It seems that a perfect storm of events has occurred over the last several weeks which has brought the discussion of health care delivery in the United States to the fore. The federally funded but state administered Medicaid plans, for example, are woefully underfunded and lacking in sufficient primary care and specialty care, and patients' frustration with a system which does not serve their interests has reached a critical mass. I've seen several recent newspaper articles on the subject, and just about all the Presidential candidates have their own ideas (mostly bad) about how to fix things.
But wait, you say, Medicaid is just a welfare program for the poor and chronically ill. You have Medicare, the federal government run program available (mandatory, actually) for those over 65. Didn't that program add a nice new drug benefit last year? It's saving me a bundle on my meds. What you soon-to-be Medicare patients don't realize is that when you turn 65, your doctor automatically gets paid about 30% on average less money for the exact same office visit with you, compared to when you didn't have Medicare. And it's illegal for you or your doctor to negotiate any fee higher than "Medicare allowable." How many doctors with full practices will be anxious to add new Medicare patients into their slots, which could be filled with non-Medicare patients paying 30% more for the exact same work? The answer is, Not Many, and therein lies a huge problem most people nearing 65 aren't even aware of. But it's real, and it's coming.
Unfortunately, another truth is that Medicaid, the federally paid but state managed health care system for the poor, pays so poorly that growing numbers of primary care and specialty doctors are refusing to lend their legitimacy to this fiasco by participating. Meanwhile Medicare payments to primary care doctors are down 9% in 10 years in inflation-adjusted dollars, and draconian cuts in payments to providers are on the way. Limitations in choice of, and even access to, providers are looming on the horizon.
Well, perhaps I'm guilty of overdramatizing a problem. Let's look at where all the new medical school graduates are going to finalize their training and choose their specialties. And over the past ten years, we've seen a stunning and unique drop in the students choosing general internal medicine, a drop of nearly 50 percentage points in ten years. These graduates are voting with their choice of specialty, and they are voting to choose more money over less, less work over more, respected work over ridiculed work, daytime work over night time.
The picture that I've drawn is one of a broken system, specifically a broken payor system. The health care you're given is still generally top notch, but that may not be for long. Clever, capable, driven young men and women will find other and easier routes to glory and service, without the debt, and where their services are appreciated. You appreciate your primary care doctor, you say? Well, unfortunately, the third party payor who pays your bills generally doesn't.
I'll give one actual example for your consideration. I recently bought a machine that allows me to assess for the presence of peripheral arterial disease. Having the machine helps me provide better care to my patients, most of whom have multiple risk factors for arterial disease. Incredibly, I get reimbursed more from Medicare for performing the test than I do for the office visit in which I use those test results to formulate a treatment plan! Not only do I get paid more for doing the test, but, even more ridiculously, it takes 5 or 10 minutes to read and interpret the test, while an office visit is 15 to 20 minutes on a good day. I'd be better off to stop caring for patients and just do ABI testing full time. Stories like this will be repeated and repeated until we finally realize that, in order to restore some balance to the health care market, patients must be put back in charge of their own health care spending.
The solution? I suspect there may be many solutions, but one solution for my small medical practice is to attempt to remove myself from being in bondage to the third party payors. I will attempt to offer to patients a guarantee of such a pleasurable and low-stress office visit environment, care that is focused on meeting the patients' needs, with bonus perks for Wellness-related services, that these patients will be willing to pay me an annual retainer just to get to be part of the practice--to have access to the annual Wellness review, the guaranteed work-in times, the "no-waiting" policy, the quarterly newsletter, the portable medical records on CD-ROM, the dietitian consultation, the massage, the discounted Aquatherapies and gym membership, and my personal cell phone number.
Having a cohort of patients who are focused on Wellness and who identify me as their doctor--that will make me no longer a slave to the third party payors, but will instead restore me to the traditional physician's role of being a servant of the patient. Instead of the government or Medicare or insurance companies determining what my services are worth, it will be the patients--the consumers of my services--who decide what they are worth. Nationally this concept is referred to as "patient-driven health care," and it results in excellent patient satisfaction survey numbers.
I believe in this concept so much, and I am so fearful of the status quo in medicine, that I am implementing a patient-driven, retainer-based protocol in my own practice. The response has been very encouraging, and I no longer have any real doubt as to its success. These patients have every right to expect from me top-notch medical care, efficiently delivered, in a manner that fits their schedule, not my own, and I am motivated to deliver for them and to be accountable to them for the results.
I'll let you know how it works out.