We, as physicians, allowed third-party payers and the U.S. Government (in the form of Medicare) to take our professional lives away from us. It is our fault that this happened and we are the only ones who can correct the problem. When Medicare and HMOs moved in, we were largely absent from the discussion on healthcare and we were complicit with those who implemented the hostile takeover. In the mid-60s, there were many medical Paul Reveres out there, warning about the risks of Medicare assignment and what it would do to the practice of medicine. Few listened. Doctors were oblivious to the dangers of losing control over their profession, because again, they did not choose to understand anything about business or the nature of government bureaucracies. They hid behind a cloak of “altruism” and somehow felt that ignorance about financial issues was “academic” or above them. How narcissistic! How irresponsible. I cannot imagine any other professional group—such as lawyers, dentists or accountants—allowing a hostile takeover without a fight for what was dear to them.
Now, if this were just a rant about mistakes doctors have made in the past, it would be a worthless exercise in complaining. It is not. The solution for the future lies in understanding the history of our mistakes, so that we can correct them and not make the same mistakes again. The bigger point is that it is NOT too late to return to direct financial relationships with our patients, which is the way it was done in the past. We did not need a massive third-party bureaucracy to practice primary care medicine before and we don’t need it now. In the 1960s and long before, patients paid doctors directly for their services. I have reverted to this model myself, which I began to do seven years ago in Tucson, Arizona—one of the most highly-penetrated HMO markets in the country, a town where a Medicare card is a virtual Gold Card. Having changed my practice—I dropped the HMOs and opted out of Medicare—I now love the practice of medicine. I am personally healthier, happier and stronger, which spills over into my practice. I practice better medicine than I did before, because I have this wonderful luxury called TIME to actually do what I was trained to do. My patients love having the extra time with me. It improves the doctor-patient relationship.
I also do what few doctors do in this town: I don’t use “hospitalists” when my patients get sick. I take care of my own patients in the hospital when they need me most. I visit them in the emergency room. I make house calls where it is appropriate. I don’t see thirty patients every day like most internists. I see twelve to fifteen patients in a day and I do a much better job.
I practice what is called concierge medicine—what some call a “direct practice”—because I have a direct financial relationship with my patients. Contrary to the belief of many doctors, concierge medicine is not just for the wealthy. There are now forms of direct medical practices affordable to the masses. One of my colleagues, Dr. Garrison Bliss, a pioneer in “concierge medicine” runs a practice in Seattle, Washington in which patients pay $39 to $79 per month (based upon age) for same-day service and excellent care. It is a cost effective, rational and affordable way to deliver primary care medicine and both doctors and patients win. Starting such a practice was not easy for Dr. Bliss, but in concept, it was very simple. Cut out the middleman.
So do people even need health insurance? Yes, they need catastrophic health insurance—coverage that is now available to the majority of Americans by using high-deductible health plans and Health Savings Accounts. These plans can be purchased at very affordable rates. I’ve got one of these plans for myself and my family and it works wonderfully well. What most people don’t need is a standard $500 deductible plan in which insurance companies tell the doctor what to do, which creates a structure that limits a patient’s access to the doctor and reduces the quality of care by forcing the doctor to see so many patients per day. Most health insurance plans are inefficient, irrational and not “insurance” at all. They are a form of pre-paid healthcare, which most of the beneficiaries never receive.
So here’s the issue and here’s the solution. We live in a free market economy. Medicine has been functionally exempt from the free market economy, because doctors have not been part of the discussion. We have ignored the business of medicine. We have been living in self-imposed monopoly, in which almost every healthcare dollar passes through the hands of insurance companies or Medicare, which have taken control of our destiny. There has been no real competition, because consumers have not been in charge of their healthcare dollar and have not been customers. This is changing. And as the demand by patients for quality care increases, doctors are answering the call by entering the free market to provide a valuable service.
When I opened my concierge practice eight years ago, there were only a few concierge doctors in the country. Now, there are almost 1,000 doctors practicing some form of “direct medicine” or “concierge medicine,” which is driven by consumers’ demand for better care.
Our free-market economy is not the enemy. Within it is contained the solution to our current problems. Doctors must learn a little bit about business before they can extract themselves from the current system. They need to start treating their patients like valued customers, not numbers that have been assigned by an HMO. We have to become an active part of the solution by acting like the best and the brightest, not telling people that we are the best and the brightest just because we got into medical school.
Socialism, whether it is in medicine or any other arena of life, only breeds mediocrity. It does not work over the long run. It will not work in medicine.