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November 30, 2012

When it Catches on They Won’t Call it Concierge Medicine

http://www.jewishjournal.com/blog/item/when_it_catches_on_they_wont_call_it_concierge_medicine/

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Photo credit: Liz Ramos-Prado
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The idea that patients are better off paying their doctor directly and using their insurance only for unaffordable catastrophes is gaining some traction. With implementation of the Affordable Care Act looming in 2014 many patients are looking at their doctor’s already crowded waiting room and wondering how their care will be impacted when their doctor is responsible for even more patients. And doctors who even now are swamped and frustrated with insurance bureaucracy are wondering how much worse things will get when they have less time for more patients.

Yesterday Bloomberg Businessweek published an article which asks “Is Concierge Medicine the Future of Health Care?” The headline lifted my spirits because of its happy presumption that healthcare has a future. The article interviews several concierge doctors. It makes the important point that practices in which patients pay doctors directly are now thriving at many different prices. From practices charging tens of thousands of dollars a year targeted to the very affluent to practices charging $50 per month for blue collar workers, doctors have found that they can take better care of patients by caring for fewer of them and by concentrating on practicing medicine the way they were trained, not by focusing on what’s covered by a policy.

The article brings up some very common criticisms of concierge medicine that deserve to be answered.

One objection is that concierge medicine leads to a two tiered system in which the affluent get attentive care and everyone else doesn't  That’s nonsense. The whole point of the article is that direct-pay care is working at many different prices and that some of the practices are targeted to middle class patients. There are already many more than two tiers of healthcare – the County system and Medicaid for indigent patients, private HMO insurance, staff model HMOs, PPOs, direct-pay practices, etc. How many tiers are there in other marketplaces, like food, housing, or clothing? A practically uncountable number. One characteristic of robust marketplaces is that they offer goods at widely varying prices. That means that those who need to save can still afford some access to the marketplace but those who can afford more can get better comfort, or better quality, or more reliability. I can get across town for the price of a bus ticket or the price of a BMW. (I ride my bike.) How many tiers is that?

Another objection is that by shrinking their practices to only those who can afford them, doctors who switch to the concierge model are exacerbating the coming primary care physician shortage. Of course the opposite is true. The physician shortage in primary care is fueled by the fact that people aren't choosing to go into primary care. Nothing will attract more students into primary care than examples of happy doctors who are making a living practicing in a way that is both ethical and enjoyable. Concierge doctors are not the cause of the shortage; we’re the fix. What would the critics prefer? That we stay in the insurance model and tell medical students how miserable a career in primary care is? That we drop out of medicine all together?

I think the main barrier to even faster growth of concierge medicine is the name. Another problem is that the insurance model is so entrenched in our understanding that we now think of getting routine care through insurance as the “regular” way it works. We don’t have a name for it anymore. If someone says “I saw my doctor” we just assume that someone else paid for it. If she says “I saw my concierge doctor” we understand that she paid herself. But it should be the other way around. We don’t have a word for an accountant or a plumber or a lawyer who gets paid directly by his clients. They’re not concierge accountants or concierge plumbers or concierge lawyers. We need to get to the point that paying a doctor directly doesn't deserve an adjective before the noun “medicine”. Paying your doctor is just medicine. Having someone else pay for you is insurance medicine.

The Buisnessweek article quotes Josh Umbehr, a concierge doctor in Whichita.

“Health insurance should work more like car insurance,” says Umbehr. “We have car insurance for all the big stuff, but we pay for gas, tires, and oil changes ourselves.”

He's right. I wish I’d thought of that.

Learn more:

Is Concierge Medicine the Future of Health Care? (Business Week)
Dealing With Doctors Who Take Only Cash (NY Times)
Dollars to doughnuts diagnosis (My 2008 op-ed in the LA Times that explains why I got out of the insurance model) 

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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