For almost any category of product or service you can think of, a huge variety of price and quality is available. From clothes to food to transportation we can all think of lousy but inexpensive choices that we wouldn’t like and incredibly luxurious choices that we can’t afford. For almost all of us somewhere in the middle there are choices that are both pleasing and affordable. That doesn’t mean that my choice is the same as yours. You may not be happy with anything less than a BMW, while I’m thrilled with my Mazda. But we both found something that meets our needs and doesn’t bankrupt us.
The peculiar thing about healthcare is that for many it’s simultaneously becoming increasingly mediocre and increasingly unaffordable. It’s hard to think of another good or service for which that’s true. In fact, most everything else is getting simultaneously better and cheaper. This crisis is most acute in primary care. Articles have been warning for years about the worsening shortage of primary care doctors as two worrisome trends intersect – fewer medical students are choosing careers in primary care just as the baby boomers age and will need more of it.
This week an article in the LA Times (link 1 below) asks “What happened to the family doctor?” and accurately reviews the dissatisfaction among both patients and physicians. Primary care physicians complain about flat or declining reimbursement, increasing demands on their time, and increasing insurance regulation. Not surprisingly, when most people in a profession are cranky, that doesn’t attract newcomers. The number of medical school graduates choosing primary care training dropped by almost half between 1999 and 2009. At the same time patients complain about increased waiting times, poor access to their physicians, very short visits, and inability to have questions answered by phone or email. And, of course, both physicians and patients are right.
Before we can understand how we got here, we have to understand how other marketplaces avoid this. Why is there no accountant shortage or shoe shortage? The answer is freedom of prices. If accountants became very scarce they would become very expensive. This would draw more people to accounting, alleviating the shortage and bringing their fees back down. Since in most marketplaces producers are free to set whatever price they wish, the result is multiple providers that compete on both quality and price, yielding a great number of options for the customer.
This doesn’t work in the current healthcare system because insurance fixes the price. In the insurance model all physicians contracted with a certain insurance company receive the same fee for the same service, regardless of whether the patient is irritated or delighted, or whether the care was outstanding or marginal. This has two destructive effects. First, it prevents doctors from competing on price. Second, it means that the only way to make more money is to see more patients. Since doctors can’t charge more per visit, the incentive is to maximize the number of visits.
How about that? A system that rewards visits and not patient satisfaction has resulted in many short unsatisfying visits. Why are we surprised?
There have been myriad attempts to fix this failed system without addressing the fundamental flaw. Countless acronyms like HMOs and IPAs have been vaunted as the solution for delivering affordable excellent care. None have. Now of course, new solutions are being proposed – group visits, virtual visits, medical homes – which will all add complexity and bureaucracy without improving care.
There is no way to fix the insurance model. The insurance model is the problem.
How can we attract more students to primary care? By demonstrating to them a primary care model in which doctors are reasonably paid, love what they do, and can practice as they were trained, not as insurance companies dictate. Escaping the insurance model by charging patients directly lets doctors do just that.
But in the very same LA Times issue Steve Dudley, a Seattle physician, writes a very critical and snarky article about concierge medicine (2). Some of his criticisms of concierge medicine are reasonable. For example he criticizes some concierge doctors for both accepting insurance money and charging an additional annual fee, a practice I also find distasteful. He also notes that many physicians set up concierge practices with the help of large impersonal corporate franchises.
But his main criticism is completely hollow. He worries that not all patients would be able to afford it. First of all, some physicians have escaped the insurance model and decided to work for their patients even in blue-collar towns. So working directly for patients need not be unaffordable. Second, having physicians work at different prices is part of what is desperately missing in this marketplace. Not everyone can afford a new car either, but we don’t blame BMW dealers.
Three years ago I wrote an op-ed for the LA Times (3) describing how I came to my current practice model. I think it answers Dr. Dudley’s criticisms. I encourage you to read it. Physicians choosing to work directly for their patients are part of the solution, not part of the problem.
(1) Los Angeles Times article: What happened to the family doctor?
(2) Los Angeles Times article: Concierge medicine has a cost for all patients
(3) My op-ed in the LA Times in 2008: Dollars to doughnuts diagnosis
My previous posts on rescuing primary care: