by Steven Reznick, MD
Like the shots fired at Concord and Lexington in 1776, concierge medicine and direct pay practices are the initial shots fired by concerned primary care physicians in the revolution against health care systems which limit access to physicians and destroy the doctor / patient relationship. Concierge medicine arose as a result of government, private insurance, and employer intrusion into the health care field destroying primary care and a physician’s ability to spend the time required with patients to adequately and comprehensively prevent and treat disease.
The only thing that is unjust or unethical about concierge and direct pay practices is that they had to be formed to begin with. They formed after 30 years of:
- Primary care doctors lobbying unsuccessfully for adequate compensation for evaluation and management services and for protesting the widening gap between cognitive services and procedural specialty practices.
- Going through channels protesting the unfair bureaucratic and administrative burdens placed on primary care practices by Medicare, Medicaid and private insurers.
- Warning that the population is aging and their chronic health care problems are far more complex requiring more time with a physician rather than less.
- Primary care physicians leaving medical practice for early retirement or for paid jobs with pharmaceutical companies, medical device manufacturers and hospital administrations where hard work and achievement were rewarded without having to deal with system imposed overheads of up to 65 cents on the dollar.
- Legislators providing no relief from frivolous lawsuits which makes seeing complex patients in 5-10 minute sessions for “single problem directed visits” a legal liability.
- Medical students realizing that the time and financial commitment to the practice of primary care medicine didn’t cover the bills essentially directing them toward more lucrative procedure dominated specialties.
Physicians also left after salaried academic physicians, who never took risk and invested a cent of their own money in building a practice, pontificated and moralized in peer journals supported wholeheartedly by biased pharmaceutical company ads that generating passive income through shared labs and imaging centers was a kickback.
If we look at the data accumulating on care from concierge and direct pay practices, we find that despite a sicker patient population these practices generate fewer visits to emergency departments and fewer acute emergent hospitalizations saving the system money. These practices provide coordinated care for their patients steering them through a complex and confusing health care system riddled with inappropriate advertising and claims and, get the patients to the best people to treat their problems.
Concierge physicians have more time to spend with their patients thus, achieving unheard of levels of retention and patient satisfaction while giving pro bono scholarships to patients who cannot afford their membership fees but were with them prior to their conversion to a retainer model.
After years of being on the conveyor belt of having to see more patients per day, every day, to stay abreast of system generated overhead cost increases and declining payment for services, concierge physicians now have time to teach students, volunteer at health fairs and screenings and participate in the stewardship of what remains of their profession.
If anything is unjust and unethical it is salaried academic non-physicians writing articles about morality and justice about issues they have no hands-on experience practicing. As a primary care physician for 32 years, I feel like a chameleon having to change colors and practice style every few years based on new rules imposed by private insurers, employers and government programs. At no time were these new rules designed to improve the patients’ access to care or total care. In each case the new rules were designed to save money and do nothing else.
Concierge and direct pay medicine is the first volley in a revolution to take outstanding care of a smaller panel of older sicker patients on a long term basis. Its proponents have worked hard for decades to change the system through channels. Failure of legislators, government bureaucrats, health insurers, employers and professional associations such as the AMA and the ACP to react and fix the inequities has generated these practices which cost less than a cup of Starbucks grand latte per day to be a patient of and provide comprehensive care and access.
Steven Reznick is an internal medicine physician.
Jason Atlas says:
I’ll read that in a bit, but nothing makes me happier than laying cash on the barrel-head for my medical care. The abuses in our third-party payor system is destroying American medicine. I LOVE for-profit, self-pay medicine!!
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Tim Martindale says:
Not sure who this guy is, but I couldn’t disagree more with what he says. 1. Opting out of the system is denying care to those who need it the most, especially Medicare and the underserved. 2. Limiting your practice to a small number of patients amplifies the primary physician shortage. If the average physician manages 2-3,000 patients, what happens when physicians decide to manage only 3-500 patients? 3. Concierge medicine chooses not to try to fix the system, but to put the physician’s profit and comfort above society’s need. That’s not the noble call that initially drew physicians to the ministry of medicine. 4. Concierge medicine only works if few do it, and then it only works for them. If many were to do it, the government will be forced into socialized medicine as its only recourse. Maybe some day I’ll consider this, but it will probably indicate I think the system broke beyond repair, and I have to think of my survival first.
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Jason Atlas says:
I’ve grown up in and around medicine and have worked in the electrophysiology field for nearly 12 years. I work in physician offices delivering clinical care directly to their patients and I work in the surgical side providing surgical support for device implants.
I see the front lines of care delivery and I see the back-office billing and reimbursement game that physicians and hospitals play to maximize their third-party reimbursements.
I’ve done this work in multiple states and I’ve worked with hundreds of physicians in dozens of private practices. I’m here to tell you, the system is already broken and you better start thinking of your own survival.
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Tim Martindale says:
Jason, I wasn’t directing my comments at you, but at Dr. Reznick. It sounds like you have a lot of exposure to the clinical delivery of medicine services, and you’re right that there are a lot of games and mixed motives that plague the business of medical care. At this moment, I remain hopeful that we can fix the process while remaining a part of the system. But politics of any kind are very complicated and frustrating.
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Jason Atlas says:
Understood. Thank you for the clarification. While I sound fatalistic that the American model of health care is broken, I prefer to think of myself more as a realist. Like you, I am optimistic and hopeful that we can fix it, but it is very complicated.
The third-party payor model removes any incentive for patients to work with providers in controlling and/or negotiating the cost of their medical care. Whether it’s Medicare, Medicaid, or Blue Cross Blue Shield, the patient and physician simply do what they’re told and they have little to no recourse if they disagree with the instructions from the organization who is paying the bill. Hence my affection for cash-on-delivery of medical treatment. Does it work for everyone? No. Does it work in every instance? No. But it’s a start.
I’d like to think that the providers who take my cash for services rendered appreciate the relationship, too. After our transaction, there is no paperwork to file with the government or insurance provider. Thank you very much. Have a nice day.
Maybe I’m too naive and simplistic to think that the rest of the the country would value such an arrangement. I guess we’ll see.
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