I should be ashamed to say it, but I get a small, very perverse satisfaction out of seeing articles in FPM that capture the essence of the insane asylum in which family physicians practice today. This issue’s cover story, “Should You Charge Your Patients for ‘Free’ Services?” (page 43), provides a glimpse of the insanity that seems particularly clear.

Say you contract with a number of commercial health care plans and accept Medicare assignment. You’ve read the cover story and you are interested in charging patients directly for certain services you don’t currently get paid for. As the first step in deciding what services you might charge for, you set out to identify the ones you would be allowed to charge for because they’re outside the scope of your current contracts. That is, you set out to determine what you’re doing that you’re not already being paid for.

And you can’t.

Why not? First, some of your contracts probably don’t even tell you what CPT codes they cover. And those that do may bundle services into the listed codes in a way that you’d never guess from the CPT manual. Your contracts obligate you to provide services they don’t specify.

Testing the limits

Admit it, now: Isn’t there a certain weird beauty in that thought? It’s catch 22 in a suit. Not that the physicians interviewed for this article have let it stop them. They’re charging for a variety of services including, in some cases, telephone and e-mail consults – and so far, it seems, they’re successful. How dangerous their charges are remains to be seen. These physicians are reaching out through the asylum fence to pick flowers, never quite sure whether the fence is electrified.

In a way, their approach is at least as adventurous as that of the growing number of family physicians who have decided to chuck the whole mess and start cash-only practices. As opposed to cash-only practice, the bulk of their practice remains within the system, providing a reliable source of income. But at the same time, the small portion they aim to bill directly to patients opens them to the risk of contract violations and charges of fraud and abuse.

And just like their cash-only colleagues, they are providing a valuable service to all family physicians, to their patients and to the health care system in general: In testing the boundaries of our moribund system, they’re feeling their way toward what might conceivably be a better system. They’re rebalancing their patients’ incentives, changing the parameters of health care in their little realm.

While they probably do not have any scientific intent in mind, they are in effect undertaking little experiments at the boundaries of the known world – the world we have become accustomed to over the past few decades, anyway. Does charging $5 for telephone prescription refills cut down on phone calls? Does it anger patients or drive them away? Does it violate any contracts? Does it increase income? Does it increase the number of requests made during appointments? Does it increase the number or intensity of appointments? If not, would charging $10 make a difference? Every one of the charges these practices are experimenting with carries a host of questions.

Looking for the future

These practices are almost certainly motivated by nothing more than a desire to find a more reasonable balance between the pain of practicing in today’s system and the income to be derived from it. But to the extent that they succeed, each is defining a semi-independent health care system on a very small scale. And to that extent, each could be a model for the future.

Size isn’t the only limit to this experimentation, though. No physician burdened with the combined restrictions of half a dozen discounted fee-for-service contracts and Medicare can escape what Don Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement, calls “the tyranny of the visit.” As long as visit-based payment is the foundation of your practice, you won’t be able to move that practice far in the direction of payment for non-visit services, including services that prevent visits. And that’s where the future probably lies. Still, no matter whether you’re interested in exploring the boundaries of the asylum yourself, be thankful for every one of your colleagues who is feeling for a way out through the fence.