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.

During my third year of medical school at Cornell, I knew the type of medicine I would practice after graduation. It was during this year that my classmates and I experienced close-up views of several types of medicine; each of us did rotations throughout the hospital, sampling the demands of surgery, OB/GYN, ER, psychiatry, and so forth.

On Match Day -- the fated morning when we all gathered in the medical school's auditorium to tear open the envelopes of where we would complete our training -- you could almost match the doctor to the specialty. The brawn attracted the orthopedic surgeons. The fashionable sorts were often those headed for dermatology, and the primary care internists? We looked a lot like our patients, like regular people. In fact, one thing that distinguished us from our surgical colleagues is that we actually liked talking to other people. We preferred our patients to be awake, as opposed to being under general anesthesia as we helped them solve their problems.

Now, nearly two decades after graduation, I could not a pick the primary care doctor out of the crowd. They are too few.  Out of the hundred-plus doctors in any graduating class, there would be but a few budding young internists.  Last week as I traveled to D.C. to discuss my book, a new article appeared in JAMA documenting the fear that we may have reached the point of no return for primary care. In a survey of almost 1,200 senior medical students from the class of 2007, only 2% said they were pursuing a career in internal medicine! Two decades ago, this number was about 50%. Medical students are instead opting for more lucrative specialty careers, where the demands are less and the reimbursement is greater.

For those who have read my concierge medicine blog regularly, you'll know that politicians are having the wrong discussion about healthcare reform. As I've said repeatedly, "health insurance" is not synonymous with healthcare. If there is any question in your mind about this statement, look at the millions of Americans that have health insurance but have little access to their doctor. Once they finally get an appointment to see their physician, they wait an additional 90 minutes in the waiting room, only to see this harried professional for 7 minutes, before he rushes off to see the next victim. 

Last month, The Arizona Republic  published an article in which I was interviewed about concierge medicine. I thought it was a good article, one that would raise awareness of the benefits of concierge medicine and its potential for delivering better quality health care at an affordable price.

So imagine my delight this past Wednesday when I returned from lunch and my practice manager, Adela, said, "Dr. Knope, we just got a call from Blue Cross/Blue Shield. They read the Republic article."

"Wonderful," I said, "I'm making waves!"  

"Not quite," Adela said, looking down. "They informed me that they're canceling your contract because practicing concierge medicine is a violation of your provider agreement. They'll be sending you written notification of your termination from the plan." 

Terminated!

Well, I guess if you're a big insurance company and you want to intimidate doctors, and if you want to prevent them from escaping the confines of insurance company contracts, it's best to make an example of a concierge physician. Even better, why not pick a guy who just wrote the first book on the subject?

Hang him by his stethoscope from the highest tree. Let all the other concierge doctors watch him squirm as he dies a slow financial death. Likewise, let's show the public that insurance companies are nipping this concierge medicine thing in the bud. No point in patients signing up with concierge physicians. We'll soon put these medical mavericks out-of-business.

The problem with the BC/BS strategy is that it backfired. It did not have the intended consequences. It did not intimidate. In fact, it had the opposite effect. This action only served to highlight one of the great benefits that come to doctors who practice concierge medicine.

Because concierge doctors do not work for third-party payers, because we contract directly with our patients for medical care, being dropped from an insurance plan does not affect us. It does not affect our patients. The real story is not that another insurance company behaved badly. The real story is that it didn't matter!

This capricious termination by BC/BS, after a 15-year relationship with their company, did not damage me; financially or otherwise. It was an ineffective, chest beating display by an 800 pound gorilla. Remember:

• I have not billed BC/BS for my concierge patients since I opened my concierge practice eight years ago. Since my concierge patients pay me directly, I will not be affected financially by losing a contract with BC/BS. 

 • All of my concierge patients can continue to see me, so it does not affect them.

 • When I opened my concierge practice, I did not terminate those BC/BS patients who could not afford my concierge plan. I continued to see them at a financial loss, agreeing to accept BC/BS's low rates, so that they would not have to find a new doctor. The poor reimbursement I've received from BC/BS did not even cover my overhead expenses. By no longer being a "provider" on their panel, my income will actually go up. The sad thing is that these non-concierge patients will now have to find a new "provider" under the BC/BS umbrella. 

So what can we say about BC/BS's possible motivations? Over the past decade, I've literally saved this company thousands of dollars by not billing them for my concierge patients. I deliver a very high level of care to their "members" at a cost savings to them. I see these BC/BS members who cannot afford my concierge program at bargain-basement rates, thereby further increasing profits to BC/BS. My concierge patients are certainly not paying me under duress, so just what is it about concierge medicine that is detrimental to BC/BS? I believe it is this: The insurance companies want to control the flow of every healthcare dollar that moves through the system. The more money that goes through their pipeline, the easier it is to divert large sums of money to cover the costs of needless paperwork, inflated salaries for their CEOs and dividends they must pay to their Wall Street shareholders. It will be interesting to examine the spin that their PR department puts on this one; and yes, BC/BS does have a PR department!

By taking this action, BCBS has done doctors and the public a great service by illuminating the coming revolution in health care delivery:

• There are an increasing number of doctors who operate very successful practices like mine who are not vulnerable to the predatory attacks of insurance companies like BC/BS.

• In fact, BC/BS has no leverage; concierge doctors cannot be manipulated by the fear of a loss of income if their contract is canceled.

• Concierge doctors operate financially independent businesses, completely separate from insurance companies. BC/BS has no more influence over my practice than does Wal-Mart or McDonald's. BC/BS is just another independent business entity, selling a different service, which has no impact on my business.  

I'm all for free-market medicine and competition. Concierge medicine is the first example of real competition to enter the medical marketplace in years. This interchange with BC/BS is an example of how the free-market sorts things out. Blue Cross has every right to refuse to do business with me. Likewise, I can decline to do business with them. I don't need the government to protect me from "big business." I can simply offer a different kind of medical care and allow the public to choose where they want to spend their healthcare dollar.

I've recently authored the first non-fiction book on concierge medicine, Concierge Medicine; A New System to Get the Best Healthcare (Greenwood/Praeger, May 2008.)   Interestingly, the very first book written on concierge medicine was a fictional thriller by Robin Cook, which describes the tale of a concierge doctor who became embroiled in a medical malpractice suit.  Are concierge doctors really at an increased risk of lawsuits? 

I am a board-certified internist with 15 years of clinical practice under my belt.  When I opened a traditional practice in Tucson, Arizona in 1993 my malpractice premium was only $8,000 per year.  Despite having no claims or judgments against me, my rates have slowly doubled over time.  I was forced to change my malpractice carriers twice because my first two insurance companies left the state.  The number of malpractice lawsuits in Arizona was just too high for the carriers to make a profit. 

Interestingly, as a concierge doctor, I was approached this year by a new insurance company, Applied Medico-Legal Solutions to ask if I'd like my malpractice premium cut by 55%.  Was this some kind of joke?  Why would an insurance company offer me lower malpractice rates now that I was a concierge physician?  Was this company just doing some kind of promotional stunt to get new business?  Insurance companies are not benevolent folk.  Underwriters are the most cold, calculating species on the planet.  So when AMS thought concierge doctors were a good risk, I wanted to know why.

Recently I had the pleasure of talking with fellow physician and health advocate, Philippa Kennealy MD, MPH. As the director of The Entrepreneurial MD site, she is on the forefront of noting the health care revolutions wrung by physicians.

Take a look at her review -- "I daresay the book will frustrate the critics of concierge medicine, but that is what is so great about freedom of ideas and speech. At least one MD in the USA is a happy practitioner!" -- and then take a listen to our conversation.

In a recent New York Times article entitled, “Yes, the P.A. will See You Now,” writer Christine Larson describes how the primary care doctor shortage is resulting in the growth of “mid-level” practitioners of medicine.

According to the physician’s assistant (P.A.) interviewed for the story, “EVER since he was a hospital volunteer in high school, Adam Kelly was interested in a medical career. What he wasn’t interested in was the lifestyle attached to the M.D. degree. ‘I wanted to treat patients, but I wanted free time for myself, too,’ he said.” Terrific. Translation? I would like all the trappings of being a doctor – a stethoscope swung around my handsome neck (see picture), the patient care, the money – it’s just the time, the education, the night call and weekend call, the dedication, and that responsibility thing that I’m not too fond of. Doesn’t this physician thing of treating patients come in a different flavor? Isn’t there a “Doctor light” on the menu? Well, apparently there is. And as primary care doctors become extinct, it appears that many patients will soon be getting their medical care from such folk.

According to the Times article, the average salary for a nurse practitioner is $92,000 per year. The average total income for physician assistants in full-time clinical practice is about $86,000. Not bad, when considering that many real doctors in primary care earn between $120,000 and $150,000 per year. When you think about the difference in training (4 years of competitive pre-med studies in college, graduating with top grades to get into medical school, 4 years of medical school and 3 years of residency training – yes, including night call and grueling hours) the difference in salary hardly seems commensurate with the differences in professional roles and responsibilities. If you look at the cost of medical school, and the years of deferred income, it makes more financial sense to become a mid-level medical practitioner than to become a doctor. Is there any wonder why we have a primary care shortage?

For all of their talk in the national health care debate, I am beginning to think none of the politicians know anything about healthcare, and therefore cannot solve the problem. Since they have no understanding of medicine from the inside out, they approach our healthcare crisis like any other business problem. Guess what? It is not like any other business problem.

Trust me, I’m a doctor, and here’s what I know:

Insurance is Not Healthcare: Nobody is talking about the simple but important fact that insurance is not health care. The two are used synonymously by politicians, but they are not the same. Read this again: Having an insurance policy doesn’t mean that you will get good health care! Universal coverage is nothing more than universal insurance, which won't solve the problem of inadequate access to good primary care doctors, who, by the way, comprise the backbone of our medical system!

Senator Obama’s proposed healthcare plan to “bring down premiums by $2,500 for the typical family” by the end of his first term has been exposed by The New York Times as wishful thinking. The plan for “reform” was created largely out of whole cloth. It is not based upon any data. It is based purely on conjecture about how much we might save by implementing changes such as electronic records, “dealing more effectively with chronic diseases” and other nebulous constructs of the imagination. There is no data to support Obama’s projected savings.

Many of my physician colleagues who continue to practice in the system, point to third-party payers (insurers and Medicare) as the destroyers of medicine. Creating a massive third-party payer? Calling it universal coverage? That’s only adds gasoline to the fire.

The Primary Care Doctor Shortage: Beyond the misbegotten notions of insurance reform, what disturbs me even more greatly are the politicians’ ignorance of an issue even more destructive to patient care: the shortage of satisfied primary care doctors. There are many reasons why young doctors are shying away, and older doctors are leaving, primary care medicine. Primary care is poorly reimbursed. It is nothing but a bad job for those who practice it by current standards. Studies show that by appropriately reimbursing internists and family practice doctors, costly specialty care can be avoided. Clinical disasters can be averted and money can be saved by allowing a primary care doctor the TIME to make important diagnoses.

Although the word concierge can bring to mind a four-star hotel, in medicine, concierge means close contact between patient and physician.

For patients with chronic diseases, the collaborative aspects of concierge medicine often extends that patient’s quality and length of life. For these patients, the word concierge never means frills.

Tessie Lucas, a resident in Jupiter, FL, hired a concierge doctor because her schedule is often too busy to accommodate day appointments. Lucas pays $1,500 per year for the access that includes housecalls, same day appointments and hospital supervision. The investment was precise for Lucas and her husband, both of whom have diabetes -- and even more striking -- carry no health insurance.

I predict as more patients with chronic diseases are rejected by insurers, and as more patients recognize the best care comes from patient-generated and monitored health care, the definition of concierge will include necessity.

A friend of mine recently hosted a cocktail party in New York in which a local, Harvard-trained internist was in attendance. My friend mentioned that he had just read my new book on the subject. The comment elicited an immediate visceral response from the doctor: “Concierge Medicine! You’ve got to be kidding. What a bunch of mercenary, elitist crap!”

Say one day, your patient comes into your office and says she is trapped in an abusive relationship. What are we, as clinicians, trained to say? What diagnosis do we give her? After we counsel her for the own safety, we address the one aspect the patient can control: her choice. We talk about the element of codependence. The excuses a patient gives us for remaining with someone who beats them up are immediately transparent. "You are not helping yourself or your children by staying with a drunken spouse who hits you," we say. It is very easy to see the problems in others; not so easy to see it in ourselves.

The notion that physicians remain in abusive relationships with third-party payers "to help our patients" is equally transparent. This codependency helps no one.