– Garrison Bliss M.D., President of the Society for Innovative Medical Practice Design
I was interested to read your recent article: Impact of Concierge Care on Healthcare and Clinical Practice. It certainly provided a balanced presentation of the usual points brought up since the 1990’s in the press and published journal articles. There are important additional points that are rarely made and that I think warrant mention.
First, monthly fee practices and similar financial arrangements between doctors and patients represent the first serious effort in the last 50 years to create a genuine marketplace in medicine. In the 1950’s the insurance commissioners of America allowed insurance carriers to insert “hold harmless” clauses in health insurance contracts that gave the insurer the right to unilaterally set the price of physician services and to constrain physicians from billing the patient for the balance. These clauses were justified by regulators because they were supposed to allow insurers to control the cost of physician services and minimize inflation. Unfortunately, insurers make more money if the price of care is higher, since a substantial part of their income results from investing the temporarily pooled money they have collected for reimbursing healthcare costs. The price of care has skyrocketed since the inception of Medicare in the 1960’s despite these clauses. They have become standard fare in all health insurance contracts in the United States. When the physicians can’t control their price, neither can the patients, who carefully monitored the cost of care prior to the days of health insurance. Since patients have had little incentive to demand lower prices, they have rarely done so. If patients have little control of the price of care, they have less control of the care or service provided to them. Physicians have not actually worked for their patients for at least the last 30 years. We have worked for their employers, insurers or the government – and the care reflects that. Doctors spend inordinate amounts of time and money trying to satisfy the needs of insurance companies. The cost of billing in many offices exceeds 25% of receipts. Physicians are forced to study the fine points of billing codes in lieu of the fine points of medicine. Physicians who spend extra time with patients and do the hard work of preventive medicine are paid the same as the ones who herd them through like cattle. As the authors appropriately point out, patient satisfaction rates of under 50% are a verifiable feature of the current system. The advent of a marketplace in which patients buy care directly from physicians should be greeted with celebration from the medical community, the politicians and the public. The beauties of the marketplace are well known and time tested. The predictable evolution in market systems is toward more consumer and vendor satisfaction, lower price, greater availability, higher efficiency, improved service and innovation. The current system provides all the wrong incentives and the outcome is also predictable: ridiculous inflation, physician dissatisfaction, patient dissatisfaction, glacial adoption rates of new technology and constant roadblocks to innovation and improvement.
Second, monthly fee designs need not be available only to the rich. The lowest price I have seen is $35 per month for the extra access and availability. When we opened our doors in 1997, we charged $65 per month for inclusive internal medicine services, with no additional charges to patient or insurer for our medical care or any the lab, x-ray or other services provided in-house. For some reason, the pundits have chosen to ignore the lower priced models because the inequality argument begins to falter and the subversive nature of this movement becomes harder to see. In truth, no sane American objects to physicians providing same-day care, longer visits, understandable fee structures and serious attention to preventive care. They only object that these services are not universally available for free. Unfortunately, nothing is free. If these services are not provided within a market environment, they will be expensive, awkwardly administered, rarely updated and eventually rationed as the cost of the system spirals out of control.
Third, we have labored for half a century in the United States under the delusion that health insurance is health care. It is not. Health insurance is simply a promise to pay for some portion of the cost of care. Insurance as a management vehicle for care is severely flawed. Insurers have not and cannot measure the quality of the services they are buying. As a result there is little incentive to improve the quality of those services. For better or for worse, the only people who have an informed opinion about the quality of care are the doctor and the patient. Neither is consulted by the health insurance industry in any meaningful way. This is not to say that insurance doesn’t have a place in healthcare. Obviously health insurance is an invaluable aid in preventing financial devastation of the seriously ill. It is time, however, to acknowledge that insurers cannot reproduce the laudible aspects of a well-tuned marketplace.
“Concierge care”, or whatever you want to call it, represents the first step in enrolling doctors and patients in a marketplace that will benefit them both. This movement has overcome some very significant resistance from insurers, the press and the government, both state and federal. We have proven that patients are attracted to these models, as demonstrated by the success of over 250 physicians so far. The leading franchiser of concierge care (MDVIP) was recently listed amongst the most rapidly growing companies in America with a growth rate of 1,814% in three years. Even our detractors have had to admit that something that satisfies the needs of both patients and physicians may not be all bad.