I will preface this by saying that I'm generally highly sympathetic to the complaints of doctors about insurance company and Medicare reimbursement. I've got three relatives by marriage who are physicians, all of whom I love and admire greatly. And I'm particularly sympathetic to the complaints of primary care physicians about inadequate reimbursement rates for preventive care. Our health care system would be vastly cheaper and more effective in improving health if it concentrated more on preventive care. That emphasis is one of the most attractive things to me about Barack Obama's health care plan.
My wife and I, as retired federal employees, have good insurance -- the BC/BS Standard Option. We deliberately bought it, rather than some much cheaper options, because we wanted the ability to choose our own doctors, and we wanted good coverage, including if we become ill while away from Maryland. But now, even though we have good insurance, we both have to find a new primary care doctor. The reason? Our primary care doctor, and all of the other physicians in his general internal medicine practice, are moving to what is euphemistically called a "retainer practice," or "boutique practice," or "concierge practice" model.
What is this practice model, which I had vaguely heard about, but which to the best of my knowledge was being followed nowhere in Maryland? Briefly, you pay your primary care doctor an up-front fee, either annually, semi-annually, or at some other specified interval, and for that, you're supposed to get an annual physical, other appointments with your primary care physician (including house calls "if needed"), quicker appointments for non-routine matters, and not having to wait as long in the waiting room with the hoi polloi (although that's never bothered me anyway, since it's a good opportunity to do some reading).
The primary care doctor doesn't have anything to do with insurance companies or Medicare, and your primary care is paid for totally out of your own pocket. Of course, you still need insurance to cover you if you actually get sick and need to go to the hospital (although your primary care doctor's inpatient visits are covered, at least if you're hospitalized where he or she practices), or to cover visits to specialists.
The fee? They seem to vary from one part of the country to another, and from one practice to another, depending upon how gold-plated the service is supposed to be. The range I've found goes from about $900-$30,000 per patient per year, with the great majority in the range of $1,500-$3,000 per year. (The handful of higher-end ones include such perks as your primary care doctor accompanying you on specialist visits, or even flying to treat you if you're away from home -- although how he or she would do the latter if they're not licensed to practice wherever you happen to be, I have no idea.) The fee for my (soon-to-be-former) doctor will be $2,000 per year, payable up front, or a little more if I want to pay in two installments. And it would be another $2,000 a year for my wife.
Although my wife and I both have a couple of relatively mild chronic conditions (as do most people our age), we basically each see our primary care doctor twice a year in most years, and what amounts to $1,000 per appointment, payable in advance out of our own pocket, certainly seems more than a little steep for our budget. It would be one thing if this were just an isolated group of doctors deciding to only treat rich people, but it's obviously far more than that. We heard about this when one of my wife's friends, upon learning that her doctor (who used to be in the same group practice as our doctor) was changing to this practice model, looked on the website of the group that he used to be with (presumably because she was thinking about finding a new doctor in that group, although I'm not sure of that). She saw the announcement of this new practice model, called my wife and asked if she knew about it, and that's how we found out. We got the letter from our primary care doctor a few days later.
We then began calling around to friends about finding a new doctor and learned that the physician to whom our retired former minister and his wife have been going for more than 30 years, who is in an entirely different group (and who is in fact in a different suburban Baltimore county than our doctor) is also switching to this practice model. They've decided to pay what I regard as the ransom (which is a little less than our doctor will be charging, but still an outrageous expenditure for people living on a fixed income), simply because they're even older than us, have some chronic health problems, and simply can't deal with the idea of finding a new doctor at this point in their lives.
When at least three different medical practices in the same metropolitan area are making this switch at roughly the same time, it's obviously a trend. And what that trend means, if it continues, is that even people with good health insurance soon won't be able to have a primary care physician unless they're either wealthy, or unless they're willing to pay a FAR higher percentage of their income for health care than is now the case.
My wife and I have decided that, as a matter of principle, we're not going to encourage this trend by going along with it. That was my first reaction, and it's my even stronger reaction after exploring some web sites discussing how making this switch is being sold to primary care physicians. Universally, the argument seems to be that they can make a lot more money by taking care of a lot less patients, but limiting their practice to patients who can afford to pay through the nose for primary care. Sure, there's also plenty of verbiage about how this "restores the relationship between the physician and the patient" by getting the insurance company and Medicare out of the equation, but that only works if the patient can afford to pay both an outrageous sum for primary care services AND to pay for insurance to cover them for everything else.
What infuriated me is that our primary care physician actually had the gall to claim that this was the practice model followed by his grandfather, who was a family practitioner. His grandfather may well have charged patients directly for his services, but he didn't do it by demanding big bucks up front for services that might or might not be required, since this practice model didn't exist before the 1990's, from everything I've read.
The doctors who are doing this say they'll limit their personal patients to 600 patients per physician, rather than the 2,000-3,000 or so that most primary care doctors now have in their practice. To the extent that they're dumping their "surplus" (non-wealthy) patients on other primary care physicians, that means those physicians will have to take care of even more patients.
One of the things the Obama administration is going to have to address early on in developing its health care program is how to prevent this approach from expanding.
Some articles describing this trend:
http://www.boston.com/...
http://en.wikipedia.org/...
http://patients.about.com/...
http://medicaleconomics.modernmedici...