Healthcare reform is a complex issue and many people seem to appreciate getting more details.  I wish I had good news, but things are becoming more irrational by the day.  Over the past 11 weeks a lot has happened with the current Administration's plans to enact sweeping changes in our healthcare system. Tom Daschle, who was Mr. Obama's nominee for head of HHS (as well as Health Czar),stepped down amid scandal over the fact that he failed to pay over $140,000 in taxes. Though Mr. Obama expressed "absolute confidence" in Daschle right up till the end, Daschle admitted that he knew the gig was up when he read the New York Times Op Ed piece, which called for his head. 

Without Daschle to rapidly move universal healthcare through Congress, a legislative tool called "fast tracking" was just approved by the House last week, so that there will be only 20 hours of debate allotted to socialized medicine before it can be voted upon by the Democrat majority.  In addition, a supplemental tactic of incrementalization is being used by Democrat politicians to advance their agenda. As an example, the SCHIP program - which pays for the healthcare of children who do not meet Medicaid criteria - has been broadened to cover 11-million lives.

In the "Stimulus Bill", legislation was inserted to begin forming government mechanisms to make decisions regarding healthcare rationing. The language is vague enough to allow Congress to make broad changes in the way that healthcare will ultimately be rationed under government programs. Under any nationalized healthcare system, such as the Canadian and English systems, there must be someone appointed to ration expensive drugs, procedures and "unnecessary prolongations of life." As our national debt reaches incomprehensible levels, the available money for a national healthcare program will shrink. Everyone cannot be allowed to have the most expensive cancer drugs, heart transplants, bone marrow transplants or dialysis. Just like in an HMO, care will have to be rationed by some ultimate authority. In a nationalized system, rationing will be done by those who brought you the U.S. Postal Service and the D.M.V. as opposed to the henchman of an HMO. This is not a political swipe. It is a statement of fact.

As I mentioned in my first healthcare letter, we do not have the money to pay for our current nationalized healthcare experiments, which we call Medicare and Medicaid. To open yet another financial wound, we do not have the money to fund Social Security over the next 30 years. So before you buy something expensive, it would seem wise to ask if you can afford to maintain it. The unfunded liabilities for Medicare and Medicaid alone have been estimated at $47-trillion dollars. This is the cost of insuring 30-million Americans. We do not have enough money for these existing programs, much less to expand these services to cover the lives of 304 million Americans.

What I am telling you is that Medicare and Medicaid will run out of money. The system will go bankrupt. It will be like AIG, which was "too big to fail", but which has failed despite pouring billions into it. People in my generation, and those younger, are "investing" in a Medicare system which promises to pay big dividends in healthcare dollars during our retirement. However, the politicians running the plan understand that this is a fiscal impossibility. It is dishonest. That money will not be there for us. It will be all used up by the time we reach age 65. The reason is that there will not be enough young workers to fund the Medicare system and keep it going for the aging baby boomers. Does this scenario sound familiar to you? Have you recently read about other people who have set up scams like this? You guessed it. Medicare is a Ponzi scheme.

Definition: A Ponzi scheme is a scam in which a gullible public is enticed with the promise of very high returns, which is based upon paying off early "investors" from the cash from (hopefully ever increasing numbers) of new "investors." The whole structure collapses when the cash outflow exceeds cash inflow. The key in running a successful Ponzi scheme is to keep it going as long as you possibly can. For this reason, I suggest that President Obama nominate Bernie Madoff for the new White House Health Czar. Though Madoff broke the law, so did Timothy Geithner, who now runs the Treasury Department. Using the same logic that "Geithner was the only man smart enough to run the Treasury" (and therefore we needed to overlook his white collar crime of tax fraud), the same argument should be made for Madoff. Only Madoff has the experience and expertise in complicated Ponzi schemes to convince Americans to ignore the pending bankruptcy of Medicare as we embark on a nationalized healthcare program, which would be 10-times larger than Medicare.

Let's keep things in perspective: Madoff absconded with only $50 billion dollars. This is chump change compared to the unfunded Ponzi scheme of Medicare, which has an unfunded debt of almost $50 trillion. $50 billion is insignificant when compared to Mr. Obama's plans to "reserve over $700 billion dollars as a down payment for nationalized healthcare" in this country. The unique skills of Madoff will be needed to convince Americans that this nationalized system will provide the needed care for all Americans.  Understand that I am not being partisan here. I am skeptical of all politicians. President Bush started this irrational ball rolling by funding the Medicare drug program under the guise of "compassionate conservatism." There was no money for this drug program, just as there will be no money for Obama's nationalized healthcare program. The numbers don't lie; politicians lie - no matter what side of the isle they hail from.

So why is a doctor like me engaging in "politics" or going on a rant about the healthcare dollar? Because money is a necessary part of the discussion! When you try to buy something on a credit plan that you can't afford, it is only a matter of time before that something is repossessed. Before we scrap private healthcare and open another credit card for nationalized healthcare, we should think about what we will do when we can't afford the payments. The answer is that people won't get the medical care they need, which is what happens in Canada.  In all seriousness, I'd start putting away some extra cash in the bank for the day when Bernie Madoff or his sons reject your request for an MRI of the brain. You'll need that extra money to travel to Dubai for your MRI or your knee replacement - to purchase quality healthcare in a free-market system that is not dominated by a government rationing panel.

What's Wrong with Insurance Commissioners Regulating Concierge Doctors?

 

So what was wrong with the Maryland state insurance commissioner getting involved as the self-appointed regulator of concierge medicine?  It has been suggested that his hearing may be "helpful" to physicians -to give guidance to concierge doctors so that they don't run afoul with insurance law.  Really?! 

 

I spent a decade of my life fighting corrupt insurance companies, ultimately opting out of the third-party system because I could not reform it.  I opted for a private practice model so that I would not be subject to the corruption of big insurance or the U.S. Government.  After ridding myself of insurance companies and Medicare, I find it difficult to believe that an insurance bureaucrat could or should regulate my private business.  Since insurance commissioners have obviously not carried out their duty to reform their own industry, why do they want to regulate mine?  Don't they have enough problems?

 

The purpose of the concierge movement is to allow doctors and patients to develop direct financial relationships, outside of the confines of insurance companies or bureaucrats.  Before the hostile takeover of our profession, this is just what private doctors did for decades.  Doctors didn't have to answer to insurance companies or commissioners.  Were doctors like Marcus Welby operating "insurance companies" because they had direct financial relationships with their patients and provided unlimited care and access to their patients?  Of course not; and neither are present day concierge doctors.  The idea that private doctors are operating insurance companies because of a few theoretical similarities between the two is absurd.  This position is not motivated by fact, but by a grab for power. 

 

The fact is that concierge doctors are private physicians operating private businesses.  To be under the commissioner's jurisdiction, Tyler would have to prove that concierge doctors meet the criteria for insurance companies.  He has not even come close to doing this in his report.  He uses words like "may" to describe whether "some" concierge doctors "might" be practicing insurance.  However, the failure to substantiate his position did not stop him from overstepping his bounds.    

 

We all know what insurance companies are and what they are not.  Since doctors do not engage in managing large risk pools of customers for unforeseen medical catastrophes - such as car accidents and bypass operations, paying for their drugs, their chemotherapy and their surgical procedures - it is very clear that primary care doctors are not acting as insurance companies.  Part of the problem, however, stems from the fact that what is now called "health insurance" is not insurance at all.  Healthcare insurance has become a bastardized form of pre-paid medical care.  Care to investigate this problem with your industry, Commissioner Tyler? 

 

The response by different physicians to bureaucrats like Tyler depends largely on your political stripe.  If you are a liberal, or support nationalized healthcare, all government oversight and intervention is good.  Business is bad.  Government is here to help people - to save them from their own weaknesses, stupidity, limited abilities and incompetence - to promote the collective good by making sure that all human beings are guaranteed the same outcome in life.  As some psychiatrists have proposed, liberalism of this kind is a delusion, by definition.  Interestingly, many of the my patients who hold liberal views in other areas of politics still recognize the importance of freedom of choice in medicine.  They understand that never during the history of man have all people lived the same lifestyle with the same resources and had the same outcome.  They never will. 

 

If you are a libertarian, excessive governmental intervention is bad news.  Libertarians believe that government's sole mission is to preserve the liberty and individual rights of American citizens.  Libertarians do not believe that people need to be saved - from themselves or from each other - by governmental oversight and regulation.  To the contrary, Libertarians believe that people need to be saved from big government, by limiting the size and scope of government. 

 

Libertarian doctors do not want to see medicine run like the DMV, the U.S. Postal Service or those who managed Hurricane Katrina.   They do not believe that government is benign and compassionate.  They believe it is largely incompetent and expensive.  Liberal physicians advocate for a single-payer system, which they trumpet as more "ethical" than a market-driven system.       

 

Commissioner Tyler's actions were typically bureaucratic.  They were presumptuous.  There are several problems with his appointing himself Grand Pooba of private medicine:

 

1)      There was not a single complaint from a citizen in Maryland about a concierge doctor to trigger this "investigation."  

2)      There was not a single documented violation of insurance law by a concierge doctor that would justify his hearing. 

3)      Without any legislative action, he has written a position statement on concierge medicine and sent out letters to private concierge doctors in Maryland asking them to consult with his office - just to make sure that no one is coloring outside the lines; lines that he alone has defined.

 

Stated simply, what commissioner Tyler did was overreaching.  When politicians overreach, there is always - not sometimes - ALWAYS a hidden agenda.  I would ask if the good commissioner was perhaps acting on behalf of big insurance, big government, or both.  Both big insurance and big government are threatened by primary doctors leaving the burning ship of third-party payer medicine.  Their concern centers on what the primary care physician shortage will do to their own self interests.  As the doctor shortage worsens, it will result in an inability of both insurance companies and government to control medicine.  Without enough primary care doctors, insurance companies cannot sell new policies.  They cannot maintain the policies that they already have. Government cannot grow and expand without primary care slaves to work in the cotton fields. 

 

Instead of reforming the broken healthcare system, Commissioner Tyler and his ilk would rather take aim at those physicians who are smart enough and strong enough to jump off the burning ship and swim to shore with their patients.  This intimidation tactic will not save the ship afire, nor will it prevent those weaker passengers onboard from drowning.  Promoting fear is not a good strategy on a burning ship.  It is frankly suicidal. 

 

I am not personally worried about politicians such as the commissioner and what they might do to me and my practice.  I am delusional enough and arrogant enough to fight those who threaten what I value.  I believe that the way to control overreaching is to confront it.   I believe that concierge doctors will fight for their liberty and that they will prevail.  We are far more motivated than insurance commissioners.  We have patients who will fight along side us to maintain their right to see the doctor of their choice; to purchase the kind of medical care that they feel best meets their needs.  We also have the U.S. Constitution on our side.  Finally, we have a much greater investment in our profession than bureaucrats have in this issue.  In battle, motivation is everything. 

 

To those who say we must "compromise" on the issue of governmental regulation of medicine, I disagree. Regulating private practice through governmental agencies transcends even the traditional differences that exist between liberal Democrats and far-right Republicans.  Concierge doctors, by the very fact that they practice concierge medicine, are taking a libertarian position in medicine, whether they realize it or not.  Patients who see a concierge doctor are also behaving as libertarians, at least in the area of their own health care.  Though most people don't truly understand what a libertarian is, they at least know that the founding fathers of this country were libertarian in their beliefs.  They were willing to fight for liberty and freedom.  If we wish to see medical freedom survive, we will have to be willing to pay the price as well; which means we will have to continue to fight for that right; not play nice with those who would take our freedoms from us.

On December 19th, Ralph Tyler, the Maryland state insurance commissioner, held hearings to determine whether concierge medicine met the state's definition of "insurance." The commissioner subsequently issued a 10-page report, recommending - among other things - that doctors contemplating opening a concierge practice should consult with his office first. Interestingly, concierge medicine was investigated by the Commissioner without a single complaint from a consumer, or a single violation by a practicing concierge doctor.

The obvious reason for even loosely defining concierge medicine as "insurance" is that it would allow the Commissioner to regulate the practices of private doctors. In fact, the calling of this hearing was so onerous to one Maryland group of five internists that they canceled their plans to open a concierge practice, despite the fact that hundreds of patients had already signed on to the new program.

As a result of what doctors consider serious overreaching by the commissioner, there has been a professional outcry from private doctors across the country, including the Society for Innovative Medical Practice Design (SIMPD), the national organization that represents concierge doctors.

"Our greatest objection to Commissioner Tyler's efforts is the ignorance of the singular attribute afforded by concierge medicine. We hold no faith in emulating any part of the insurance system. In fact, it is our frustration with insurers continuously interfering with our ability to practice good medicine that led us to the concierge medicine model," notes Dr. Thomas LaGrelius, president of the Society for Innovative Medical Practice Design (SIMPD), the national organization which represents concierge doctors.

Physicians in Maryland and elsewhere have joined to issue a response to the Report of the Maryland Insurance Administration on "Retainer" or "Boutique" or "Concierge" Medical Practices and the Business of Insurance.


Highlights of the report include:

o There Is No Justification for the Commissioner's Hearing or Report: The Maryland Insurance Administration did not identify, or document, any abusive practices by concierge physicians, nor made no findings that any concierge physician had engaged in wrongdoing or improper practices of the sort Insurance Administrations are uniquely suited to regulate. No justifications were suggested for why concierge physician practices should be subjected to the cost, expense, and administrative burdens of complying with the plethora of regulations and requirements that have been instituted to avoid and remedy misconduct by insurers and health care insurance plans except for the possibility that subjecting concierge doctors to such regulations will effectively discourage them from ever becoming concierge physicians.

o Concierge Practices as "Insurers:" Different Conclusions in Washington and Maryland: The State of Washington began a review of concierge care prior to formulating draft regulations in 2003, and ultimately adopted a specific statutory scheme in 2007. The statute imposes nondiscrimination, contractual, disclosure, and reporting obligations on concierge care doctors, but concludes that concierge doctors are not insurers. The Washington Legislature also concluded that concierge medical practices: "represent an innovative, affordable option which could improve access to medical care, reduce the number of people who now lack such access, and cut down on emergency room use for primary care purposes, thereby freeing up emergency room facilities to treat true emergencies."

 o Concierge, or Direct Practice Medicine, Is Not Just Healthcare for The Rich: In many cases a patient's participation is less than $1,000 per year. Additionally, use of a concierge medical doctor does not preclude use of traditional insurance.

o The Objective of the Commissioner's Actions was to Discourage Growth of Concierge Medicine:  As acknowledged by MIA, the objective of the effort to apply "insurance" regulations to concierge practices is to discourage "[t]he growth of retainer practices [because they] may decrease the number of primary care physicians available to those who cannot afford to pay an annual fee." Report at 5. This conclusion is inescapable. It is confirmed by the fact that the MIA does not specify any abusive or harmful acts by concierge physicians that need a remedy within the scope of the Insurance Administrator's authority and by the fact that the best MIA can do in the effort to characterize concierge doctors as insurers is to identify a few isolated parallels between concierge care agreements and insurance contracts that "could" justify "treating" those the contracts as "insurance agreements."

o Concierge medicine Is Essential to Solving One of the Nation's Most Critical Health Care Crisis; Exodus of Primary Care Physicians:  In a 2008 Physicians Foundation survey of U.S. primary care physicians, nearly half the respondents said that they would seriously consider getting out of the medical business within the next three years if they had an alternative. Similarly, according to a survey published in the Journal of the American Medical Association in September 2008, "only 2 percent of the medical school class of 2007 plans to make a career in internal medicine primary care."  As such, SIMPD agrees that the dwindling numbers of primary care doctors in Maryland is at the heart of the MIA investigation of concierge care. However, efforts to discourage concierge care - which is what we believe is at the core of the MIA investigation - will only exacerbate the underlying cause of physician exodus from primary care and distract the MIA and other concerned agencies from identifying and solving the real underlying problems.

o Concierge Medicine Does Not Adopt Any of the Principles of Traditional Insurance: The modest and insignificant parallels between the direct care agreements used by most of our members and the business of insurance are too inconsequential to support the effort to characterize concierge care as "insurance." To the extent there are risks that concierge doctors might engage in improper practices (such as overcharging, taking on more patients that can be served, abandonment, or coercion), there is already a plethora of applicable legal and ethical restrictions and no shortage of individuals and
interest groups to assure that these appropriate restrictions are enforced.

o Conclusion: "In conclusion, the MIA effort to enlarge the definition of "insurer" to cover concierge medicine doctors is wrong as a matter of law and unnecessary, distracting, and counterproductive as a matter of fact. It is big government latching onto an easily available tool (insurance administration oversight) to address a problem to which that tool is not suited (the exodus from primary care), while avoiding the real problem (the stifling, frustrating, oppressive, and parsimonious system for the delivery of primary health care).

The Wall Street Journal just published a brilliant article entitled, "Obama Will Ration Your Healthcare." So why is this article so brilliant and why am I so confident that this is true?

Tom Daschle is Obama's choice for secretary of Health and Human Services.   As the Journal points out, "Mr. Daschle complains about overuse of new technology and praises the United Kingdom's National Institute for Health and Clinical Excellence (NICE), a rationing system that controls government costs. NICE's denial of care is legendary -- from the arthritis drug Abatacept to the lung cancer drug Tarceva. These drugs are effective. It's just that the bureaucrats don't consider them cost effective."

It is not just "Obamaphobia" (the opposite of Obamamania) which makes me so confident that medical care will be rationed by a government oversight board, just like an HMO.  There is simply no other way to run such a system.  If patients on a national plan had a blank checkbook for their medical care, the system would go bankrupt long before the projected insolvency of Medicare.  There is only so much money that Congress can appropriate for healthcare.  Somebody has to ration that taxpayer money.  If the money is controlled by the government, who else but government bureaucrats will decide what care gets rationed?  You, the patient?  Your doctor?  Hardly.  There will be some group of people, equivalent to "medical directors" at an HMO, who decide if, when and at what age you can get your knee replacement.

My advice:  Maintain your private medical care if at all possible.  If you are relatively healthy, look into a high-deductible health insurance plan linked to a Health Savings Account (HSA).  Start putting money away in that HSA for a rainy day.  Find a "concierge physician" or doctor with whom you can establish a direct financial relationship; someone who will act as your medical advocate in a system that is broken and will only get worse.  You get what you pay for and medicine today is no different. 

All indications are that there will be attempts to ram a national healthcare program through Congress early in the Obama administration.  They will create a false sense of urgency, just as they did with the "financial bailout" of our economy.  No time to study the issue; this must be done or the society will collapse!  Tom Daschle has studied Hillary Clinton's failed national healthcare attempt and he does not want to make the same mistakes she made.  He was just quoted in the WSJ as saying that the new Congress needs to act quickly.  "We need to be on the offense.  This time around, lawmakers cannot try to address every detail when it comes to legislation.  Details kill."  Daschle said.

"Details kill?"  "Lawmakers cannot try to address every detail?"  We are just going to guarantee medical coverage for every American on the backs of the American taxpayer and we don't have time to discuss the details of how it will work or how it will be paid for?  Every good lawyer I've ever retained has reminded me that the devil is in the details!  It looks like we are in for a devil-of-a-new program.      

National attention has been drawn to recent hearings held by the Maryland insurance commissioner regarding whether or not concierge doctors in that state are, in effect, operating insurance companies without a license. Md. Ponders Regulation of 'Concierge' Medicine. If this were "found" to be the case, the insurance commissioner in Maryland, along with the state, could then regulate and control private doctors offering concierge care. What a great way to nip any physician independence in the bud!


Let's take a look behind the scenes and examine what has really been going on in Maryland. During a recent trip to Washington, D.C., I met a well-known internist from Maryland who is a member of a practice with five other internists. This group of doctors had planned to convert their practice to a concierge model two months ago. However, word of this move touched off a storm of public criticism, which generated considerable media attention (all negative, some quite vehement). This criticism ultimately led to this hearing by the insurance commissioner.These events resulted in a reversal of the doctors' decision to open their concierge practice. Fortunately, at least one concierge physician in Maryland, Dr. Tom Lansdale, stepped up to the plate and wrote an op-ed piece, In Defense of So-called Concierge Medicine, for the Baltimore Sun, which though cut and "edited" down to almost nothing, was nevertheless a voice of reason.  


Disturbing, though not surprisingly, the Maryland internal medicine group caved into public criticism and dropped their plans to open a concierge practice at this first sign of resistance. I say "not surprisingly," because doctors are often unable to confront criticism, even if it means standing for their deeply-held principles. Having met the head of this physician group personally, and knowing him to be a good doctor, I have no doubt that he felt concierge medicine was a better medical model for his patients. So it wasn't as if the insurance commissioner or the public pointed out some criticisms of concierge medicine that he had not previously considered. He simply got scared! He gave in to pressure. This is just what those who oppose any form of private medicine wanted. They rattled their saber to see if the doctors had any balls and they got their answer; NO BALLS here! Can you imagine a group of lawyers or dentists acquiescing in such a manner? It would never happen. This kind of resignation only happens with doctors.


When I opened the first concierge practice in Tucson eight years ago, there was a quote on the front page of the Arizona Daily Star from a University of Arizona School of Medicine professor which read: "This is boutique medicine at its mercenary worst." Being on the cutting edge of change involves taking a little heat and a little risk. Eight years after this scathing criticism, the Director of the University of Arizona Cancer Center, Dr. David Alberts endorsed the back of my book Concierge Medicine; A New System to Get the Best Healthcare (Greenwood/Praeger, 2008) with the following comment: "I call him, 'The Answer' -- i.e. the answer to our dysfunctional, impersonal healthcare system." Dr. Alberts not only endorsed my book, he is one of my concierge patients. As a leading academic physician, he is a strong supporter of concierge medicine. He knows that our current third-party system is broken and that patients in this system often get suboptimal care.


Those who wish to continue to enslave primary care doctors in third-party payer relationships are watching to see how concierge doctors and their patients will respond to these early shots across their bows. The Maryland experience is one of their first salvos and it is a win for the bureaucrats, simply because these doctors went down without a fight. This little hearing by the insurance commissioner also sends a clear message to other doctors contemplating opening a concierge practice in Maryland.


Let's look at the insurance commission's inquiry objectively: Does anybody, for a single moment, believe that concierge doctors are trying to emulate insurance companies by using a retainer model? The fact is that we are doing just the opposite. Most concierge doctors want nothing to do with insurance, which is why we opted out of the system in the first place. ALL of us explain to prospective patients that we are not insurance companies and that they must have - at a minimum - catastrophic health insurance to cover medical expenses outside of our professional services. Our written contracts document all of this in detail so that there is no ambiguity.


It is a frequently quoted truism for patriots in this country that "Freedom is not free." We have the freedoms that we enjoy only because those who preceded us were willing to go to war to preserve those freedoms. The same is true in the practice of medicine. If doctors want to preserve the right to deliver the kind of care that they feel is best for their patients, they are going to have to go to war with the insurance companies and politicians who would prefer to enslave them. Make no mistake about it, this is war. We are fighting over our freedom to practice medicine on our own terms. The patients who flank us will be fighting for their freedom to use their own money to purchase the kind of healthcare which is best for them. On the opposing side, the insurance industry will be fighting to maintain their huge corporate profits, their exorbitant CEO salaries and their shareholders' dividends. There is much at stake on both sides.


The real issue in this drama is that concierge medicine is a major threat to the big insurance companies, along with those politicians who support a nationalized healthcare system. Both big insurance and big government are now aware that there is a serious shortage of primary care doctors in this country. Without large numbers of primary care doctors under their control, they will not be able to implement their plans to control the flow of the healthcare dollar. This is what motivates these early attacks on concierge medicine. Follow the dollar and you will understand the motivation of the inquirers. This is all about big insurance and big government trying to control the healthcare dollar.


Before the insurance companies get too cocky about this recent victory, they should realize that all concierge doctors and patients will not respond the way that the Maryland group of internists responded. I am a board member of SIMPD, the national concierge physicians' organization that represents private doctors across the country. We are fiercely independent professionals. We are strong patient advocates. We will not relinquish our hard-won right to control the way that we practice medicine. All of us in this organization have fought many fierce battles with the insurance industry and we are not only surviving, but thriving. We have thousands of loyal patients who will never return to the kind of fast-food medicine that is dished out by HMOs and big insurance companies. Freedom to deliver and receive the kind of medical care that citizens in our country deserve is a right worth fighting for and I encourage like-minded doctors to fight along with us to preserve that right.

One of the more persistent vendors to solicit my concierge medicine practice are those for electronic medical records systems. They are "shocked" that I prefer to keep paper rather than electronic records in my office.

To be frank, I've been amazed by the stupidity of many physicians and politicians who believe that electronic medical records are cheaper, more efficient or somehow superior to a paper record. Finally, someone with a technology and business background agrees with me: Why Tech Can't Cure Medical Inflation.

Electronic records will not solve any of our escalating medical costs. Forbes' Lee Gomes strongly disagrees with President-elect Obama that electronic medical records will somehow save the system 80 billion dollars per year. Instead, Gomes suggests that electronic medical records may actually make things worse, by adding more "boxes to check," thereby increasing the number of billing codes used by physicians and their coders.

Gomes hits the nail on the head with the following analysis: "Instead, the heart of the problem is the U.S. fee-for-service system, in which doctors get paid to do things to people. The more technical and invasive the procedure, the more money they make. Doctors have responded in the expected Pavlovian manner, collectively shifting away from basic primary care toward expensive specializations that run up costs without necessarily improving medical outcomes."

I couldn't agree more. As the primary care shortage reaches crisis proportions, medical care will get more fragmented and more expensive. A system that imposes an electronic record system will do nothing to improve this crisis. Furthermore, those doctors who adopt electronic systems will have medical records that will be little more than templates for diagnostic codes - leaving out important individual elements in the patient's history, along with a loss of documentation of the physician's critical thinking.

At present, politicians hawking healthcare reform and drafting nation healthcare legislation are doing little more than paying lip service to the shortage of primary care physicians. The idea that medical students are going to flock to primary care if their loans are forgiven for several years of primary care service - as has been done in the National Health Service Corps - is ludicrous. This may drive a few students at the bottom of the class into primary care, but cannot do the same for attracting the best and the brightest. On the other hand, practice models like concierge medicine, where primary care doctors can earn a salary that is on par with what a specialist earns, WILL improve the primary care shortage. More primary care doctors practicing cognitive medicine, as opposed to procedural medicine, will not only help curb medical inflation, will also result in better care for patients.

 

Are you looking for a concierge physician in your area?  Dr. Steven Knope, the author of Concierge Medicine: A New System to Get the Best Healthcare (Greenwood Praeger, 2008)has just created the first online Concierge Physician Directory. Patients looking for a concierge physician can conveniently search the Concierge Physician Directory  by the state in which they live or by entering the last name of a physician. 

Concierge physicians who would like their names added to this Concierge Physician Registry can send an e-mail request, along with their contact information, to knopeadmin@gmail.com.  

This service is provided to both patients and concierge physicians free-of-charge in an effort to promote the concierge medicine movement and foster the development of direct financial relationships between patients and doctors. 

For those of you who have been following this blog, you'll know that I've taken the position that we are having the wrong discussion regarding healthcare reform in this country.  We do not have a crisis of insurance; we have an impending crisis of access to physicians, due to the primary care shortage.  The reason for the shortage is simple: nobody wants to practice primary care medicine under a third-party payer system.  This is why only 2% of the medical school class of 2007 opted for a career in internal medicine.

Finally, the mainstream media has awakened to this issue, as evidenced by a story in today's Washington Post entitled For Medicare, the Doctor is Out. 

The only thing that will save medicine is a return to the private sector, free of third-party interference, where patients have direct financial relationships with their physician.   This will allow primary care doctors to provide excellent care to a reasonable number of patients.  It will allow young doctors to repay their student loans should they desire to pursue a career in primary care medicine.   Attempting to enslave the limited number of primary care doctors in some nationalized insurance program will only make the shortage worse.  It's time to start talking about the real problem. 

It was only a matter of time before the insurance giants showed their hand in the poker game we call nationalized healthcare.  This morning, the Wall Street Journal reported that officials from America's Health Insurance Plans have proposed a universal healthcare program which will save us all. 

It doesn't take a degree in economics to understand that the U.S. Government cannot operate a nationalized healthcare program on its own.  They will need the big insurance companies to provide the massive administrative machinery required to operate such a large program.  Big insurance companies have been contracting with the government for years in the senior HMO market.  Not surprisingly, these insurance middlemen make huge profits by "managing" the government dollars Medicare beneficiaries have paid into the system over a lifetime.  Now big insurance is offering to provide the same services for 300 million Americans, as opposed to a mere 30 million Americans on the Medicare and Medicaid programs.  In creating a nationalized healthcare program, the pot of money will potential increase 10 fold!  How very generous of the insurance industry to offer suggestions of how best to spend this unimaginable sum of money.

So how do big insurance companies manage to turn a profit while providing all of the care needed by sick patients on Medicare and Medicaid programs?  How do they pay doctors and hospitals a fair fee for their services, so that doctors don't need to see huge numbers of patients just to pay for their overhead?  The answer:  They don't.  They can't!  Insurance companies cannot magically stretch the healthcare dollar anymore than you can magically stretch your own paycheck.  They can't print money.  They simply RATION care to the sick and underpay doctors and hospitals, for the sole purpose of generating enough money for their own administrative fees, plus the not-so-small profits for themselves and their shareholders. 

Here is how the insurance industry stated they would make their plan work:  "The group called on Congress to establish a public-private advisory group to recommend action in three areas: reducing wasteful spending, changing how doctors and hospitals are paid, and reducing administrative costs."

Let me translate this insurance double speak for you.  "Reducing wasteful spending" translates into rationing medical care to patients for profit.  "Changing how doctors and hospitals are paid" translates into paying them less.  Clearly, if doctors and hospitals were paid more or even paid at current rates, spending could not be reduced.  This fee reduction will result in doctors seeing even more patients than they see now, spending less time with each and further rationing healthcare.  Finally, "reducing administrative costs" translates into allowing the insurance companies to become the administrators for the program.  What this means is that much of the new healthcare dollar will flow through insurance company pipelines, which will be designed with leaks in strategic places. 

This is all a game of power and money is the language of power.  The name of the game played by the insurance companies is to control as much of the money as they possibly can.  It is no more complicated than this.  Welcome to our new nationalized healthcare program: HMO medicine for all.  The plan will be brought to you by the two most trusted groups in the country:  insurance companies and politicians.

When you combine the involvement of big insurance with a false sense of urgency being fostered by politicians like Tom Daschle and Ted Kennedy, we are in big trouble.  According to the Associated Press, the new Obama administration is working fervently to avoid some of the mistakes made by the Clinton administration during their attempt to implement a socialized medical program.  In Daschle's words, "We need to be on the offense.  This time around, lawmakers cannot try to address every detail when it comes to legislation.  Details kill", Daschle said.  It is clear that he does not want to discuss how the program will work, or how it will be paid for.  He simply wants to get a plan enacted into law, before any real discussion can take place regarding the ultimate costs.

This approach to nationalized healthcare sounds remarkably similar to the recent bailout legislation, which the majority of Americans opposed.  We were told that a massive 700-billion-dollar bailout was required immediately, lest we face another great depression.  Congress did not have time to explain the details of the bailout to the American people, nor will it apparently have time to explain how we will pay for a nationalized healthcare program. 

If you think 700-billion-dollars sounds like a lot of money, think about this:  "According to the Medicare trustees, the program's excess costs over the next 75 years -- that is, the difference between expected outlays and revenues -- is more than $36 trillion, which even they acknowledge is several trillion too low given current trends. Even if Congress doubled all individual and corporate tax rates, it still wouldn't raise enough revenue to pay for Medicare and Medicaid." 

So even if we were to double all individual and corporate income tax rates today, we could not pay for our current Medicare obligations, much less a new, much larger nationalized healthcare program. 

Have we learned nothing from the current financial crisis?  Wasn't this crisis due to Americans spending money that they did not have?  Who is going to take the shovel away from the Congress? 
 

 

The current controversy over plans from both Presidential candidates to raise taxes on the top 5 percent of earners won't hurt just the average Joe; in my view, the damage will spread to one of the most necessary of American small businesses: primary care practitioners.

According to ABC News, under Obama's plan, individuals making more than $200,000 per year, or couples making more than $250,000 per year, would pay higher taxes on income, capital gains, and dividends. McCain's campaign folds in a similar scenario, but with a longer time span.

 

In a fiscal environment already unfavorable to doctors -- student loans, startup costs, and deferred income during training -- I wonder why any new doctor would choose a career in primary care.

As I noted to national media this week: "In discussing healthcare insurance, the candidates are missing the boat.  The Journal of the American Medical Association just announced that only 2 percent of this year's medical school class will be entering the field of internal medicine. Now is not the time to penalize young doctors further with onerous taxes. Doctors defer any real income for 10 to 15 years due to their rigorous training. Once they finally start earning a living to pay back those loans, they are hamstrung by excessive taxes."

In an election season filled with conversation about health care access, I am amused by the final irony: Unless we do something to make conditions more favorable to practicing primary care doctors, insurance is a moot point; there will soon be no more doctors to access.