When Health Insurance Gets in the Way of Good Medicine

Why slowing down, paying cash, and building a real doctor-patient relationship often works better.

Most Americans get health insurance coverage through their employer. The rest purchase their own commercial health insurance or get coverage through Medicaid and/or Medicare.

Here are the important things that I don’t think are covered through traditional health insurance. Cash-pay or direct-pay options seem to be the most affordable alternatives if these are important to you.

Welcome to the Healthy Aging Newsletter, a free publication translating trustworthy medical research into simple habits to age well, free of chronic disease. I’m Dr. Ashori, a family medicine doctor turned health coach.

1. Time to dive deeper

Sometimes I need more time with my patient to have deeper conversations and investigate more. Sure, I could just refer them to a specialist but that has its own risks.

Insurance is a volume game for most clinics but sometimes it needs to be slowed down.

2. Access between visits

Emailing your doctor just to get a message back from a medical assistant 3 days later is rather dissatisfactory.

Some of my patients need a closer watch. I want to text or call them anytime and vice versa. This is what solidifies a good treatment plan.

The conversations we have between appointments are some of the most pithy exchanges, turning episodic care into true continuity of care.

3. Care coordination

If I refer my patient to ortho and they come back with a surgery clearance request, I need to find out if the surgery is really necessary.

Having time to review the note and the visit with my patient and then calling the surgeon myself to clarify things is a must in my practice.

In the traditional insurance model, the word of the specialist will trump the care of the primary care doctor. Often, there isn’t enough time to tease out what really should be done next.

4. Personalized prevention

In clinical medicine we have ‘population-level care’ and ‘individualized care’. The former is of little value because it offers the least amount of health benefits.

A personalized prevention plan focuses on the person sitting across from me. To do this effectively I need to have lots of conversations with this person and collect a lot of data.

Age-based screenings like mammography and colonoscopy are no longer enough.

5. Lifestyle = medical care

In mainstream medicine lifestyle is something you have to figure out on your own. It’s not that your doctor doesn’t know how to address it, but they aren’t paid to do it.

Lifestyle interventions are among the safest medical options we have. I don’t see the value in prioritizing prescriptions and surgery when lifestyle can help.

6. Thoughtful medication decisions

Starting a prescription medication too early could lead to side effects and erode the trust my patient has.

Sometimes it’s better to wait and monitor and properly assess someone’s risk before starting a medication.

If meds are needed, it should be started at the lowest dose with close monitoring. That’s the only way it’ll stick.

Patients want to know how to afford their drugs if they lose their insurance or change states.

7. Clear explanations without rushing

A 10-minute visit doesn’t allow enough time for a plain-language conversation and interpretation of labs and imaging studies.

People need time to formulate their questions. Once they leave the doctor’s office, they’ll have many more questions.

8. Follow-ups

People fail their health strategy because they didn’t get a chance to experiment and ask their questions.

I can offer accountability only when I can help my patient ask their follow-up questions and help them get rid of pressure and guilt.

In the health insurance world, doctors aren’t offered enough appointments per patient to bring them back as often as necessary.

9. Care not driven by billing structure

A patient-doctor visit can’t be a commodity because health doesn’t respond well to profits.

False incentives are those that prioritize more profits and ignore the individual human being represented by a train of numbers on their health ID card.

10. A long-term relationship with primary care

The health insurance model doesn’t care about maintaining your continuity with your primary care doctor. That’s because the average patient keeps their health insurance for less than 2 years.

But we know that fragmented care leads to worse health outcomes that’s more expensive.

A good primary care doctor can help a patient navigate the healthcare system and avoid costly interventions.

11. Denial of appropriate care

It’s happening more frequently where patients are denied care that their doctor approves.

The doctor is on board, so is the patient, but the insurance company says no.

This is why it’s valuable to have a good understanding of the US healthcare system. If your care is denied through your health insurance, you can still pay for it out-of-pocket.

Health Insurance Isn’t Bad

Health insurance is a financial product, often confused for health or healthcare. It is meant to mitigate against a major financial catastrophe.

If it’s used for day-to-day health decisions then the outcome is unnecessary treatment, more harm, and a rapid rise in the cost of healthcare delivery.

Some situations call for your insurance card. Others call for the phonebook.

20 Million Americans Agree

Somewhere around 20 million Americans get their medical care through a direct primary care (DPC) doctor. They pay a monthly premium to be part of that medical practice.

Their meds, labs, and imaging studies are either paid for out of pocket or through their insurance. Usually it’s much cheaper to pay cash.

Disclaimer:

Dr. Mohammad Ashori is a U.S.-trained family medicine physician turned health coach. The content shared here is for education and general guidance only. It is not personal medical advice, diagnosis, or treatment, and it does not create a doctor–patient relationship. Humans are complicated and context matters. Always talk with your own healthcare team before making medical decisions, changing medications, or ignoring symptoms. This information is to help you add more depth to those conversations.