Primary health care is changing in Southern California: a number of physicians (but we don't know how many) are cancelling their network contracts with health plans.  The reason? Too much paperwork. Gynecologist Felice Girsh submitted a $110 claim to a health plan that would not process the claim until she sent in 5-years worth of patient records.

Some patients are okay with the change: one paid cash, submitted a claim to her health plan, and then received partial reimbursement soon after.  Another was very anxious: her deductible for using an out-of-network provider was too high to allow her to stay with Dr. Girsh, so she switched doctors.

So, far there are no reports of catastrophe among Dr. Girsh's patients.  The oddest comment in the article was from Dr. Girsh herself, who expects to earn less money.  I would not be so sure: Yes, she'll lose some patients, but her office administrative costs will plummet.  I'll bet if the Orange County Register checks in with her in another couple of years, she'll be wondering why she waited so long!

This change is kind of "back to the future" for doctors, who only earn about 10 percent of their incomes today from patients directly.  In 1950 it was over 80 percent and still about 40 percent as late as 1980.

How will this change play out?  One anxiety I have is that health plans who offer consumer-directed health plans with high deductibles have no idea what's going on out here.  I expect that a significant number of beneficiaries know that they are highly unlikely to meet their deductibles in a year, so doctors cash and don't bother submitting a claim.  They just keep the receipts in a shoebox in case they hit their deductible, at which point they ship it off to the health plan as one "omnibus" claim.  Obviously, a few kinks have to be worked out before the massive bureaucratic costs of U.S. health care get worked out!

There is also the question of how an "opted out" primary care provider co-ordinates with other specialists and allied health professionals in a Patient Centered Primary Care Collaborative, which is a model that a large group of medical societies, insurers, and employers are developing.

People ask me what consumer-directed health care will look like, but I have more questions than answers myself at this point.  But that's the way free choice works.  After all if I knew what it was going to look like, I wouldn't advocate consumer-directed health care, would I? It would be Graham-directed healthcare, with me in charge.....or Hillary.....or Obama.....