Even as a fledgling physician more than 25 years ago, Dr. Tim Ryan said he never felt truly alone with his clients.
"When I'm in the room with a patient, I could just sense how the patient not paying the doctor directly interfered with a good encounter," he recollected. "The insurance was always this sort of invisible third entity in the room, affecting how you think and how you diagnose things or how you document things. It was just a burden, and really, a barrier between me and the patient."
In 2007, Ryan sat down at a table with a small notepad and started crunching the numbers.
Working part-time as a chief medical officer at Cartersville Medical Center (CMC), he deduced that if he saw a certain number of patients per week — at a certain price point — he could feasibly open up his own private practice.
And he could do so without meddling with insurance companies whatsoever.
"I thought if I could just go back to like the old days and see patients directly and have them pay me directly, it would keep my costs low, keep me honest and keep the relationships strong," he said. "It just seems like a much better system."
For half a decade, Ryan split his time between CMC and his own clinic, The Physician's Practice at 84 Pine Grove Road in Cartersville. He decided to go full time with his own practice about five years ago.
"The first couple of years, we didn't take any money from the business," he said. "We just paid our expenses and saw patients and we just grew it from there."
Today, Ryan sees about 20 to 25 patients a day. He said his business normally has three employees on staff, but right now he's going through a transitional phase.
He currently has one employee — his wife Jonna.
"That's hard for people to understand, but it really is much more simple without the insurance," he said. "I can draw the blood, I can do the tests … a lot of my doctor friends, they ask me 'how do you make money if you don't have insurance?' They can't get their head around it. The income I have to generate, every day, it is so much less than they have to."
Ryan, 51, said his "no insurance policy" does leave money on the table. A similar family physician practice that accepts insurance payments, he said, would likely generate three to four times as much revenue as his practice.
But he said the tradeoff — more flexibility, more freedom and more time to interact with patients instead of filing electronic records and finagling with insurance companies — is well worth it.
"I don't have the huge staff to deal with the insurance companies. If you take insurance, you get your money from the insurance, and that's a hassle," he said. "You've got to have a lot of computers, a lot of phone lines, a lot of referral issues. The confusion factor and the overhead goes way up."
There's no confusion, however, over how much Ryan's patients can expect to pay at his clinic. A standard visit is $75, an EKG is $40 and a hemoglobin test is $25. And if need be, he charges $150 for a home visit.
"If you imagine there's an elderly person that can't get out of bed, to get them to the doctor is just a huge burden — you have to call an ambulance sometimes to haul them to a doctor," he said. "If it's a fit, I'll just go do the house call. I can't do a major procedure, but I can do enough often to help them out."
The insurance-less model also allows Ryan to do things that are inconceivable at other practices, such as occasionally negotiate lower fees for patient services — or even waive them off altogether.
"If they're medically needy and we're sensing they're just stuck, we'll see them, and if we don't charge them, we don't charge them," he said. "We do that a lot, and we don't mind doing it at all for people who need it, but we have to have some way of just tempering that, and it just seems to work out."
Going against the grain
"What any typical family doctor would do in their office, I do that here," Ryan said. "Common chronic medical conditions, diabetes and high blood pressure, thyroid conditions or back pain ... I can do all the labs they would need to have done."
But he said there is a major difference between the way he runs his practice compared to most physicians.
"When a doctor's seeing a patient, in their mind they're just thinking 'what's the code I have to enter in the chart to get this test, this referral?''' he said. "They always have to think in terms of how the insurance companies are going to interpret what they do, so it's always a distraction."
Ryan, who grew up in Corning, New York, and graduated from SUNY Upstate Medical University, has worked in Cartersville since 1995. Before starting The Physician's Practice, he worked with Dr. Carl Bevill's family practice clinic for four years and at CMC's occupational clinic for about seven.
His brother, Tom Ryan, is also a physician and operates Pediatric Medicine of Cartersville.
He didn't pinpoint an exact "breaking point," so to speak, but he said he's long been dissatisfied by the influence insurance providers have on health care services.
"What's happening is that a lot of the clinical decisions that are being made by the doctor and the patient working together, they're not making those decisions," he said. "They're being made by the insurance, which in the end, is sort of a bureaucratic entity of people who know nothing about medicine."
He said one of his biggest complaints about modern health insurance is that, in his eyes, it really isn't insurance anymore.
"Insurance used to be a tool used to pay for the unexpected, expensive and relatively rare problems," he said. "Well, now, it's a health payment system. If you have a cold, you've got to access your insurance to get into the system, and that's part of the problem. It shouldn't be that way."
However, he said he's not 100 percent opposed to health insurance, in theory or practice.
"There are a lot of procedures that really are expensive and you need a whole infrastructure to help them, a hospital with a nursing staff and an O.R. team," he said. "There are people who need those really expensive procedures, and they need insurance."
But that shouldn't be a deterrent to health care providers offering less expensive services, he said.
"All hospitals are like this, the bill is so astronomically high — $80,000, $40,000 for a one-day stay," he said. "People look at it and they're like 'it's ridiculous,' but it doesn't really cost them that much to do."
Instead of relying on coverage providers to foot the bill, he said physicians that do accept insurance could cut costs by employing aspects of the same "direct pay" model he uses.
"I want other doctors to be open to ways they can do things less expensively, because there are ways to do it, as much as it is legal for them to do with their contracts with the insurance companies, to find ways to work with patients to do things that are reasonably priced," he said.
"There is a middle ground to where most people would say 'I would pay several thousand dollars to have my knee fixed.' I would just challenge people to be open to ways to just look at the market price, to look at your patient directly and figure out a way to meet them halfway."
The future of health care?
Ryan said he anticipates the "direct payment" model becoming more commonplace, especially among family physicians and internal medicine practitioners.
"Right now there are no legal barriers, thankfully," he said. "I always kind of worry about that, that at some point there will be a law that's passed that says you can't see a patient unless you do it through the insurance system."
Not that he isn't already dealing with the federal bureaucracy.
"With Medicare, for example, I have to document with the federal government that I 'opted out,'" he said. "I send them an affidavit and they agree to it, telling them I will not bill Medicare for anything I do … that's the only way I'm legally allowed to see a Medicare patient and charge them directly."
He said he doesn't expect legislators in Washington, D.C., to do much to address some of the problems he sees with the health care insurance industry — specifically when it comes to the after-effects of the Affordable Care Act.
"I'm a cynic about the ability of politicians to fix it," he said. "Despite what the Republicans say about dismantling it, I really don't think they want to do it because there are too many forces influencing them, like the hospital industry, the pharmaceutical industry, doctors that benefit from insurance. People on the receiving end of these trillions of dollars of insurance money benefit from it, to some degree."
Ultimately, he said the end result will be a slow slide into socialized medicine.
"They're moving toward a one payer system, and it just can't go on like it is," he said. "It's currently taking 20 percent of our [gross domestic product] anyway — 20 percent of everything we earn is going into health care and if you get more insurance, it's going to get worse."
Ryan said long waits and rationing of care are already happening, even for patients with private insurance. "You call your doctor, they call it universal coverage, but it's not universal access," he said. "If you call and say you need to be seen for high blood pressure, they say 'we'll see you in two to three months.'"
Which begs the question — what type of health insurance plan does the doctor who doesn't accept health insurance have for himself?
As a member of Christian Healthcare Ministries, technically, he doesn't.
"Christian sharing ministries were actually written into the Obama law, where if you're a member of those, you're not going to get penalized for not having insurance, although it's not really insurance," he explained. "Essentially, I agree as a member of that to pay my deductible up to a certain amount ... if it's beyond that, I appeal to the ministry to have the other thousands of people who are sharing cover my bills."