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    Wednesday, March 22, 2006

    Help Wanted II: An anesthesiologist and PBS doctor says patients should demand more time with their doctors:

    If you cannot get more than a seven-minute face-to-face encounter with your doctor, he needs fewer patients. The true power in the health care economy rests not with the doctors and certainly not with the backroom business staff. It rests with you. If you insist on being treated with care and respect, you will be. And the system will improve as a result.

    There's a truth there that patients often forget . They own the power in the doctor-patient relationship and if they're unhappy , they should go elsewhere. But will patients going elsewhere result in a change in insurance company behavior? It's hard to see how. The insurance companies don't suffer when patients change doctors. They really don't care. They only care if patients switch insurance companies in large numbers. And patients (or their employers) only switch insurance companies when premiums become too costly. And how do insurance companies keep down the cost of premiums? By paying doctors and hospitals less. And what happens when doctors and hospitals get paid less? They try to make up the difference in volume. And where does that lead? The seven minute office visit and the discharge-them-as-fast-as-you-can hospital stay. The customer really isn't present in the doctor-patient relationship anymore. That's the problem. The customer's business is with the insurance company. And do you really think that customer is going to pay more to the insurance company so his doctor can see fewer patients? Hardly.
     

    posted by Sydney on 3/22/2006 08:31:00 PM 9 comments

    9 Comments:

    Excellent analysis - you hit the nail on the head. Primary care physicians cannot practice good primary care medicine because we cannot earn the income we would like and spend the amount of time we would like with each patient. Both sides of the equation must balance. More money = more time. Less money = less time. Are primary care physicians going to accept a continued downward income spiral in the face of mandates to provide more care? I think not.

    By Anonymous Anonymous, at 9:00 PM  

    A few years ago, in my large multispecialty clinic, it was reported that patients had been surveyed to determine how much of a premium they'd pay in order to stick with their current doc; as opposed to switching to a cheaper plan that didn't include that doc. At the time, as I recall, it was about $7.50/month...

    So there's a bottom line for everyone. I noted that the doc who wrote the piece in question was a professor of medicine; I infer he has at least a signifcant part of his income based on a fixed salary. He can, in other words, afford to take extra time. We'd all love to. Those who don't, for the most part, as has been pointed out here, simply have no choice in the matter...

    By Anonymous Anonymous, at 12:14 AM  

    You just made an eloquent argument for concierge medicine, which you derided a few days ago. Concierge medicine is exactly the model through which patients, by paying directly, can demand more time, availability and attention.

    By Blogger Albert Fuchs, M.D., at 1:33 AM  

    ...or in other words, everybody wants to go heaven, and nobody wants to die.

    Dr. Fuchs is right. You want concierge-level of care? You gotta pay concierge prices.


    Flea

    By Blogger Flea, at 5:42 AM  

    Whatya know. I did make a sort of argument for concierge medicine. My problem, however, with concierge medicine isn't that they introduce payment by the patient to the doctor. One concern is that I'm not convinced they actually offer that much more in service than doctors practicing in the traditional mode. My bigger problem with it, however, is that it excludes a significant portion of the population from the services of physicians.Not many people can afford to pay an extra $1500 a year on top of their insurance premiums and doctor visits. Although some of the more liberal medical bloggers often describe me as cold hearted, I do believe that physicians have an obligation to treat the people who live in their communities. I don't think they should have to go broke doing it, but I don't think they should get rich by gaming the system in favor the wealthy few, either. That's why I'm more in favor of the traditional model with health insurance for catastrophes (hospitalizations, cancer treatment, etc.) and patients paying their regular doctor's visits themselves.

    By Blogger sydney, at 9:30 AM  

    I think you and I actually have much common ground. I agree that healthcare is purchased most efficiently (and at the highest quality) when the patient pays, and that insurance is best used only for unaffordable catastrophes. The use of third parties to pay for routine care inflates prices and lowers quality. The reason the marketplace hasn’t done away with this is because there is currently a tax incentive to buy care through insurance: insurance premiums are tax deductible while payments to doctors aren’t. Health savings accounts may fix this problem by letting patients pay their doctor with pre-tax dollars.

    Re your concern that I don’t offer much more in service than traditional doctors: Then why are my patients willing to pay more? They’re not dumb suckers or looking for frilly luxuries. They’re successful professionals. Frequently they switched from a much less expensive doctor due to the frustrations of having to compete with 2000 other patients. I don’t promise better care. I promise better access, and I promise to be respectful of their time. That’s worth something.

    “I do believe that physicians have an obligation to treat the people who live in their communities.”

    I volunteer one afternoon a month in a clinic that cares for indigent patients. That’s not patients with a PPO who don’t feel like paying more for a less busy doctor, that’s patients with nothing. I don’t feel I’m obligated to take care of patients with PPOs who can’t or won’t pay more, and there are lots of doctors happy to care for them.

    “Not many people can afford to pay an extra $1500 a year on top of their insurance premiums and doctor visits.”

    I have serious misgivings about that practice model also. My model involves a single annual fee without charging patients (or their insurance) subsequently for each visit. I think the MDVIP model of staying in Medicare and still charging the annual retainer borders on Medicare fraud and is at least unethical.

    By Blogger Albert Fuchs, M.D., at 2:07 PM  

    Albert Fuchs MD wrote "The use of third parties to pay for routine care inflates prices and lowers quality. The reason the marketplace hasn’t done away with this is because there is currently a tax incentive to buy care through insurance: insurance premiums are tax deductible while payments to doctors aren’t."

    Actually, both insurance premiums and all medical/drug copays and coinsurances are tax deductible. However, for federal taxes, a person's yearly medical costs must be more than 7.5% of their adjusted gross income. Any costs above the 7.5% are deductible, as long as a person itemizes their deductions.

    Why does the market still have routine care covered by insurance? Because employers want it this way; they want primary care doctors to act as gatekeepers, so patients cannot see specialists without a referral. It's specialist care that really ramps up medical costs.

    By Anonymous Anonymous, at 5:16 PM  

    In a malpractice climate like this, with so much defensive medicine, how is the primary care physician going to act a an efficient gatekeeper ?

    By Anonymous Anonymous, at 2:45 AM  

    Because employers want it this way; they want primary care doctors to act as gatekeepers, so patients cannot see specialists without a referral.
    This is true for HMOs but not necessarily for the employers. Many PPOs don't require referrals, for example, ours also allows out-of-network visits as long as we pay higher co-insurance. In fact, my employer - a large Fortune 500 company - significantly reduced a number of offered HMOs in favor of a couple of PPOs and a high-deductible plan with personal health account. Apparently having a gatekeeper didn't save them that much money since cost was the main reason sited for dropping HMOs.

    By Anonymous Anonymous, at 11:19 PM  

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