Welcome to my blog! I thought my first blog post would be an introductory post about me. But recent events (specifically the UHC CEO who was shot and public outrage that Anthem BCBS was going to deny coverage for anesthesia) have led me to turn my focus to insurance and healthcare policy in America. This post will delve into my thoughts as a physician practicing in the US healthcare system, and it will also explain why I left my thriving group practice to open Clarity Eye and Face and why we are out-of-network with insurance providers except for Medicare.

My Background and Path to Medicine

Many may not know that I have a Bachelor of Science in Public Health. I was very lucky to attend the University of North Carolina at Chapel Hill, which has one of the top schools of Public Health in the nation. That gave me the unique opportunity to pursue an undergraduate degree in healthcare and administration. My mother was a nurse and had encouraged my sister and me to go to medical school. However, realizing how difficult it was to get into medical school, I figured pursuing a bachelor’s degree in Public Health would be practical. It would be useful knowledge if I became a physician but also a good alternative if I was unable to attain my goal.

I learned a lot about the healthcare system, like how some state Medicaid programs reimburse LESS than the cost of providing care. But it barely scratched the surface since healthcare is so multi-layered, complex, and ever changing. Needless to say, my years studying health policy didn’t enlighten me on the perfect solution for our healthcare woes. Instead, it started my first foray into understanding how healthcare is delivered in our country and other countries. It also convinced me that for-profit corporations shouldn’t exist in healthcare, as they prioritize profits and shareholders at the cost of providing care.

My Path to Choosing My Specialization

For a long time, I thought I would become an Emergency Medicine doctor and pursue my health policy interests more extensively. I took the LSATs and contemplated going to law school so I could influence health policy in our country. But with time, I discovered that I had talented hands and a knack for surgery. And I started appreciating several fundamental issues:

How complicated our healthcare system is
How every healthcare system has its pros and cons and there is no “perfect system”
How many big businesses are financially invested in the US healthcare system
How these industries have deep pockets with powerful lobbies in Washington watching out for their interests

All this made me feel that changing our healthcare system was nearly futile.

I pivoted. I decided to use my talents where I knew I could make a difference: in the lives of patients. I still read health policy news with casual interest, but I was now dedicated 100% to absorbing the huge mountain of knowledge needed to master my newfound specialty: ophthalmology and, eventually, oculofacial plastic surgery.

Working in a Broken System

For years I studied and took care of patients the best I could in a broken system. I knew that we were long past the “glory days” of medicine, but I didn’t become a doctor for the money, so I didn’t care. I didn’t pay attention to reimbursement. I wasn’t raised with any expensive tastes or habits. I grew up doing road trips for family vacations, sitting in the back of our blue minivan, sweltering without air conditioning, and staying at Motel 6. Money was never my motivation.

I saw the articles about how medical reimbursement has declined 29% since 2001. I reflected on how annual raises are expected for employees in most sectors, but this is not the same for physicians. The trend for declining reimbursements dictates that doctors will earn less with time or have to see more patients to maintain the same income. But I didn’t pay attention and just kept my head down, working hard as I had always been trained to do. After 15 years of training during which I made no income or less than minimum wage, I still felt very blessed and fortunately loved my job.

A Shifting Healthcare Market

The market has been changing a lot in recent years. HCA Healthcare bought Mission Hospital in 2019, representing the first for-profit hospital in Western North Carolina. That brought significant changes to the local medical community. I ended up leaving the emergency call pool at Mission Hospital because I, like many other doctors, felt unsupported to meet the demands of providing high-level trauma care. In addition, I was not willing to sacrifice my time and energy for the financial benefit of investors and shareholders.

In addition to HCA, for-profit medicine has been entering the WNC market in the form of private equity. Private equity companies are investment partnerships in which funds buy companies and manage them before selling them. It is an attractive option for many medical practices as a relief from the high administrative and financial burden of running a practice. However, the model is geared toward reducing overhead and cutting expenses so that businesses can be sold at a profit. While the purchasing power they provide can represent improvements for some practices by updating their technology or negotiating better contracts, their priority is profits and shareholders. That makes me cringe. Unfortunately, private equity is taking over more and more medical practices across the nation, and it is taking a toll on the delivery of healthcare.

The Current Insurance and Healthcare Situation

With steady reductions in reimbursements every year, the past few decades have seen a wave of practices consolidating and selling to hospitals, corporations, or private equity. Not only is reimbursement reducing every year, but staffing costs keep increasing. That constant increase took a sharp turn during the pandemic because of the “great resignation” that heavily affected the healthcare sector. Patient demand was through the roof as many flocked to WNC, given the increase in remote working options.

Simultaneously, many doctors retired or left the market. The wait time to get in to see a doctor got longer and longer despite everyone’s efforts to see more patients and be more efficient. The demand was endless. Patients were often unhappy with the experience and sometimes took it out on staff, which further contributed to staffing turnover. Inevitably, maintaining that breakneck pace is only possible with skilled, experienced staff, and those staff deserved good compensation, especially when high inflation was draining everyone’s wallets.

Enough Was Enough

I was exhausted. It is not possible to be thorough and also get patients in promptly while running on time. I was determined to continue to provide the high standard of care I had been trained to give, but that often led to long days getting home, often past 7 PM. My solution was to talk really fast. That was the only way I could be thorough but also not fall too far behind on my schedule. I also felt the constant pressure to be present for my family, who rarely got to see me. Even when they did, they got the husk of a mother who was completely drained after pouring herself out for strangers all day. Sadly, they had no choice but to accept the dregs of what I had left. I watched my kids grow and develop so quickly and felt that I was on the sidelines, a bystander to her own life.

If you ever go into an eye doctor’s office, you’ll see a lot of equipment. Fancy machines that can do advanced analyses of the eye and vision function. These are really amazing technologies that represent true advancements in vision sciences. They also are very expensive machines to buy, maintain, and operate. I needed none of them, but as an equal partner in my practice, I paid for them and for the staff to operate them. Because of the mountain of expenses needed to operate an eye office, I felt like I was sprinting on a treadmill. If I faltered, I would fall. This pace was burning me out. I could not see any way forward to stay with my former practice without a significant change in the practice structure. Meanwhile, they could not see how to make a change that was fair as the model worked for everyone else.

Opening My Own Practice

And so it happened that in February 2024, I gave notice and took the leap to open a solo oculofacial plastic surgery practice. It was a crash course as I was pushed out of the comfortable nest I had helped build and had to quickly learn to fly. I learned so much in the ensuing months. Previously, I never paid attention to how I was reimbursed. Now, as a fledgling business owner, I had to.

I came to see the truth; in our current healthcare system, our customers are the insurance companies, not the patients. Insurance companies dictate how we practice. Don’t get me wrong. Doctors fight every day to care for their patients. They jump through whatever arbitrary hoops insurances require to get care covered; they appeal denials and do peer-to-peer reviews. But insurance companies set the rules, and doctors who don’t play by the rules get cut from their networks.

Insurance as a Barrier to Receiving Healthcare

I started to realize I had been working for the biggest for-profit player in the healthcare space all along: insurance companies. My sacrifices and dedication to my craft were benefiting CEOs and shareholders. The outsize compensation enjoyed by insurance company CEOs is grotesque, and the profits these companies rake in are staggering. Insurance premiums keep increasing despite the fact that insurance companies are covering less and less. Insurance companies are expanding tactics like deductibles, co-payments, co-insurance, in-network vs out-of-network out-of-pocket maximums, requiring prior authorizations, or just outright denying necessary care using arbitrary algorithms sometimes helped by AI. And they count on these denials not being appealed by patients by making the process extraordinarily onerous.

Additional Insurance Hurdles

These are just the publicly known issues with health insurance. Physicians in all specialties regularly deal with insurance companies getting in the way of them providing the care that they want, including:

Reducing the scope of services they cover
Step therapy, which requires patients try and fail cheaper drugs before covering a more effective medication (in the meantime delaying care and necessitating more patient visits to the doctor)
Denying services that were already pre-authorized
Requiring patients to come back for another visit when a same-day procedure could be offered for the patient’s convenience

All these arbitrary rules feel designed to reduce claim payouts and bring in even more revenue for their C-suite and shareholders.

A Tangled Mess…

To make it even more complicated, each insurance company makes its own rules about how they want things coded, and those rules are changing all the time. It is not uncommon to not know about a change until a claim is denied. And if you are in-network with an insurance, you are under contract and thus bound to follow their rules. You need to hire staff to stay on top of those rules, spend hours on the phone doing prior authorizations, and chase down denials. The infrastructure to provide care is costing patients and taxpayers billions of dollars.

Not only do insurance companies siphon off money that could be used for patient care to benefit investors. But also, the never-ending hoops they create for hospitals and doctors to jump through requires expanding administrative staff, which further reduces how much money goes into direct patient care. It is no wonder that the United States spends more on healthcare than any other country. Big businesses are taking their pound of flesh off the backs of doctors, nurses, and other allied health professionals.

…With Shady Practices

On top of all this, insurance companies often own pharmacy benefit management companies that negotiate discounts on pharmaceutical drugs but don’t pass along the savings to patients, force practices to accept payments in the form of virtual credit cards (taking another 2-3% shave off the reimbursement through mandatory transaction fees) and have been caught upcoding patient diagnoses to make their patient pool appear sicker, thus getting a higher share of taxpayer money. It is no wonder that doctors often call them Medicare DIS-Advantage plans.

Unfortunately, for-profit insurance companies benefiting financially from the Medicare Advantage market means less taxpayer money to fund Medicare, and healthcare providers are looking at another almost 3% reduction in reimbursement in 2025 while patient deductibles and premiums are increasing 7% and 6%, respectively. Since commercial insurances commonly base their rate on Medicare rates, when Medicare reimbursement goes down so does reimbursement across all insurances.

A Shrinking Workforce

Healthcare workers, including doctors, are leaving clinical medicine in droves due to burnout. Some are choosing early retirement. Some are opening non-healthcare-related businesses. Some are going into non-clinical fields like medical research or pharmaceuticals or even working for insurance companies. Once someone leaves clinical medicine, it is very difficult to bring them back. Not only because of licensing and credentialing barriers but also because staying in clinical medicine requires an endless pace of constant learning so as not to fall behind. The brain drain we are experiencing will take decades to replenish.

Fortunately, some doctors are choosing to stay in clinical medicine on their own terms by opening direct primary/specialty care practices or concierge practices, cutting out insurance companies, and once again making patients their customers instead of insurance companies. By reducing the overhead needed to have an insurance-based practice, they can once again focus on patients, have a smaller patient panel, longer face-to-face time with patients, greater availability, and greater price transparency. I know many of my colleagues who have gone this route hope for reimbursement to change and be more feasible to accept insurances in the future. But in the meantime, they are staying in the game and taking care of patients in the way they can.

A More Humane Approach to Healthcare

I never intended to not take insurance. Due to how quickly I had to launch my practice, I was forced to learn out-of-network billing because it was not possible to be credentialed and in-network with insurance companies in that short a period of time. As I learned more, I began seeing it as a viable way to have a more sane and humane medical practice. Given my ability to offer cosmetic plastic surgery, having a purely cosmetic practice would be far more lucrative. However, my unique skill set and training provide an invaluable service to the community, and making a difference in someone’s life is truly priceless.

So far, staying out-of-network has made a huge difference in the patient experience. I had a patient who saw me at my prior high-volume practice but ended up having surgery with me at Clarity Eye and Face. She told me very frankly that she didn’t really like me when she had met me at my former practice. If I hadn’t had such a good reputation in the community, she wouldn’t have chosen me as her surgeon. Now, at Clarity Eye and Face, she commented I was a totally different doctor. I was more relaxed and personable. Other long-time patients have commented on how I seem much less stressed, and they are so happy with me and for me. For the first time in a long time, I am truly having fun again. I enjoy connecting with my patients, and I have the energy to be present for my children.

The First Step of Many

Obviously, I don’t know what the future will bring. So far I’m not hopeful for significant improvement in the insurance and healthcare system in the US in the near future. But I feel blessed that I have this option when many of my colleagues do not. It is as much for my fellow healthcare workers as it is for myself that I stay out-of-network to tell insurance companies this is not OK. But at least I’m still staying in the game.

Insurance and Healthcare Policy in the US