Monday, December 31, 2007

Getting Better Care

Concierge medicine or retainer medicine has been discussed by other, far more eloquent bloggers. I suggest that you read their material before continuing with this thread – but that’s just my humble opinion (don’t expect this to tell you much of anything about the topic as I really haven’t researched it to the Nth degree - more just my opinion than anything).

What I understand of the problems with primary care medicine has a lot to do with reimbursement and physician/ patient dissatisfaction. Considering that you have to deal with insurance company flunkies telling you that you’re not getting paid for some obscure reason or having a jackass with no medical education whatsoever pouring through years of medical files in order to request that you pay back the meager amount of money they considered adequate you can begin to understand why medical students throughout the US are avoiding primary care like the plague (now that’s a long sentence).

You should also be able to see that a doctor, burdened with these restrictions, increasingly diminishing returns for each patient, and the increasing cost of keeping a business running feels that they have to take care of patients in less than an optimal manner. Because of these feelings the physician becomes depressed, hates his profession and field, and ultimately leaves medicine earlier than planned.

Enter the new breed of physician. One who realizes that their time is not being spent wisely, that the insurance companies are forcing doctors to practice dangerously in order to make ends meet, or that docs all over are just opting out of medicine altogether. Some of these younger physicians, strained by the largest debt load ever encountered for their education, have decided to throw off the traditional shackles bestowed upon them by the myopic, arrogant, older generations and take their businesses back.

Retainer medicine is a form of this revolution. I remember seeing a report, long before medical school, about a doctor who performed house calls, saw ten or fewer patients a day, and was loved by his patients. It was surprising to learn that he required all his patients to pay a monthly premium, regardless of their usage, and was not considered “greedy” by those he treated. This was my first encounter with retainer medicine and it honestly made a lot of sense.

My understanding (faulty perhaps) is that a doctor, refusing to take insurance, asks his patients to pay a sum each month for services – regardless of whether the patient uses them or not - wherein the physician enters into a contract with them. The patient then has the ability to see the doctor when they need them and both parties can “fire” the other based on contractual agreement. This allows the physician to see fewer patients in their clinic, take as long as needed with each patient, and manage them to both the physician’s and (major plus) the patient's satisfaction.

You see, paying doctors per visit or procedure, as is done by most insurance companies, only forces primary care docs to see more patients each day – thus reducing their ability to care for their patients as they desire. It is hurtful to each, but the doctor suffers greatly from a feeling that they are betraying their patients in order to stay in business or meet every absurd insurance mandate. In effect they are at war between taking care of the people entrusting their care to them and the compensatory aspect that is absolutely mandatory to medical care. Concierge or retainer medicine reduces this because the patient pays the doctor, not their insurance, and they can treat the patient as they feel is necessary.

For primary care doctors, I feel that this a tremendous advantage to provide quality healthcare. At the same time it allows the patient to be more involved with their care, enables them to get a clearer understanding of their diseases and medications, and decreases feelings that they aren’t being cared for appropriately.

Some argue that there is an ethical disparity inherent in this program. Essentially their argument centers around the idea that the poorer populations will not be able to receive the same care and they feel that physicians who employ this form of practice are not allowing indigent populations access to healthcare. While I do understand this concern I don’t agree that the physician who decides to practice retainer medicine is being unethical. In fact, I feel they are more ethically motivated as they are now able to see and care for their patient based entirely on their training and medical expertise – not a medical officer hundreds of miles away who never sees patients.

I offered you two opposing view points earlier. Clearly I feel that Dr. Centor makes a valid observation and clearly illustrates reasons that this form of medicine allows for better health care. Given his years of experience, both personal and second hand, I feel he understands this concept more fully than the opposing view offered by Graham.

My appreciation of Graham is that of a medical student who, being a very bright and energetic individual, still completely buys into what’s being sold him by the old guard. While I’ve enjoyed some of his posts, I feel that Graham’s ideas are erroneous and posses a great deal of martyrdom to them that's bereft of responsibilities beyond them. There is absolutely no reason that a physician, regardless of their ability, should be required to care for people who can’t offer adequate compensation. I certainly applaud those who wish to help those who can’t pay, like Graham who states that he enjoys the prospect of EM because “seeing uninsured patients, [is] something I love about the field”. That’s great, but don’t force others to commit to providing less than stellar care to their patients just to see patients who can’t pay.

1 comment:

Old MD Girl said...

Graham is just another case of "because I sacrifice myself, everybody else must also, or else they are unprofessional." It's a bs rhetorical argument. He also knows spit about economics. He can pontificate until he's blue in the face about ethical obligations, but if you make being a doctor financially untenable then the quality of care that is provided to ALL patients will suffer. THAT is unethical.