American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, September 11, 2013

How could pre-paid and concierge medicine help us be great?

American health care is expensive. We pay lots of money for it and we have outcomes that we aren’t proud of. We gnash our teeth at how terrible we are and look to other countries with lower costs for ideas on how to improve. I have been combining personal and second hand experience of countries that spend very little on health care with what I know about medicine in the U.S., and we really aren’t entirely bad. In some ways we are outstanding.

Singapore is a city-state comprised of 20 islands, near Malaysia, which began its modern prosperity when it was reinvented as a port by the British Empire. It spends a tiny proportion of its gross domestic product (GDP) for health care, on the other hand, and ranks in the top 20 countries in the world in both life expectancy (15th) and infant mortality (1st).

So how do they do it? There are many factors that might enter into the overall health of the population of Singapore. One very striking thing about Singapore is how strict their laws are and how rigidly enforced. There are high taxes on both alcohol and cigarettes. Trial is by judge, not by jury, and trafficking drugs is punishable by death, as is possession of large quantities of drugs of abuse. Trafficking in arms is a capital offense, as is using a gun in the commission of most crimes. Cigarettes and alcohol are heavily taxed, and cigarette use is prohibited in most public areas, transgression punishable by rather high fines.

Singapore provides universal health care by a combination of health savings accounts funded by salary deductions along with partially government funded health insurance for catastrophic costs and a government fund to pay for the care of patients who are unable to afford medical care or for those whose resources are inadequate. There are also private health insurance companies to pay for medical services not provided for by the government programs, which many people of means purchase.

Actual medical services are subject to market forces since the majority of care is out of health savings accounts which are controlled by the individual patient. Medical care is very good, but is quite limited for those entirely dependent on government programs. Expensive care is not necessarily available, and the basic level of health care available to all citizens is not what most Americans would consider adequate, at least according to my experienced ex-pat source.

Eastern European countries spend only a small proportion of their GDP on health care and they have poor outcomes, with rising rates of various preventable diseases and deaths. When the Soviet Union collapsed, the universal government-funded health programs were suddenly unfunded and, although patients could choose their own doctors, those doctors didn’t necessarily get paid and the technology they needed to function well gradually became unavailable. There is no good assurance of quality of care or of practitioners, and they make less than the national average salary. They depend on illegal payments and bribes to survive, and routinely receive money or gifts which are not acknowledged but are a vital part of the survival of health care providers. The quality of care is spotty and terrible, or so say my informants. Extremely brief doctor visits with next to no information imparted and no assurance of quality or accuracy is the way things roll.

In the U.S. we are very picky about who gets to be licensed to work as a doctor and there are many assurances of adequate education and skill as part of the process of becoming one. Doctors who practice medicine poorly or do things which can be considered unethical frequently lose their permission to practice medicine. Even though we sometimes get shoddy or inattentive care we expect more, which is not true in Eastern Europe. Doctors actually talk about how to delivery higher quality compassionate care and they feel bad when their patients are dissatisfied. There is some terrible inconsiderate and stupid doctoring going on, especially in situations where doctors are overworked and burned out, but this is certainly not the rule and it is not an expected part of our culture. We sometimes become greedy and mercenary, but we have the decency, usually, to feel bad about it.

So, what I’m saying is that I don’t think we should trade our system in for Singapore’s, even though they do get more health care for their money, or Eastern Europe’s, even though there are more than enough doctors there to go around.

We, here, have the luxury of a health care system that is lushly supported and heavily replete with technology and infrastructure. We have high standards which we sometimes live up to. We also do crazy things like spend lots of money on high end intensive care medicine for people who put no energy or resources into taking care of their bodies and who subsequently become disabled and despondent and live short miserable lives. We conversely spend no money on the basic health care that could keep the average poorly or uninsured middle class people from becoming very ill, and we have treatment routines that are poorly thought out in terms of value for the patient, leading to medical debt related bankruptcy. Still, every day I work I see miracles of effective, well thought out care delivered with respect and consideration. This sort of thing is not the exception, but more often the rule.

I also see too many doctors losing their joy of practicing because they are encouraged to see too many patients and follow too many guidelines and spend scarce energy on the demands of the many third-party payers.

Just a few days ago I read an article about doctors who are moving to “cash only” practices, in which they are paid monthly by patients to be their primary doctor, sometimes with better access than patients whose medical care is paid by insurance. Even though a doctor who is paid by an insurance company is really working for his or her patient, a significant portion of the energy put into an encounter goes toward the insurance company, and the insurance company, be it Blue Cross or Medicare or Medicaid, always defines in some way what care we deliver.

Not so in a “cash only” practice where there is no third party payer to please. Because there is no third party payer, the physician can afford to treat fewer patients, providing at least theoretically better care to each one.

Critics argue that only the rich can afford this kind of care and that it will lead to primary care doctors being less productive in a time when primary care doctors are scarce. Since cash-only practice cuts out the very complex insurance billing piece, it is actually a less expensive way of delivering medicine, and there are many affordable cash-only practices, which are way cheaper than paying for health insurance. Someone with zero money can’t afford this sort of thing, so it is not of help to patients receiving state funded health care. Still, it is affordable to middle class folks who often can’t afford to pay health insurance premiums.

Cash-only practices preserve the intimacy of the client-provider relationship, since it is that relationship only that determines what kind of medical care happens. To build a practice, physicians in this kind of a payment scheme have to deliver care that is valued by the patient.

Combining a cash-only (also called “concierge” medicine, especially at the high end of cost and service) primary care model with a catastrophic type insurance coverage for hospital, procedure and emergency care could help hold on to what is good in American medicine at the same time we tighten our belts and try to start delivering more cost-efficient care.

Primary care coverage, in the pre-paid, cash-only model, could be paid for out of health savings accounts, much like in Singapore, which could be compulsory and tax free. This would help control costs and improve quality as I’ve heard it does in Singapore. Most people who get good primary care rarely need expensive hospital based care so a catastrophic policy just for the expensive stuff still need not cost much. If there was some cost sharing for tests and procedures and hospitalization, there would be even more motivation to use primary care and healthy lifestyle based preventive strategies to keep from needing high tech and high end care.

Since cash-only physicians get all of the payment associated with their care, rather than paying for an insurance industry which in turn sucks up their energy, they can survive with fewer patients on their panels. The patients they see can conceivable actually use less time since there is no need to spend time and energy on dealing with insurance.

Dealing with insurance companies is, actually, a big energy and overhead sink. These doctors usually treat fewer patients because this practice model hasn’t entirely caught on, so it’s really kind of hard to have a large panel of patients. Since, however, treating more patients means making more money, I believe our quite human greed will make us as busy as we need to be. If cash-only practices really started to make an impact on medical care and clearly were a better way to practice medicine, government programs such as Medicaid might give patients the opportunity to use their benefits to pay for care.

After two years of looking at all kinds of permutations of medical communities I am more impressed with how desirable our medical system is, in terms of quality, though not affordability or access. Ideally we would not get rid of what we have that is excellent, but instead make it more available to everybody. We have such creative people in the field of health care and they have thought of so many ways to make their doctoring rewarding to all of us, as doctors and as patients. We should embrace some of these ideas when they are obviously good.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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