More On Retainer Medicine
Wanted to address a few other issues:
Shadowfax comments that perhaps the retainer medicine trend will be a driver of change, saying that in order for change to happen to health care payments and financing, “physicians need to take the hard and painful step of saying, “No, I won’t see you,” to Medicare patients. And that is basically what concierge care is.”
I don’t think this approach that Shadowfax mentions is the right one. There’s a reason that every year, doctors are chosen by Americans as the most trusted profession. Despite some may think of us, they know we work our asses off to care for them. We dedicate our lives to the task. We embody the definition of the true professional: the person that puts the needs of his or her patient ahead of his or her own. We lose that trust from our patients–that we have their interests ahead of our own–and we risk losing much more than just money. (And ignoring economic theory of medical school being an investment in later higher salaries, when you look at it from the average American’s perspective, making $38,000 a year, doctors complaining about only making $150,000 a year will look pretty ridiculous to most of the US.)
I also fail to understand why physicians would be willing to “protest” by joining retainer/concierge practices yet still work within the current health care non-system than “protest” for reforming the entire health care system. Not to go all single-payer on you, but those hundreds of billions of dollars (we can argue if it’s $300B or $100B later) wasted on administrative duplication and entire billing departments in hospitals and clinics sure seem like a great pot of money that we could pay primary care physicians with. Call me crazy. Many do.
And as I’d mentioned before, Josh has been writing a lot about concierge medicine at KevinMD. One post shows a sample practice with a huge reduction in hospital admissions for concierge care-managed patients. That’s great! Fantastic! Awesome! Amazing! I have no doubt that it’s true. If you can spend more time with your patients and watch them closer, you can keep them out of the hospital. Which is good for the patients and great for our health care system. But why should we only provide this to the rich patients (yes, the overwhelming majority of these concierge patients are wealthy) that can afford it? Why not fix our whole health care system so that the diabetic gets a 45 minute visit instead of a 15 minute one?
We embody the definition of the true professional: the person that puts the needs of his or her patient ahead of his or her own.
You will likely learn in residency that this is not a sustainable model for any career or profession. In residency, you work so much that you are unable to care properly for yourself, and it definitely impacts your ability to care for your patients. Once you get out, you learn that if you don’t take care of yourself, you won’t be able to stay in this game over the long haul.
Similarly with economics. If you see patients for free, or for reimbursement below costs, you won’t make enough money to stay in business, or you will have to work so hard to stay in business that you will burn out. Scale that up over all of primary care, and the result is simply that medical students, en masse, decline to pursue primary care careers.
The solution is to restructure the compensation rules. Note that I am not saying that we need to throw a greater fraction of GDP into physician compensation. We need to shift some of the excess dollars from specialists towards PCPs. This is unlikely to happen given that the RVRBS is so weighted towards specialists, and the specialists control the RUC (as RCentor and I blogged on earlier this month). I suppose this is a problem that could be solved by throwing money at it, which would be easier but less efficient.
When the rules of the game are so rigged that it has become a no-win system (for PCPs and patients, as access to care diminishes), the only solution sometimes is to allow the crisis to develop such that systematic change is obligated. Primary Care is teetering on the edge of such a crisis, and concierge practices are one symptom of that; others include the dearth of new PCPs to replace those leaving the field, the huge fraction of practices that no longer accept new Medicare patients, the complete inability of Medicaid patients to find PCPs, etc etc etc.
So again, I don’t like it — who does? — but this is how sweeping changes happen. They arise out of crisis, not out of a stable, well-functioning system.
I totally agree that often great change happens in crisis, not in stability, Shadowfax, I just worry about the human costs during said crisis.
Concierge medicine is not prohibitively expensive for most people except that there is a mindset that medical care should be free and therefore spending priorities are skewed towards other things. There is a concierge practice in my town that charges a 600 dollar retainer and then a sliding fee depending on the length of an appointment with a typcial half-hour costing 150 bucks. Even if you are in the middle class you could afford this kind of arrangement but only if you valued a physician’s time which most people clearly do not.
Putting the patient’s interests over your own sounds fine in theory but in reality, while your patients will definitely respect you this does not translate into them placing any value on your time or your services. Their interests are to have you give them an unlimited amount of your time for the price of a McDonald’s Value meal and, as they don’t understand the economics of your business, they will be resentful when you have to move them through like cattle to make ends meet on the reimbursements offered by the insurance company or the gubbmint’.
Naturally it is in the interests of yer’ buddies in the quasi-socialistic, “We-Swear-the-Government-Isn’t-Going-To-Be-Involved” single-payer movement to foment class envy by justifying cutting your salary because most Americans only make 40,000 bucks a year and you should therefore be happy with whatever the government allows you. But that’s just an emotional problem. People willing to pay for concierge medicine value your service and look for more and more doctors to go to this model especially if the we go to a single-payer system.
“…a sample practice with a huge reduction in hospital admissions for concierge care-managed patients…”
Maybe this is because concierge care-managed patients also tend to be healthier, on average (in addition to being wealthier) than other patients?
That’s the one part of this equation that I don’t see being addressed. Yes, most patients can afford a $150 office visit 4x/year (just to pull some numbers from Panda’s comment above). But what about a hospitalization? What about surgery? What if the patient has an accident and needs emergency care? What about screening tests? What about medications?? These are the reasons American health care is so costly, not because everyone wants to see their PCP once a year.
Again, to use Panda’s numbers, what’s that average American who makes $40,000/year going to say when you tell him/her that your concierge practice doesn’t cover the cost of the rotator cuff surgery from his/her fall last month, or his/her Lipitor or Synthroid for 2008???
Synthroid is incredibly cheap, you know. And so are generic statin drugs. Most people need to pay for thier own primary care but have insurance for major medical problems.
Most patients who sign up with retainer practices have insurance to cover medications and hospital stays, etc., the point of the retainer is to free up the PCP from having to bill insurance. The retainer provides increased access and personalized care. I believe a family physician in my community who has this practice charges something like $110 per month per person. I’m with Panda–this is definitely within reach of many middle class people; don’t you know folks who have a daily latte?
I wholly support doctors who choose to open retainer practices; I’ve talked to a few, and they did it to be able to continue to practice medicine. The crisis is already here, and about to get worse if the government cuts Medicare payments by 10%. Specialists will find ways to increase their procedure rates and maintain their incomes, and PCPs will completely stop taking new Medicare patients, and may stop seeing them entirely, because they can’t see any MORE of these patients than they already do, and survive.
We individual physicians can’t fix the system; all we can do is take good care of our patients, and ourselves. Docs are leaving primary care in droves, and very few young ones are choosing it. How much worse can the state of primary care get? If the only way to get some new grads into primary care is for them to open retainer practices, I’m all for it. Hopefully Shadowfax is right, that this might, eventually, lead to some meaningful healthcare financing reform.
[...] medicine…..then somehow we are morally commiting a sin againt our fellow man (No offense Graham I just don’t buy it). Soon P4P will force us to convert to emrs and spend at least some of [...]
With regards to your last post: “One ethical framework would suggest if all physicians just practiced retainer medicine, there would not be nearly enough physicians to go around. In that framework, retainer medicine would be viewed as unethical.”
This is a rather ridiculous assertion. You do realize that, according to this logic, being part time is unethical? Somehow I doubt your liberal idealism is quite ready to condemn the increasing number of female physicians who want to work part time and raise children.
Of course I do, Robert, but it’s not ridiculous at all. It’s merely playing the devil’s advocate and making people consider the opposite side of the argument. Read any primer on ethics, and you’ll see it’s one of the standard frameworks used.
I can see why PCPs are so frustrated. Part of the problem may arise from the nature of their practice. Their main function is to preserve status quo; thus, after quarterly visits for many years, successful patients do not detect any change in their health (and these are the lucky ones, given the second law of thermodynamics). PCPs are like risk managers (somewhat like insurance underwriters) whose main job is to prevent a disease.And most of the time PCP do it by causing patient discomfort and expense while the patients are relatively asymptomatic(medication expenditures and side effects, and health maintenance lecturing). Most specailists, on the other hand, address specific problems with titratable endpoints which the patients can evaluate and even appreciate. Thus, they judge the specialist to be effective in his/her mission; therefore, society at large is willing to pay more for the specialist services. If patients were given their elective health care dollars to control, they would much rather see a specialist for their specific problem, rather than have their care choreographed by a PCP. For example, given limited funds and a choice to make, most patients would rather have their vision checked and glasses changed in a particular month, rather than go for a quarterly PCP visit to have HbA1c checked yet again and be lectured to. Also, allowing patients to control their own elective health care funds (obviously with a limit) would increase their level of responsible health behavior as well. And who knows, we may not need as many PCPs with MD degrees, but instead lower level clinicians with abundant access to medical informatics by them, as well as the patients.
I was a structural engineer for many years, a job that is perhaps more important to society than medicine because while most people never need a heart cath, everybody drives over bridges and works in buildings. Why not forbid engineers from working on retainer seeing that the job is so important to society? Was I unethical negotiating private contracts with private companys? Even when I did work for the state (something I stopped doing because the red-tape wasn’t worth the money) they paid me much more than their own pet engineers.
Your problem, Graham, is that in your heart of hearts you believe that everything including private property, money, and labor belong to the State which magnanimously allows us to keep some of it if we’re good…but can allocate it however they want for some ridiculous concept of social justice, an ideal which is really nothing more than politicians bribing deadbeat voters with other people’s money.
[...] can look at concierge medicine, which I discuss here and here, as symptoms of this lack of time and money problem. Thanks to Roy Poses for this [...]