Putting the Physician-Patient Relationship First

All in all, these ambitious plans create situations in which physicians, instead of being the system’s heart, are asked to help finance their downfall. As Medscape, an online newsletter for physicians, put it in its July 9 issue, President Obama wants to address the needs of…virtually all Americans, with the possible exception of physicians. A Medscape reader poll bears that out: 76% of respondents agreed that physician oversight of health care reform is the only way to get the job done right for patients and for themselves.

Because physicians are the only people licensed to practice medicine, they have the power-often sadly unused-to make or break health care reform schemes. Some pioneers, seeing the handwriting on the wall, have protected themselves by going bare-not taking any insurance reimbursement and opting for a patient-funded practice. Called concierge medicine, direct care, or subscription-based practices, they all allow physicians a different way to practice medicine.

A Very Different Alternative

With some form of health insurance overhaul likely to accelerate the trend of rising practice costs coupled with declining reimbursement for physicians, some doctors will join those who have already exited a practice model funded by insurance payments. Physicians such as Garrison Bliss, MD, a Seattle-based primary care physician and vascular surgeon John Kenagy of Belmont, MA, disgusted with governmental and insurance company constraints on how they practice medicine, have escaped health care hell by stepping away from the madness. They hearken back three-quarters of a century to pioneers like Dr. Fred Mott, an internist who established a cooperative prepayment plan for physicians serving Depression-era farmers at risk of losing their farms due to ill health.

Thirteen years ago, Dr. Bliss had a plan to get out of jail, as he recalls it, by no longer accepting any insurance reimbursement, including Medicare. Instead, he offered patients a subscription service for 24/7 medical care. Back then I realized I was working for the wrong people-insurance plans that didn’t value primary care. Medicare is the ringleader of not caring, especially since the advent of RBRVUs [Resource-Based Relative Value Units], which looked great on paper but continued to reward expensive care while punishing cheaper care, he explained. He claims that with a subscription-based practice, physicians can earn three times as much income in half the office time, practicing medicine the way they dreamed about in medical school.

Today Dr. Bliss’s plan, Qliance, costs consumers between $39 and $79 a month, depending on their ages and whether or not they opt for direct supervision of hospital care ($20 per month). Most patients in Qliance and other concierge practices purchase a high-deductible health plan (or wraparound insurance) with a health savings account for expensive and catastrophic care. Although subscription-based fees may, at first, seem to resemble capitation in that doctors get paid one fee to manage care, Dr. Bliss explained that such fees differ in that when insurers pay, the insurers’ interests come first. When patients pay, the patients’ interests and satisfaction come first, or they’ll vote with their feet.