Putting the Physician-Patient Relationship First

The otolaryngologists and pediatric surgeons who watched President Obama’s July 22 press conference must have been astonished to hear themselves vilified by the Health Care Reformer-in-Chief. Apparently, the bemused president believes that a pediatrician treating a child’s bad sore throat whips out a fee schedule, finds that he could make a lot more money by performing a tonsillectomy, and then blithely goes ahead with the gratuitous surgery. Never mind that based on medical necessity, the pediatrician might refer the young patient to an otolaryngologist or pediatric surgeon to remove the offending tonsils and adenoids, which usually do not magically heal themselves. Hopefully, through the necessary surgery, the pediatric patient would have breathing return to normal and avoid a life-threatening condition such as obstructive sleep apnea.

The sore throat/tonsils brouhaha illustrates the dangers of overhauling our complex and nuanced health care system without putting physicians in control of a process that could affect more than 300 million lives. Should bureaucrats-particularly the bureaucrats and politicians who promise universal coverage for everyone regardless of health status, paid for by projected savings-really be in charge of running the doctor-patient relationships rather than the only two parties who actually belong there?

Unfortunately, President Obama has not yet learned the cruel lessons of the four failed statewide plans that have tried to provide a public option based on private insurance plans without raising costs-TennCare (Tennessee), MassCare (Massachusetts), Dirigo Choice (Maine), and Keiki Care (Hawaii). All of them have suffered from the same toxic combination of wrong-headed policy and perverse incentives:

• Costs always far exceed budget projections-because giving more people access to health care means they will use it.
• Consumers are smart. When health insurance premiums are heavily subsidized, they figure out that paying their premiums for a short period of time, getting all their medical needs attended to, and then not paying the premiums makes economic sense.
• Consumers have figured out that having a penalty assessed on their taxes, like Massachusetts’ $800 penalty for not having insurance, is a lot cheaper than paying premiums once your medical needs have been taken care of.
• Consumers and their employers leave private plans in droves when a cheaper public option appears. Hawaii’s well-meaning governor Linda Lingle pulled the plug on Keiki Care, her state’s universal insurance plan for children, after only seven months. It didn’t take long for employers to realize that when parents dropped their expensive private insurance and piled into the subsidized public plan, Keiki Care’s cost ballooned. It was not intended to cover middle-class families with private insurance, but when employers saw the loophole, they took advantage of shifting their costs to the state.
• As costs of public plans escalate and anticipated savings never materialize, politicians have little choice but to shift the ballooning costs to hospitals and doctors by lowering their reimbursements.
• Physicians refuse or become overwhelmed with prospective patients with newly minted health insurance policies they were forced to buy. Those patients then find themselves without a doctor who will take them on.

 

All in all, these ambitious plans create situations in which physicians, instead of being the system’s heart, are asked to help finance their downfall. As Medscape, an online newsletter for physicians, put it in its July 9 issue, President Obama wants to address the needs of…virtually all Americans, with the possible exception of physicians. A Medscape reader poll bears that out: 76% of respondents agreed that physician oversight of health care reform is the only way to get the job done right for patients and for themselves.

Because physicians are the only people licensed to practice medicine, they have the power-often sadly unused-to make or break health care reform schemes. Some pioneers, seeing the handwriting on the wall, have protected themselves by going bare-not taking any insurance reimbursement and opting for a patient-funded practice. Called concierge medicine, direct care, or subscription-based practices, they all allow physicians a different way to practice medicine.

A Very Different Alternative

With some form of health insurance overhaul likely to accelerate the trend of rising practice costs coupled with declining reimbursement for physicians, some doctors will join those who have already exited a practice model funded by insurance payments. Physicians such as Garrison Bliss, MD, a Seattle-based primary care physician and vascular surgeon John Kenagy of Belmont, MA, disgusted with governmental and insurance company constraints on how they practice medicine, have escaped health care hell by stepping away from the madness. They hearken back three-quarters of a century to pioneers like Dr. Fred Mott, an internist who established a cooperative prepayment plan for physicians serving Depression-era farmers at risk of losing their farms due to ill health.

Thirteen years ago, Dr. Bliss had a plan to get out of jail, as he recalls it, by no longer accepting any insurance reimbursement, including Medicare. Instead, he offered patients a subscription service for 24/7 medical care. Back then I realized I was working for the wrong people-insurance plans that didn’t value primary care. Medicare is the ringleader of not caring, especially since the advent of RBRVUs [Resource-Based Relative Value Units], which looked great on paper but continued to reward expensive care while punishing cheaper care, he explained. He claims that with a subscription-based practice, physicians can earn three times as much income in half the office time, practicing medicine the way they dreamed about in medical school.

Today Dr. Bliss’s plan, Qliance, costs consumers between $39 and $79 a month, depending on their ages and whether or not they opt for direct supervision of hospital care ($20 per month). Most patients in Qliance and other concierge practices purchase a high-deductible health plan (or wraparound insurance) with a health savings account for expensive and catastrophic care. Although subscription-based fees may, at first, seem to resemble capitation in that doctors get paid one fee to manage care, Dr. Bliss explained that such fees differ in that when insurers pay, the insurers’ interests come first. When patients pay, the patients’ interests and satisfaction come first, or they’ll vote with their feet.

Dr. Bliss’s practice includes nine physicians and three nurse practitioners who greet their patients in the waiting room, personally dispense 150 generic drugs, and directly supervise hospital care. Once I exited the dysfunctional health care system, I was able to see 10 to 12 patients a day, versus 25 to 30 before. We were also able to manage fixed costs, and there aren’t a lot of incremental costs, so monthly fees cover the practice costs quite well, he said.

Dr. Kenagy, a physician for 40 years and author of Designed to Adapt: Leading Health Care in Challenging Times, pointed out that the government’s effort to try and buy a solution won’t work. Our current system is way too expensive and wasteful. Lowering costs isn’t complex. Physicians can figure out how to problem-solve their own practices if left alone by the government, he said. Doctors and other health care professionals know their jobs and can create value if no one interferes in the doctor-patient relationship.

Doctors Speak Out

Dr. Bliss is a member of the Society for Innovative Medical Practices (www.simpd.org ), whose mission is helping doctors exit the insurance-driven practice morass. Although no entity tracks the number of concierge practices, the AMA estimates that only several thousand physicians are in such practices.

A number of physicians may be willing to join concierge practices if President Obama’s health care reform becomes law. Zane Pollard, MD, a pediatric ophthalmologist in practice for 35 years whose group is the only such practice accepting Medicaid in Atlanta, has a long list of reasons for fighting ObamaCare-repeated denials by Medicaid of antibiotics to treat corneal ulcers and intraocular lenses for congenital cataracts; a drop over several years in Medicare reimbursement from $2500 to $500 for cataract surgery; and at least two unreimbursed operations he performs every month on illegal aliens are a few. He said, The government said that any doctor that does Medicare work cannot accept more than the going rate, or he or she would be severely fined. It said it was illegal to accept more than the government-allowed rate. What I’m driving at is that those of you [the patients] who are well off will not be able to go to the head of the line under this new health care plan just because you have money. No physician will be willing to go against the law to treat you. He urged all physicians to contact their elected representatives to defeat the current health care reform bill. I promise you will not like rationing of your own health. Furthermore, how can you trust a physician who works under these conditions, knowing that he is controlled by the state? I certainly could not trust any doctor that would work under these draconian conditions (www.theexaminer.com/blog ).

In early July, physicians started a new organization, the American Society of Medical Doctors (www.theASMD.org ), to give physicians a unified voice on issues that affect their relationship with patients. Alfred Bonati, MD, ASMD’s chairman, said of the Obama health care proposals, If these are enacted, the American health system could be opened up even more to bureaucrats making critical health care decisions instead of physicians with patients and their families….No longer will we stand by while others speak on our behalf. We will stand up and speak for ourselves. We will defend ourselves and our patients.

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