In the US private health insurance has become the standard that most didn’t want.
I posted about this recently on Linkedin, discussing the purpose of cash-based care in our US healthcare system. In Europe, private health insurance helps bridge access in their nationalized healthcare system.
Supplemental Health Insurance
Growing up, I’ve lived in Germany, Italy, Spain, and Iran. All of these countries have healthcare systems citizens are generally proud of. Regardless, at least 25% of the population purchases private health insurance to be seen sooner, get elective surgeries, and get tests done that aren’t covered.
Is this supplemental care necessary? Usually not but neither is a car – you could just take the bus to most places. That would be quite an inconvenience for many.
In the US we have a nationalized healthcare system in the form of Medicaid and Medicare. Medicare beneficiaries can purchase a supplemental plan through a commercial insurance company to get broader care.
“…until AI performs your prostate exams, expect someone to get off on fingering your bum” -Dr. Mo
Cash-Based Care as a Supplement
In my own cash-based Direct Primary Care practice, most of my patients use me not for basic care but to be seen sooner, have tests done that aren’t covered, and to have deeper discussions about health related topics.
On average, people stay with me for under 2 years. Once they get the tests done and have talked about dietary options ad nauseum, they are ready to move on, perhaps realizing that it’s not the knowledge that’s the limiting factor but motivation to change lifestyles.
There are various degrees of cash-based care in the US, from DPC or other Direct Specialty Care services, often in the $100 – $200 a month range, all the way to concierge care, well into the $150K a year range.
“My Doctor Sucks”
There are lots of Reddit, Quora, IG, and FB posts along this line. My doctor doesn’t care, they gaslit me, they don’t listen, they won’t work up my condition, I know I’m walking around with full mets all over my body … why won’t anyone listen to me.
Doctors are human, we have as many charlatans, incomepents, stars, liars, cheats, sociopaths, and saints as the average population – maybe in slightly different ratios but until AI performs your prostate exams, expect someone to get off on fingering your bum.
If the doctor sucks, it doesn’t mean that healthcare sucks or that medications sucks. But if you feel that your entire health trajectory would change if you just had that one echo that everyone denies you, have at it, go to a cash-based doc and have it prescribed or done in their office.
The Mainstream American Patient
Health literacy is on a rapid decline not because of lack of education but due to biased media reporting, aka, marketing.
- “More meat is better”
- “You need more protein”
- “Seed oils will kill you”
- “Vaccines cause autism”
- “Doctors make money prescribing you pills” … well, okay, the last one isn’t too far off but not fully accurate.
The mainstream patient has drank the Kool-Aid and is living their life peacefully, waiting for their next primary care appointment where they’ll have their “preventative visit.” This preventative visit is 7-10 minutes long and screens for disease: anemia, diabetes, hypertension, hyperlipidemia, and hypothyroidism – and, now back by popular demand, obesity.
Meds are prescribed, blood tests ordered, and the patient is silently gritting their teeth, angry that they are only getting sicker, collecting more Rx bottles, waiting for the right time to sue, file a medical board complaint, or write that eloquent, ChatGPT-edited online scathing review.
This isn’t wrong and it’s not misguided but it’s not how all consumers of healthcare in the US view health and wellness. Next, let’s talk about the other 10-15% of the population.
The Modern Patient
The modern patient is modern because they don’t believe that the old ways of healthcare are that effective. They likely have taken active steps towards better health and realized they got 10X more from a gym membership or walk shoes than their parents got from a lifetime of doctor and hospital visits.
This person knows that acute care is critical and should they get pancaked by a truck, catch an early cancer, develop a major autoimmune disease, or have a serious infection, the true magic of US healthcare will pop out of the hat for them.
But they also realize that some for-profit entity decided that anyone with an LDL-C of >100 should be on meds and at 99, it’s fine, they can wait.
Bullshit!
They realize that their doctor is forced to practice defensive medicine and ain’t no mainstream doctor gonna call you out on the extra 98 lbs you carry because they don’t want a bad online review.
Instead, the modern patient wants a more collegiate relationship with their doctor:
I’ll tell you what’s up with me, you tell me what’s bullshit and what works in medicine, and I’ll try my best to do what I can to improve my overall health, and if necessary, you can help me with a medication or surgery – if all else fails! I am not here to sue you, I’m not here to pick a fight with you, and I won’t tell you that I only eat lean turkey breast and boiled broccoli every day! Deal?
Cash-Based Resources
As a cash-based doctor I’m the master curator for cash-based resources. Need a knee surgery, I know where to send you to have the best possible outcome at the best possible prices.
Need an MRI? I know where to send you and you won’t get a shit read by a shit radiologist.
And you know what I do best as a cash-based doctor? I help you not do something that you didn’t need to do in the first place. I get it, Dr. Attia says that if you just got that one special type of PSA test or that low-dose CT of the lungs, you’d catch that cancer sooner and live forever, running some centennial marathon. He might be 100% right, or he might be full of feculent shit – who knows, we don’t have the right data – or, actually, he does – I don’t.
My Guide to Using Cash-Based Care
- Find the one PCP who you respect and communicate well with
- Make sure this PCP has time for you and plans on sticking around
- Your doctor should be passionate about the practice of medicine and take their art seriously
- They should be extremely resourceful
- If you have a specialty-focused chronic disease, go hire that doc cash as well (Direct Specialty Care or such)
- Don’t expect concierge care from your cash-based doctor unless you hired a concierge doctor
- See your doctor regularly, focusing on actual prevention
- Invest into your long-term patient-doctor relationship because one day you’ll have to withdraw from that bank
- When you have a medical emergency, use your insurance-based care and go to the ER
- Your doctor is not a magician but they can guide you on achieving your ideal definition of health
- Define your idea of health, or else someone else will do it for you
- Be patient, the first few visits will be rough – for both you and your doc
- A lawsuit will make your lawyer rich but won’t bring back your health – better communication is better than suing
- Your needs are very different than someone else’s, make sure your doctor treats you as the individual that you are
- When in doubt, see your doctor
- Make sure your financial agreement with your doctor doesn’t incentivise them to do more to you but more for you