On one of my last days of residency at the University Hospitals Case Western Reserve, my mentor said to me, “You will soar in the practice of dermatology. My concern is that you will be disappointed if you cannot please every patient.” It took a few years in a private practice setting to finally understand what he truly meant by his comment. There were too many obstacles in the current healthcare model to be able to provide the level of care that I felt my patients deserved. It took me a few more years in a hospital-based practice to build the courage to attempt to find a solution.
During my first five years of practice, I was faced with many questions centered around patient care and satisfaction. How is it that we are so removed from the coveted doctor-patient relationship? What obstacles have made it difficult for physicians to provide and patients to receive better quality care? Why does it take months to see a doctor (particularly a dermatologist)? Why is pricing opaque and nontransparent?
When I polled my patients on the most important aspects that define a good encounter with a dermatologist, it became even more obvious to me that an engaged patient and a caring physician share the same goals—better access to quality care at an affordable and transparent price. So if our goals are aligned, why is it so difficult to obtain them?
I quickly realized that the challenge is not in identifying the problems; that was the easy part. The true challenge is in the fact that the current healthcare system has created barriers to developing a solution to these problems. From this moment, I was committed to finding a way to build a practice where there are fewer barriers to providing quality care. I envisioned a practice where patients can see a dermatologist in weeks instead of months, where there is transparency of healthcare costs, where there are no biases in treatment due to the influences from insurance companies, and governmental reglations are held to a minimum as to not distract from time spent where it really counts—with my patient.
At the point in my career where I became the most frustrated and discouraged with the healthcare system, a journal arrived in the mail with a few words on the cover that caught my attention. A dermatologist in Oregon had found a way to build a practice sheltered from the problems that plague our current healthcare system. Ironically, it was not too dissimilar to how traditional healthcare was over 100 years ago. I used this model as inspiration when building my own practice.
Kittridge Dermatology opened in July 2018 as the first direct care dermatology practice in Pittsburgh, Pennsylvania. My practice excludes third-party payers from any control or influence in my office. In my direct care practice, I work to restore the practice of medicine when medical decisions were made between doctor and patients—not dictated by third parties. This type of practice model allows me to spend quality time face-to-face with patients and eliminate needless paperwork, and to have transparent up-front prices for medical and surgical care. Because I have lower overhead costs in this model, I am able to pass these savings on to the patient and provide reasonably priced time-based care. I couldn’t be happier to have the opportunity to present an alternative to healthcare delivery in the South Hills and be given the opportunity to provide the highest quality dermatology care to my community.
While similar direct care practice models exist in primary care, Kittridge Dermatology is not a concierge/subscription service like those arising in family practice settings. Fees are listed on our website and are based on the length of the appointment and the complexity of care. Our fees are lower than you would likely find as a cash pay patient in other practices. Additionally, the average length of time I spend with each patient face-to-face is 30 minutes. This is unheard of in the common dermatology practice. Feedback from patients has been overwhelmingly positive.
I certainly do not claim that the direct care model is the best or only solution to the current state of our healthcare system. I do, however, believe it introduces a great option for a lot of people. The wonderful thing about my practice is that I can see any patient regardless of insurance type or whether a patient is insured at all. Those with high deductibles or no insurance or with the desire to have completely personalized care that is not dictated by a third-party payer are some of the people that my model serves best. For those with great insurance (a rarity these days), it may not be the best choice financially, but we strive to deliver quality. In fact, the convenient and timely appointments that we offer have been so well-received that many patients with generous insurance benefits choose to visit us and pay out-of-pocket. I suppose this highlights how the direct care advantage is priceless!
The concept of insurance has been so ingrained into our minds that we do not think that we can afford healthcare without it. Sometimes we don’t think healthcare is even an option without insurance. Let me be very clear, insurance does not provide healthcare, doctors do!
I do believe that health insurance is beneficial, but in my opinion we have lost sight of the proper place for it. Like car, life, and disability insurance, the role of medical insurance should be reserved for large, expensive, and catastrophic events—not typical day-to-day care. Could you imagine using your car insurance to pay for gas, oil changes, or new tires? The result would be insanely high car insurance costs, lack of price transparency, over-utilization of services, and subsequent insurance control of the care of your vehicle. This is exactly what has transpired in medicine.
When we explain to prospective patients how things work in my practice, some understand and embrace our practice model enthusiastically. Others assume this will be a costly option until we take the time to explain to them why waiting weeks to months to be seen by an in-network physician may not be necessary, even on a tight budget. The best way to explain the direct care model is to provide a hypothetical, but realistic, scenario.
Mr. Basal Cell Mr. Basal Cell has a high deductible insurance plan. He pays $500 per month for his premium and has a $5000 personal deductible. He is 50 years old and has never met his deductible, so he does not anticipate meeting it this year ei ther. He has a health savings account (HSA) into which he deposits pre-taxed funds to use towards his health expenses. Mr. Basal Cell is seen for a full skin exam and has a biopsy done. He also elects to remove three skin tags that are only cosmetically bothersome. The dermatologist discusses skin cancer risks and lifestyle modifications Mr. Basal Cell can make to minimize his risk of skin cancer.
Option A: Mr. Basal Cell schedules an appointment at Kittridge Dermatology and gets an appointment within a week with the doctor. He pays out of pocket or uses his HSA card. His charges for this visit are: Copay: $0 (there are NO copays in my practice!) New patient 40-minute relaxed office visit, including biopsy and skin tag re moval: $260, pathology fee: $70 (*you may also choose to use your insurance for pathology) Total paid to Kittridge Dermatology at appointment: $330 Option B: Mr. Basal Cell schedules with an in-network dermatologist and gets an appointment in four to six weeks with the first available provider. He has NOT met his deductible so the practice requests payment at time of service. Copay: $40 New patient 15-minute office visit: $115 Cash rate for cosmetic treatment of the skin tags: $120 Biopsy charge: $115 Contracted pathology charge (billed by the lab): $170 Total paid to in-network dermatology office at appointment: $390 Grand total (office visit + pathology fee billed by lab): $560 Above paid charges will go towards his $5000 deductible.
Option C: Mr. Basal Cell is seen by an in-network dermatologist. He has met his deductible on his 80/20 plan (i.e., after he has met his deductible, his insurance company pays 80% and he pays 20% of the charges billed to insurance). He does not know what his charges will be until he receives a bill in the mail after his visit. Office visit copay for specialist: $40 Office visit charges for a 15-minute visit for which patient is responsible (20%): $23 Cash rate for cosmetic treatment of skin tags: $120 Biopsy: $23 Patient portion of contracted rate for pathology lab to read biopsy: $34 Total paid at appointment at in-network dermatology office: $206 Grand total (office visit + pathology fee billed by lab): $240
* Charges listed for Kittridge Dermatology are the current actual cash prices. Using insurance, the actual charges to you and the plan may be higher or lower than those in this scenario depending on the contracted rate between your insurance and your physician/lab, as well as your plan details, including copays, co-insurance, and deductibles. See ad for Kittridge Dermatology in the Health and Wellness guide on page 53.
If I could highlight one take-home point it would be that healthcare in the United States is changing at a rapid pace. Physicians and patients will need to adapt in order to preserve the level of high quality healthcare that we desire and deserve. My amazing and dedicated staff and I are ready, are you?