There have been a number of problems plaguing medical practice over the last quarter-century or so, but never have there been so many all converging at the same time. Concurrently, we are seeing aggressive medical cost containment; personnel and equipment shortages; expanding technology; strenuous and appropriate efforts at medical error reduction; soaring litigiousness and settlement awards; rising ancillary costs; a bewildering multiplication of health-insurance products, including managed care with its associated intrusion into medical decision-making; and even the changing role of hospitals. All of these forces have contributed to making the bedrock of medicine—the practice of primary care—a nightmare, if not impossible. For a primary-care physician to stay in business, meaning earning enough to keep the doors open and the lights on (or staying employed in a managed-care environment), he or she must see patients at an extraordinary rate with an entirely predictable result: dissatisfaction on the part of both the doctor and the patient and, ironically enough, increased utilization and cost and rising litigation.
Consider the following example: A patient with some mild ongoing medical conditions (for example, high blood pressure and elevated cholesterol) visits his primary-care physician with new complaints of shoulder pain and abdominal discomfort. In the current practice environment, the doctor has a mere fifteen minutes to deal with everything, including basic social civilities. Understandably, the conditions the doctor had previously taken responsibility for would take precedence (the high blood pressure and cholesterol level). Only then would the new symptoms be addressed. With the clock ticking and a waiting room full of disgruntled patients because the schedule was thrown off by an earlier minor emergency (an almost daily occurrence), the doctor resorts to the most expeditious approach: for example, ordering an MRI or a CAT scan for the shoulder and referring the patient to a gastroenterologist for the abdominal discomfort. With the pressure to meet the practice overhead, there is no time for the doctor to investigate each complaint properly with a careful history and examination. The result is a tendency for overutilization and inconvenience for the patient, much higher cost, and less than satisfaction for both the patient and the doctor. The doctor is forced by circumstance to function more like a triage assistant than a fully trained physician. This is especially true if the doctor is a board-certified internist, many of whom practice primary care.
Getting back to the question of why concierge medicine has evolved now and not in the past, it is my belief that it is a direct result of the “perfect storm” in healthcare and the resultant physician disillusionment and dissatisfaction with medical practice, which is reaching epidemic proportions as indicated by numerous polls. Doctors are unhappy, particularly primary-care doctors. In this light, concierge medicine is a reactionary movement rather than a mere marketing stratagem. It is an attempt to rectify the disconnects physicians have come to face between the medicine they learned in the academic setting and had hoped to practice and the medicine they are forced to practice, whether constrained by bureaucracy (government or managed care) or poverty (no equipment or facilities), and between the expectations of patients and the reality of what the physicians are actually providing.1 Concierge medicine has started in the United States, but because current physician disillusionment and dissatisfaction is a worldwide phenomenon, it will spread, if it hasn’t already, to other countries.
Intellectually, I have trouble with the concept of concierge medicine for the same reasons Dr. Herman Brown offers during his testimony for the plaintiff in Crisis. In short, concierge medicine flies in the face of traditional concepts of altruistic medicine. Indeed, it is a direct violation of the principle of social justice, which is one of the three underpinnings of the newly defined medical professionalism, requiring physicians “to work to eliminate discrimination in healthcare, whether based on race, gender, socioeconomic status [italics mine], ethnicity, religion, or any other social category.”2
But there is a problem. At the same time that I am philosophically against concierge medicine, I am also for it, which makes me feel decidedly hypocritical. I fully admit that if I were a practicing primary-care physician in today’s world, I would certainly want to have a concierge practice rather than a standard practice. My excuse would be that I would prefer to take care of one person well rather than ten people poorly. Unfortunately, it would be a rationalization and a rather poor one. Instead, perhaps I’d say I have a right to practice medicine the way I want to practice medicine. Unfortunately, that would be denying the fact that a lot of public money is spent training all doctors, including me, which comes with an obligation to take care of all comers, not just those capable of up-front fees. Maybe then I’d say that concierge medicine is akin to private school and that patients with means have the right to pay for more service. Unfortunately, that misses the point that those people who send their kids to private school also have to pay for public school through their taxes. It also misses the point that medical service, even basic medical service, is inequitably distributed, and I’d be adding to that inequality. Ultimately, I’d have to admit to myself that the reason I wanted to practice concierge medicine was probably more because it provided me with day-to-day professional satisfaction, even though deep down I’d lament that I’d become a doctor different from the one I had started out to be. Such an admission means that I don’t fault M.D.’s practicing concierge medicine but rather the system that has forced them to do so.
It is always easier to be a critic than a problem solver. Yet, in regard to concierge medicine, I do think there is a solution to limit its growth, and it’s a rather simple one. It involves merely changing the mechanism of reimbursement for primary care, which today is based on a simple, flat rate of slightly more than fifty dollars per visit as determined by Medicare (Medicare serves as the de facto trendsetter for health policy). Primary care is, as I have mentioned, the bedrock of healthcare, and accordingly this low, flat-rate reimbursement is counterintuitive, as evidenced by the example I gave. Patients and illnesses vary considerably, and if the patient needs fifteen minutes, thirty minutes, forty minutes, or even an hour, the physician should be paid accordingly. In other words, the reimbursement for primary care should be predicated on time and should include phone and e-mail time. It should also be on a sliding scale, depending on the level of training of the physician. It is only reasonable.
If primary care was reimbursed in such a rational fashion, quality care would be encouraged, significant autonomy would be appropriately returned to the primary-care physician, and satisfaction of both the physician and the patient would go up. As a corollary, the impetus toward concierge medicine would go down. I also believe such a reimbursement scheme would have the paradoxical effect of lowering overall healthcare costs by lowering utilization of subspecialty services. To help in this regard, reimbursement should be tipped away from procedure-based specialty care, which is the case today, and toward primary care.
Some people might worry that basing reimbursement on time would throw open the door to the kind of abuse that is seen in those professions where charges are based on time, but I disagree. I think abuse would be the exception rather than the rule, especially with the strong movement afoot to reassert medical professionalism with the newly promulgated Physician Charter.
On a final note, I want to say something about medical malpractice. When I finished my long medical training in the 1970s and opened a small private practice, I was welcomed into the throes of the first medical malpractice crisis, which had been provoked by a surge in litigation and plaintiff victories. What I experienced, like many other physicians, was a difficulty in obtaining coverage, since a number of the major malpractice insurers suddenly abandoned the market. Luckily, things settled down with the creation of alternative methods for physicians to find malpractice insurance, and everything was fine until the 1980s, when a second medical malpractice crisis loomed. Again, there was a sudden upswing in malpractice suits as well as a marked increase in the size of awards, resulting in a sh
arp and unsettling increase in insurance premiums.
During these two crises, the healthcare system was resilient enough to absorb the increased costs, mainly by ultimately passing them on to patients and the government through Medicare. As a result, the system didn’t suffer any huge disruption other than a marked hardening of the medical profession’s dislike for the legal profession, particularly what they considered the “greedy” malpractice plaintiff attorneys. I can remember the time well, and I shared the feelings. With my close association with academic medicine, it seemed to me that only the good doctors who were willing to take on the difficult cases got sued. Consequently, I was fervently behind what most doctors thought was the solution, namely tort reform, such as capping noneconomic rewards, capping attorneys’ fees, adjusting certain statutes of limitations, and eliminating joint and several liability.
Unfortunately, there is now a new malpractice crisis, and although its origins are similar—namely, another significant bump in litigation with even higher awards—it is different from the two previous crises and far worse. The new crisis involves both problems of coverage and soaring premiums, but more important, it is occurring during the “perfect storm” that is wracking the healthcare system. Indeed, it is one of its causes. Secondary to a number of factors, some of which I have mentioned, the increased costs the crisis is engendering cannot be passed on. Beleaguered physicians are weathering the full force of the gale, adding immeasurably to their dissatisfaction and disillusionment. Consequently, it is affecting access to healthcare in certain areas, with doctors moving or leaving practice and various high-risk services being curtailed. Beyond the economic woes, being sued is a terrible experience for a doctor, as Crisis clearly illustrates, even if the doctor is ultimately vindicated, which most are.
Since this new medical malpractice crisis is occurring despite a number of states having passed elements of tort reform, and because new information about the extent of iatrogenic injury has surfaced, I have changed my position. I no longer see tort reform as the solution. Also, I no longer myopically see the problem as a confrontation between the “good guys” and the “bad guys,” with altruistic doctors pitted against greedy lawyers. As the storyline of Crisis suggests, I’m now convinced there’s blame on both sides of the equation, with good and bad in both camps, such that I am embarrassed about my original, naive assessment. Global issues of patient safety and appropriate compensation for all patients who suffer adverse outcomes are more important than assigning blame and more important than providing windfall settlements in a kind of lawsuit lottery for a few patients. There are better ways of dealing with the problem, and the public should demand it over the objections of the current shareholders: organized medicine and the personal-injury malpractice trial bar.
The fact is that the tort approach to medical malpractice is not working. Studies have shown that, in the current system, the vast majority of claims are not meritorious, the vast majority of cases that are meritorious are not filed, and payments are often made with little evidence of substandard care. Such an outcome is hardly a commendable record. In short, the present method of dealing with malpractice is failing in its supposed dual goals of compensating patients with adverse outcomes and providing effective deterrence to medical negligence. On the positive side, there is plenty of money available for a better stratagem with malpractice premiums doctors and hospitals are forced to pay. Currently, very little of this money ends up in the hands of patients, and those who do get some all too frequently don’t get it until far down the road after a bitter struggle. We need a system that takes the money and gives it to injured patients without delay while, at the same time, openly investigating the reason for the injury, to ensure that it doesn’t happen to the next patient. There have been many suggestions for such a system, ranging from a kind of no-fault insurance to something akin to workers’ compensation to methods of arbitration/mediation. The time for an alternative approach is now.
Zuger, A. 2004. “Dissatisfaction with Medical Practice.” NEJM 350:69-75.
“A Physician Charter.” 2005. American Board of Internal Medicine Foundation, American College of Physicians Foundation, European Federation of Internal Medicine.
FOR FURTHER READING
Brennan, T. A. 2002. “Luxury Primary Care—Market Innovation or Threat to Access.” NEJM 346:1165-68.
Brennan et al. 1991. “Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of Harvard Medical Practice Study.” NEJM 324:370-76.
Brennan et al. 1996. “Relation Between Negligent Adverse Events and the Outcomes of Medical Malpractice Litigation.” NEJM 335:1963-67.
Kassirer, J. P. 1998. “Doctor Discontent.” NEJM 348:1543-45.
Melo et al. 2003. “The New Medical Malpractice Crisis.” NEJM 348:2281-84.
Studdert et al. 2004. “Medical Malpractice.” NEJM 350:283-92.
Zipkin, A. “The Concierge Doctor Is Available (at a Price).” NYT. 31 July 2005.
Dr. Robin Cook lives and works in Florida.
Robin Cook, Crisis
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