The Scales of Karma

Since my announcement yesterday, I am so happy to hear all the positive “way to go!” comments. But one comment spoke to me by bringing up an important point, one that gave me great pause in making this decision.

Im sorry to say – this all would be very cool but ultimately it excludes poor people and there is nothing about that which addresses the health care crisis – as far as I can see you are just doing what they do on the TV show “Royal Pains” – being a concierge doctor and just because you’re doing it at home doesn’t make it folksy -perhaps you should consider barter and give less fortunate folks a chance to have a doctor’s care that doesn’t make them feel like a number – otherwise everyone is still a number – the number that you charge!

There is a large national Concierge Medicine company based in Florida that has recruited me for several years in a row. This company charges patients anywhere from $2000-5000/yr to sign up with their doctor. The doctors agree to limit their panel sizes to 200-300 patients, and they still charge insurance companies for services that are covered. Frequently the offices are in high rent districts in big cities and wealthy suburbs. To justify the prices, the physicians provide additional services, such as aesthetics or “executive” physicals, running every unneeded test available once a year. That, to me, is Concierge Medicine.

By comparison, Direct Primary Care practices are usually retainer-based only, or monthly retainer plus small per visit price. They’re often focused towards patients that are underinsured or uninsured, offering primary care at a much lower rate than insurance premiums. They typically focus more on wellness and prevention and don’t try to sweeten the pot by adding extra, unnecessary services.

Now, ultimately, Concierge. Boutique. Direct Primary Care. It’s all just semantics. Either way you look at it, I will no longer participate as an insurance provider and will be holding my knowledge and ability for ransom, asking people to pay for it at a time when every dollar counts. Call it what you want.

But. If I do this right, in addition to providing better care for those that sign up, I think I can save money overall, as I have no doubt that I will be able to keep people OUT of the ER and OUT of the hospital by being there when needed and by proactively managing chronic disease. I think I will be avoiding burnout that is causing a lot of my colleagues to just drop out of the profession all together, worsening the doctor shortage, which is so extreme here on the island. And, hopefully, such an arrangement will give me the time and ability to do exactly what you talk about , to work for barter and to work for free for those that need it. I have already been in contact with community health centers on the Cape to try and learn of ways to better meet needs here on the island.

The ethics of this are important to me. I feel like it came down to deciding between providing good, ethical care to a small number of patients who can pay for it or providing mediocre, inadequate care to a large number of people, rich and poor, and continue focusing more on the entities that control the money in healthcare (employers, hospital systems, health insurance companies, the government) than on patients. It’s estimated that for every scheduled visit, a primary care physician spends 7 minutes face-to-face with a patient and then, along with staff, spends 45 minutes on managing the patient’s payer needs, i.e., on getting paid. That, to me, is unethical.

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