A Brief History…

UPDATE: This article from from the New York Times discusses the “retainer model” of practice but has some misinformation.

Another, more expensive option is concierge or “boutique” care, which comes in two forms. In the most popular kind, doctors accept Medicare and other insurance, but charge patients an annual retainer of $1,600 to $1,800 to get in the door and receive services not covered by Medicare, like annual physicals. Before signing up and paying the retainer, patients should get a written agreement spelling out which services the doctor will bill Medicare for and which the retainer covers. And always check carefully for double-billing.

I do not believe this is accurate. You cannot bill for services that Medicare does not allow, such as annual physicals or more frequent visits. That is why the geriatrics specialists are dropping out of Medicare. Also, the reporter vastly overstates the cost of most retainer practices.

Things are getting so bad for doctors, especially primary care doctors but specialists too, that some are taking radical steps. Medicare is the worst with radical cuts in reimbursement and onerous rules, especially for such specialties as geriatrics. The advent of the RBRVS in 1992, foisted on the profession by a combination of the AMA and Harvard School of Public Health, was supposed to equalize reimbursement for “cognitive services” (thinking) and procedures. The internal medical societies supported this initiative thinking they would be making more money and surgeons less. Of course they were tricked and everyone ended up making less.

Geriatrics is a specialty that should be most concerned with the aged and therefore involved with Medicare. However, Medicare rules prevent frequent visits to frail elderly patients and private care in addition to Medicare is banned. A physician who cares for elderly patients requiring frequent care may have to drop out of Medicare to avoid being harassed or even prosecuted. Geriatrics as a specialty is suffering.

What is the result ? Some primary care physicians are choosing “boutique practice” or “retainer practice.”

Perhaps more than most people, Reitz, a senior HIV?AIDS scientist with the Institute of Human Virology in Baltimore, appreciated the need to be examined quickly. And thanks to a recent trend to help personalize physician care, he got an appointment the same day — but not because of his professional status.
Reitz, like any patient of Dr. Philip Henjum, can get a same-day appointment because Henjum and his partner, Dr. Robert Fields, practice retainer medicine in their Olney office.
Their patients pay a $1,500 annual retainer fee to see them as soon and as many times as they need to. They also make house calls.
As it turned out, Henjum diagnosed Reitz with Lyme disease, an infection from a tick bite, and prescribed antibiotics. If not diagnosed and treated early, Lyme disease can lead to severe headaches, muscle pain and serious heart problems.
Fields and Henjum are two of about a dozen doctors in Maryland and an estimated 600 nationally who won’t take insurance coverage. Instead, they charge a yearly or monthly retainer. Some work out of comfortable medical office such as Fields and Henjum, next to Montgomery General Hospital.

The cost is modest for the patients although more than the poor could afford. It is a growing trend and Medicare may soon have the reputation that Medicaid has now.

Most family doctors will convert to a retainer-type practice within the next 15 or 20 years, said Dr. Christopher Ewin, president of the nonprofit Society for Innovative Medical Practice Design in Fort Worth, Texas.
‘‘We believe that there is a primary care problem in this country,” said Ewin, a primary care physician. ‘‘We have been working for the wrong employer for way too long — the insurance companies and the government.”
Ewin’s retainer practice, he said, reduces the cost of an MRI from about $1,500 to $500. Laboratory blood analysis that would normally cost $300 through insurance costs $33.

This is a small but growing phenomenon. Here is another example.

But the best part of the event for DrRich was getting to meet Alan Dappen, MD, and one of his colleagues, Valerie Tinley, NP. Both write for Better Health. Alan and colleagues have set up a primary care practice in the DC area that really does put patients first.

Dr. Dappen and his colleagues are actually doing what DrRich has been begging disgruntled primary care physicians to do for over two years now – drop out of the grid, and offer medical services to patients who pay them directly. Dr. Dappen does not have a concierge practice, nor does he have a retainer practice. His practice charges patients a fee, in 5-minute blocks, only when patients use his services. Those services can be provided in the office, over the phone, or even in their homes. If they don’t need a doctor patients pay nothing. If they need a doctor they pay only for the services they use. The fees are very reasonable. Patients who can affort to pay a plumber, an electrician, a neighbor kid to mow the lawn, a cell phone bill or a cable bill can afford to have Dr. Dappen as their primary care doctor.

More here.

I am now aware of orthopedic surgeons who have dropped Medicare and are practicing for cash payment now. The Medicare patient may use the program to pay the hospital bills but the doctor does not participate. The basic argument is this:

In the attempt to control healthcare costs (as they have been deputized by society to do), the feds and the insurance carriers have, in uncountable ways, coerced physicians to place the needs of the payers ahead of the needs of their individual patients. That is, they have systematically and purposefully destroyed the doctor-patient relationship, killing medical professionalism, and abandoning patients to their own devices as they attempt to navigate an increasingly hostile healthcare system.

This process has been firmly established. It has been legislated by Congress, embodied in volumes and volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the U.S. Supreme Court, and finally (and most tellingly) sanctioned as being entirely “ethical” by revered medical organizations.

It has therefore become impossible to fight this reality while remaining a “traditional” primary care practitioner. To escape, one must either become a specialist (since outpatient primary care has been the main lever on which the third-party payers have pushed to date), a deep-sea fisherman – or a retainer practitioner. That is, a primary care doctor must either try to survive in a system that ruthlessly pushes them toward an unethical, demeaning, public-health-destroying style of practice, or (one way or another) get out.

To argue that retainer-style medicine – or indeed, any innovation that somehow restores both the professional integrity of medical practice and the patient’s rightful advocate – is unethical is completely wrong. It is one of the few viable pathways toward restoring the foundational (but currently obsolete) medical ethic of always placing the patient first.

If the Democrats’ health legislation passes, this will become even more important.

Notice this blog post which is about Massachusetts but the comments are really interesting.

I wish health insurance was more like auto insurance – not in the being madatory sense, but in the “designed for large, unpredictable, fairly unlikely losses instead of for paying everything associated with the thing being insured”.
If something unlikely happens, like I don’t notice a pizza-delivery person driving down the street and end up sideswiping a Pontiac, my car insurance covers it. But if I ding the fender on a pylon in a parking lot, or need an oil change or new tires, I pay for it out of pocket. I think health insurance should work more like this – you pay for things like doctor’s visits and minor prescriptions out of pocket, and use insurance if you have a heart attack.

YES ! That is exactly what this is about. We used to have indemnity style health insurance in this country but it was superseded by the prepaid model we have now and which we cannot afford. Maybe we can go back to the old model, at least for those prudent enough to care for themselves.
Here is another useful concept, which is called “reinsurance.

Senator John Kerry’s proposal from 2007 looks very attractive in comparison. At its core is the concept of federal reinsurance, an idea I’ve long wanted conservatives to embrace.

One percent of patients account for a quarter of healthcare costs. And 2 out of 10 patients account for more than 80 percent of all healthcare costs. Under Kerry’s plan, the federal government would reimburse a percentage of these high cost cases if employers include preventative care and health promotion benefits in their health plans, make quality coverage available to all full-time workers, and implement practices proven to make care more affordable. This means lower costs and lower premiums for both employers and employees.

This is another example of the indemnity approach to health insurance. He even makes this assertion.

My long-term preference is for the logic of catastrophic coverage to replace the logic of insurance as pre-payment. The federal government’s responsibility should be providing social insurance against income shocks, not to subsidize health spending per se. The reinsurance approach can help get us there.

All this is useful context but Obama’s approach must be stopped to be able to consider alternatives.

UPDATE: Canada seems to be showing the way although not the way that Obama supporters would choose.

This entry was posted on Sunday, July 19th, 2009 at 12:17 pm and is filed under health reform. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.