cannot, well, in the words of Dr. Reidbord " as long as there is poverty and wealth, the poor will never have the same services the wealthy have".Je Suisnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-11000767679760189942014-01-22T12:25:44.814-05:002014-01-22T12:25:44.814-05:00@Je Suis: I'm glad we agree my analogy was fl...@Je Suis: I'm glad we agree my analogy was flawed. Isn't it nice to chat with people of like mind? <br /><br />You'll be happy to know that your incessant repetition about involuntary commitment and your right to commit suicide doesn't apply here. I can't recall the last time I committed anyone — it must have been 20 years ago. People are free to leave my taxicab anytime and for any reason, including if the meter reads higher than they are able or willing to pay. Moreover, many who come to see me do so to *avoid* electronic databases and recorded medical histories that are out of their control. Nothing leaves my office without my patient's permission. Those of us in private office practices, outside of insurance networks, are the *least* likely to offend you. Makes you feel good, yes?<br /><br />Early in my career, I worked in a Community Mental Health Center for 3 years, not the 20 that Dinah can claim. Both the patients and the providers at CMHCs face limited resources and much added stress. Nonetheless, "real care" does happen there. I wouldn't call it deplorable, but it could certainly be improved if our society made it a higher priority. I have a great deal of respect for my colleagues who work in these challenging settings, and equally for the patients who do the best they can with limited resources. I feel, too, for the poor souls stuck waiting for the Muni bus on a cold foggy night, and I feel grateful I have other options.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-92039379257558560022014-01-22T11:30:03.095-05:002014-01-22T11:30:03.095-05:00" They are the people with 2 weeks vacation, ..." They are the people with 2 weeks vacation, and no time for doctor's appointments, who reserve their resources for their children." I wonder if this a typo? A lot of working poor have zero vacation time and only get time off when they lose their jobs.catlovernoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-30918269303533194182014-01-22T09:07:40.062-05:002014-01-22T09:07:40.062-05:00I'm going to disagree here that the poorest an...I'm going to disagree here that the poorest and most vulnerable members of society have no access to care. I've worked in Community Mental Health Centers for 20 years. Yes, there is some waiting/paperwork to get in the door, but someone does it because many people are treated in these clinics. And the poorest and sickest of people have Medicaid and Medicare -- if they get sick enough, they get hospitalized and the hospital gets them enrolled (so they can get paid, granted, but it happens). It may not be perfect, there may be the P-K's out there who can't negotiate it and would starve before figuring out how to apply for food stamps, but it may be a long cry to a paper-work free America, and even to enroll your in child in free public schools, you have to get them vaccinated, produce paperwork, and register them. You have to get to Dr. Reidbord's bus stop, so to speak.<br /><br />And out-of-network care is not un-reimbursed-- most people get a chunk back; some tell me they get full reimbursement for the sessions.<br /><br />When it comes to medical care of all types, it's the working (or not working) poor who get screwed. They earn too much to qualify for Medicaid, but often have jobs that offer no health insurance. Or substandard insurance with no mental health benefits or no out-of-network benefits. They are the people with 2 weeks vacation, and no time for doctor's appointments, who reserve their resources for their children. No room on the bus and not a taxi in sight.Dinahhttps://www.blogger.com/profile/09227988351623862689noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-18119932134248960802014-01-22T07:10:06.201-05:002014-01-22T07:10:06.201-05:00@Dr Reidbord
Your public transportation analogy r...@Dr Reidbord<br /><br />Your public transportation analogy regarding mental health care is indeed flawed, in a number of ways. off hand these spring to mind:<br /><br />1)The transportation required to get you to your destination is limited in cost and duration, meaning that there is a fixed outcome with a set price - the bus fare or a regulated taxi fee, for a set distance. Not so with mental health care, which can run on indefinitely, with ever-escalating pricing.<br /><br />2) As you stated, you could have chosen not to engage the services of public or private transportation at all. As far as I know, no bus or taxi driver holds the authority to force someone into their vehicle against their will, while mental health providers carry that constant threat with them at all times. <br /><br />3) Once on the bus, or in a cab, you still have the option of leaving by getting off at the next stop - or the next corner - unlike the 'patient' who has been involuntarily committed. The driver is not the authority on when you are free to go; instead, you retain your autonomy.<br /><br />4) An interaction with a bus or taxi driver does not have the potential to strip you of certain constitutionally guaranteed rights based solely on the driver's opinion of 'dangerousness'.<br /><br />5) You are not permanently flagged as problematic in an electronic database, nor do you carry a history of habitual transportation use. You are not subject to the myriad ways in which someone with a mental health history is treated differently by health care and law enforcement personnel here - there is no stigma attached to public transportation use, unlike mental health care services usage. If you doubt this, just look at the mass shootings, or any recent major newsworthy event with a perpetrator; among the first things reported is whether the actor in the incident had a history of mental health issues. There doesn't seem to be much interest in how they arrived at the location of the incident, however. <br /><br />So: force, stigma, loss of freedom, rights, dignity and autonomy, as well as economic hardships, are all absent in your encounters with public transportation (well, with the possible exception of dignity, of course - that is questionable), while remaining a valid concern in encounters with mental health care - really, the analogy is anything but. The parallels are shallow at best.<br /><br />P.S. I found this interesting:<br />"I agree that mental health care is not available for the poor like public transit is" - "My analogy".. "was about providing private services over and above what is available in the public sector"<br /><br />This simply states that the real 'care' is reserved for the wealthy, acknowledging the deplorable state of mental health care for the poor while distancing oneself from it. Simply put, it's a business. Fine, but then let's stop with the enforced business practices, such as involuntary commitments. As a business, it should be completely optional, and you are free to charge as you wish.Je Suisnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-23046746957574469572014-01-20T23:37:38.216-05:002014-01-20T23:37:38.216-05:00To anonymous:
I do not have an insurance ID numbe...To anonymous:<br /><br />I do not have an insurance ID number yet. I signed up through Covered California website, then was emailed instructions by Covered California to not contact the insurance company after signing up, but to wait for a letter of instruction on how to make payment which would be sent by the insurance company. When I had not gotten the letter of instruction by January 6th (the original last day to pay for January, before it was changed to January 15), I called Anthem Blue Cross, and they took my checking account information. I asked for an ID number and they told me I would have to wait for a packet with the ID card in it. Their estimate was 25 day wait. My internist, Dr. John Jones, Oakland, receptionist said that anyone with the Affordable Care Act coverage must go through their business office and have their policy approved before being allowed to make an appointment. I have not tried making other appointments, but assume I would be regarded as uninsured without proof of insurance. Meanwhile, Anthem Blue Cross has sent me a letter confirming that I cancelled my former Individual policy, then they sent a letter which is a certificate of former insurance for my former policy, but they have never sent the instructions on how to make payment on my ACA policy, nor has my packet arrived.Sunny CAhttps://www.blogger.com/profile/11451116932556227816noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-74893744783617848482014-01-20T19:04:04.655-05:002014-01-20T19:04:04.655-05:00I too have held off responding. Dinah has written ...I too have held off responding. Dinah has written an excellent post and I agree with what she says. I would add, though, one point that has not yet been mentioned. In my experience psychiatrists care a great deal about their patients and feel a real commitment to helping them. Psychiatric intervention might be limited to a few sessions per year or sessions that are several times per week. There is great flexibility and this has to do with the goals of the treatment.<br /><br />In my several decades of working with patients there has not been one time when zi stopped working with a patient who wanted to continue treatment because of finances. There was always a way to come to some agreement, whether it meant seeing that patient at vastly reduced rates or decreasing the frequency of the sessions, or both. And I know many psychiatrists who can say the same thing.<br /><br />Psychiatrists who work in a system or for a group that sets policy might not have this flexibility. But i completely believe that no one goes into psychiatry as a profession unless he cares about people. Yes, I am fortunate in the way I practice and in the fact that I have that flexibility, but I know many psychiatrists who can say that their decisions of how to practice were made for reasons of what they thought best for their patients and not for what would reimburse them the most.<br /><br />Dinah herself represents the best in psychiatry: a commitment to understanding and helping people. jessehttps://www.blogger.com/profile/11077223398907532291noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-55728005409481183482014-01-20T18:22:24.656-05:002014-01-20T18:22:24.656-05:00@P-K: I agree that mental health care is not avai...@P-K: I agree that mental health care is not available for the poor like public transit is. This is a political/public problem, with political solutions: hold rallies, sign petitions, vote the bums out, etc. My analogy, admittedly faulty in a number of ways, was about providing private services over and above what is available in the public sector, or even through commercial health plans. Yes, we have to do a much better job providing access to the poor. However, even in a best-case scenario, as long as there is poverty and wealth, the poor will never have the same services the wealthy have. Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-2180308173243928202014-01-20T15:49:58.792-05:002014-01-20T15:49:58.792-05:00I think the analogy is not a good one because ment...I think the analogy is not a good one because mental health care simply is not available for the poor like public transit is. It's not a matter of wanting a better doctor or wanting better care, it's accessing care at all that's the problem.<br /><br />When I was most ill, indigent, etc, I would have been looking at a long waiting list, it would have required going to a particular office to get a form to prove lack of income, etc. Is it common sense to think someone who is that ill is going to be able to handle all that is required to access those services? No. So, they don't go. Likewise, although I qualified, I didn't go sign up for food stamps, I simply didn't eat. Apparently I looked so skeletal at one point, a doctor actually handed me money for food. This is the reality of what happens when people are too disorganized and/or ill to go through all the hoops required to get community services.<br /><br />Public transit requires a bus ticket. That's it. It's not hard to pull it together enough to come up with the means for public transit. It's a lot more reliable.<br /><br />We have to do a much better job providing access to the poor.<br /><br />Pseudo-KristenAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-25914658369252484342014-01-20T12:53:30.512-05:002014-01-20T12:53:30.512-05:00Despite my avid interest in this topic, I've h...Despite my avid interest in this topic, I've held back for a week to read others' comments. Dinah's post is a pretty level-headed account of why most psychiatrists, except those with high-volume, brief med-appointment practices, aren't on insurance panels.<br /><br />In light of the comments here, I thought about my evening last night, when I decided to use public transit to go downtown. San Francisco's "Muni" is mediocre at best, and sure enough my trip was delayed and required an unexpected transfer. It was pretty irritating, but I got to my destination (just) in time anyway. By contrast, a taxi would have cost nearly 10x as much and they aren't always easy to catch. But once in a cab the trip is faster, more personalized, and less uncertain.<br /><br />Not everyone can afford a cab, including some of the people most in need of one. Nonetheless, we don't assume taxi companies are out to gouge anyone, nor that they crassly "put money first" and "squeeze the poor". A cab ride costs more than a bus ride to get to the same place because it costs more to provide, and because the "creature comforts" are superior. Even someone like me who can afford cabs sometimes takes the bus; if they cost the same I never would.<br /><br />The analogy to mental health care isn't perfect. I could have decided not to go downtown at all last night, whereas a patient in crisis may not consider a psychiatric visit optional. And cab rates are regulated and standardized within a city. But to me the comparison illustrates that there is nothing inherently suspect about providing a private service, even one lacking guaranteed outcomes or empirical superiority, as an alternative to more widely accessible and affordable options.<br /><br />The comparison to health insurance is that coverage, public or private, will always be more like bus tokens than cab vouchers. Wealth helps one get downtown quickly, or see the "best doctor in town", even when public transit and health coverage are available — as they certainly should be.Steven Reidbord MDhttp://blog.stevenreidbordmd.comnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-51100145468360596002014-01-20T04:08:13.623-05:002014-01-20T04:08:13.623-05:00SunnyCA, I am perplexed as I saw a a doctor on 1/2...SunnyCA, I am perplexed as I saw a a doctor on 1/2 without an ID card under the ACA even though I had made my payment. Even though I had my ID number, I forgot to look up the group number. No problem as the doctor's staff person looked up everything and all I owed was the co-payment.<br /><br />Sorry you have had so many difficulties. Can you get the card online?<br /><br />My former psychiatrist only took one insurance plan which I didn't have but still charged one of the lowest rates in the area. He also was very accessible after regular hours. So I never felt his motivation was money in spite of complaints that my being on psych meds was useless treatment.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-26666124.post-82062653796298904012014-01-20T01:06:29.995-05:002014-01-20T01:06:29.995-05:00All of my doctors have fees that are higher than t...All of my doctors have fees that are higher than the insurance company reimburses, and the doctors bill me for the balance after the insurance company has decided how much they will pay. I paid my psychiatrist much more than the standard MD co-pay, because he told me that is what he charges in addition to insurance reimbursement.<br /><br />You can charge you patients for the part of the fee that the insurance companies refuse to pay.<br /><br />As far as the mound of paperwork, somebody needs to end the madness. <br /><br />My one doctor who does not take insurance results in my paying 100% of his fee, since my insurance company paid nothing when I submitted the paperwork. Endocrinologist. $350 for 10 minutes. Makes psychiatrists seem a bargain, except I only see the endcrinologist twice a year.<br /><br />As a patient I have a few gripes with insurance myself:<br />I paid roughly $1,500 a month for insurance last year, had more than $10,000 out of pocket medical expenses, but enough of my costs were disallowed by the insurance company so I never reached my deductible.<br /><br />I switched to the Affordable Health Insurance, and my "affordable" payment is $1,148 a month, a cost that increased from the initially posted rate of about $960 a month when I consulted the rate charts October 1 to my December sign up. I have paid my January $1.148, but as of January 19th, I have no ID card, so still can't make a doctor's appointment. My payment is retroactive to January 1, but I effectively have not had insurance this month. They said I can pay full costs out of pocket and they will determine later if they are willing to pay.<br /><br />As a patient who pays what I consider to be pretty hefty insurance payments, I find it annoying to pay full fee to a doctor who does not take insurance. If I could find an endcrinologist I like other than my royally expensive one, I would, but he is the best I have tried, and ultimately my health is worth it. To not take insurance, a doctor must be really good. Doctors who are not excellent will not retain private pay patients because patients can find mediocre doctors in network.Sunny CAhttps://www.blogger.com/profile/11451116932556227816noreply@blogger.comtag:blogger.com,1999:blog-26666124.post-44835400200460808072014-01-19T19:39:32.560-05:002014-01-19T19:39:32.560-05:00I never said physician care is cheap or ethical, b...I never said physician care is cheap or ethical, but more concretely priced with outputs more directly related to patient outcomes. It is no ok for physicians to proceed with non-emergency care without talking through the costs. I always here the "I have the patients best interest at heart when I make decisions without considering the finances" from doctors, but I find that outmoded. Quality care is efficient (most effective with fewest costs) and informed. Doctors should take time time to talk about the potential treatments that could be helpful, and their risks/costs, and work with the patient to decide what is best for them. If a procedure will cost $25,000 and is likely to have the same outcome as a procedure that that will cost $5,000, the doctor should ethically, in consultation with the patient, talk about the price of differences of choices. Nathannoreply@blogger.com