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Commentary Health Care

Frank DeFilippo: Health Care as Wealth Care Instead of Medicare

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Squeezed by ever-decreasing government reimbursements and overwhelmed by compensating increased patient-loads, primary care physicians are, in growing numbers, entering a way around both. It’s called concierge medicine.

And a major consequence, intended or not, is that they’re abandoning established patients along the way who won’t play or pay, or can’t afford, the high fees for fewer patients and more face time with their doctors.

Concierge, as anyone who’s been to France or stayed at a luxe hotel knows, defines a person who attends to the needs and wants of guests.

Concierge medicine is very much the same. But it comes with a hefty price, often around $1,800 to $2,000 a year out-of-pocket and on top of the costs of a patient’s health care plan. The annual fee gets a patient a doctor’s cell phone number, 24/7 response, and, as available, same-day appointments.

The up-front fee is not reimbursable or covered by any health care plan, including Medicare, which is mainly the squeeze factor on doctor’s fees through repeated cuts. Health care plans, including Medicare, will cover only most tests and lab work ordered by a concierge physician.

In other words, concierge medicine is becoming a costly alternative to crowded waiting rooms, emergency rooms, health hubs, and all those Docs “R” Us urgent care pop-ups along well-traveled roadways. And it’s an anodyne to anyone who has the plan and wakes up with, say, a sore toe and needs soothing reassurance from a personal physician.

Simply put, health care in America is headed right back to where it started, a two-tier system – those who can afford it and those who can’t.

And in the U-turn, primary care doctors are a vanishing breed as they abandon group practices, or the rare individual practice, for the more lucrative and personal practice of concierge medicine, which greatly reduces the number of patients they see in exchange for the up-front fees.

In many cases, those physicians who continue to practice primary care medicine are declining to accept new patients because they are at the maximum number they can reasonably treat. The search for an acceptable primary care doctor can be frustrating and often inconclusive.

The American Medical Association headcount of primary care physicians in Maryland is 5,281, a state with two major teaching hospitals, and others in the adjacent District of Columbia, while the national number is around 209,000, by another count. The shortage in Maryland is especially acute in the rural Eastern Shore, Southern Maryland and Western Maryland.

The shortage could become desperate over the next decade. The Association of American Medical Colleges predicts a shortage of primary care doctors of between 17,800 and 48,000 by 2034. To try and meet the need, 72 percent of medical schools have created programs to encourage enrollees to choose primary care as their field. Still other ideas include free medical school for low-income students to enter primary care.

The University of Maryland Medical School launched a five-year program a number of years ago to increase the number of students who choose a special primary care track which includes specialty areas such as pediatrics, family medicine and internal medicine.

To be fair, many doctors are simply fed up with government and insurance company actuaries dictating how to practice medicine.

The American Medical Association estimates that Medicare plans a total of 9.75 percent in payment reductions for health care in 2022, including a 3.75 percent across-the-board cut in addition to other cuts.

The average primary care doctor sees 2,000 patients or more a year, a patient manifest that usually allows about 15 minutes, or less, of actual face time, plus recommended lab work that does not involve a doctor, and possible referrals to specialists. As Medicare and other forces reduce or limit payments, patient loads at group or individual practices are increased proportionately to make up the losses.

One physician confided that “one cash customer is worth ten Medicare patients.” A patient coordinator at another group practice observed that “every time Medicare cuts fees, we increase the number of patients a doctor must see.”

As an added fillip, under Maryland’s unique hospital rate regulation system, about seven percent — or an estimated $1,100, by one accounting — of every health care premium paid by Marylanders goes into a pool to pay hospitals for the care of patients who are uninsured or can’t afford to pay. In 2015, for example, $958 million was paid to hospitals for care of uninsured or indigent persons, according to the Maryland Hospital Association.

The idea that spawned concierge medicine was the light-bulb balloon of a physician for the Seattle Supersonics who wanted offer the same personal time and attention for his private patients as he allowed for his superstar basketball players.

Concierge medicine has been around since its incubator days in 1996, and by 2000 a handful of doctors entered the nascent field. By 2010, about 5,000 primary care doctors had made the transition into concierge medicine which, by then, had become a corporate enterprise with a couple of companies providing the cover-to-cover conversion to willing physicians.

It’s basically a how-to program from setting up an office to marketing the idea to existing patients and reaching out for new bodies to replace those who decline to join the pay-to-play variation on the old annual physical.

Those patients who decline to join are encouraged to shop elsewhere for a doctor, or they are usually dumped and not assigned to another doctor within a practice. Presumably, the corporate guides get a nice piece of the action.

Concierge doctors are usually members of a network under the direction and management of a corporate sponsor. The corporate promoters, in their sales pitches and brochures, caution, in advance, that admission to the charmed circle of 600 is on a first-come, first-served basis. Fence-straddlers and those who hesitate are given the option of landing on a waiting-list.

An alternative moniker for concierge medicine is “retainer” medicine: The patient pays, in effect, a membership fee — either up front, or in monthly, quarterly, or bi-annual installments — to retain a slot in the practice, kind of like country club dues with golfing privileges. And it brings with the fee a range of services, screening and testing, needed or not, under the umbrella term of “wellness.”

The alternative: Stay healthy.