Claudio Smuclovisky, M.D., has an ambitious vision. He wants to return to a world without managed care.
The Fort Lauderdale, Fla., radiologist believes managed care has severely damaged the patient-doctor relationship. He wants a world in which uninsured working people have access to medical care and can choose their doctors freely. He wants to encourage more rational consumption of healthcare resources by making people assume more responsibility for the source and cost of their medical care.
In an effort to make this vision a reality, Smuclovisky decided in 1995 to form a provider network that would sidestep managed care and serve uninsured workers at steeply discounted rates.
Today, that organization, Fort Lauderdale, Fla-based North American Care, has more than 500 participating physicians and 8,000 members, most from South Florida. Members pay a $15 monthly fee, which entitles them to discounted fee-for-service rates from any physician in the network. For a $20 monthly payment, they also can receive discounted dental, vision and other supplementary healthcare services. Members typically save about 60% of what the same care would cost if they had to pay on their own.
NAC helps doctors as well as the uninsured, Smuclovisky says. "Managed care has failed for many people, both on the patient and provider sides," he says. "Our reimbursement is generally better than managed care, without all the administrative hassle. Doctors don't have to spend time or staff resources negotiating with managed-care organizations, and they don't have to compromise their professional autonomy."
What's more, Smuclovisky says, NAC pays doctors within 30 days, which is substantially faster than the 90 to 120 days typical of many HMOs. And the discounts are not as steep as many managed-care companies demand. NAC members currently comprise a small percentage of most affiliated physicians' patient populations, but Smuclovisky hopes to eventually increase that amount to about 50%.
In April, NAC planted the seeds of a national expansion by offering chiropractic, dental, hearing, pharmacy and vision services through more than 75,000 providers nationwide. As of late June, however, it had not drawn any subscribers outside of Florida. In addition, Smuclovisky says NAC is negotiating to contract with an organization that would add 295,000 physicians and 5,000 medical facilities to its roster. Due to the ongoing negotiations, he declined to name the organization.
Any doctor who agrees to NAC's fee schedule and regulations and provides proper credentials can participate.
Smuclovisky declined to disclose the financial performance of NAC, which is a privately held company. Because it does not offer insurance and is not at risk for the cost of care, NAC is not regulated by state or federal healthcare agencies. It works primarily as an administrative and marketing agency, retaining 10% of total billings.
The physician leaders of NAC consider themselves patient -- rather than physician -- advocates. Many doctors are eager to work with NAC not only because it saves them managed-care hassles and pays a fair fee, but also because it expands their patient base to include those without health insurance, Smuclovisky says.
"(NAC) is really good for patients with no coverage, because they receive good care," says network provider Neri Franzon, M.D., a family practitioner in Fort Lauderdale. "Doctors are able to help these people without losing money."
Michael Dolchin, M.D., another Fort Lauderdale family practitioner, says he expects NAC's way of doing business to catch on nationally. "I treat many recent arrivals from abroad who have no health insurance," he says. "This is a good system, because it allows us to treat the uninsured at a reasonable cost and receive prompt payment."
After joining the network, members receive a list of participating physicians and a description of their specialties and backgrounds. They also are given a telephone pager number to call in the event of a medical emergency.
When a patient has a medical problem, the treating physician estimates the total cost of services -- including all physician visits and any necessary treatment or testing -- based on NAC's discounted rates. Under NAC rules, physicians cannot bill for costs beyond the initial estimate. Except in the case of emergencies, patients pay to NAC the full estimated amount two days prior to the service. NAC then takes its cut from that amount and reimburses the physician with the remainder within 30 days.
Smuclovisky says the majority of the time, patients are able to pay their bills in full. When they are not, most doctors in the network are willing to work out a payment plan.
Marketing is done by word of mouth, a small amount of advertising on the Internet and mailings to people identified as uninsured who live in areas the network wants to serve.
To help people handle catastrophic incidents, NAC recently signed an agreement with Tarpon Springs, Fla.-based insurance brokerage Healthcare National Marketing to develop a high-deductible PPO. The new PPO is called Health Pro.
"Most medical costs are less than $5,000," says Tom Lane, president of Healthcare National. "With our program, a family might select a deductible of $5,000, pay an annual premium of $150 for four people and receive $3 million in medical coverage. We also have higher premium and lower deductible arrangements available."
Lane says organizations like NAC are needed because so many employers don't provide health insurance. "About 45 million U.S. citizens are uninsured," he says. "They may be working two jobs, but for employers that don't want to provide coverage."
Eventually, Smuclovisky would like to create a not-for-profit foundation to help people who cannot afford insurance. NAC would commit 5% to 10% of its profits to the foundation.
The network is one of few existing entities attempting to link the working poor with physicians willing to discount their rates. Another is Simple Care, which makes available on the Internet a national listing of such doctors. The list was compiled by a Renton, Wash.-based physician.
Smuclovisky believes the idea of discount networks will catch on with a public that is angry and frustrated with managed-care controls. This kind of service empowers people by allowing them to play an active role in their own healthcare, he says.
David Volz is a Plantation, Fla.-based freelance writer and a frequent contributor to Modern Physician.