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ACA Threatens Promise of Concierge Medicine

Doctors in Texas are showing us what a medical system without comprehensive insurance might look like. The NYT profiles the rise of Texan “direct primary care” practices that don’t accept insurance. Instead, patients pay flat fees out-of-pocket. In return, doctors save both time and money that they can then pass on to patients. By not having to process reimbursements through third party payers, fill out convoluted forms, or hire administrative staff, they can charge their patients less and spend more time with them. Here’s some examples of how different practices are implementing this approach:

In Austin, Drs. William and Mason Jones — a father-son team — practice “concierge medicine,” treating patients under a membership model in which patients pay annual fees for access to a variety of services, including unlimited office visits, routine vaccinations and round-the-clock medical assistance by phone.

Mason Jones said his office was a “low-volume practice” that gives him the “luxury of time” to spend with patients. “This works out great for preventive medicine,” he said […]

In Laredo, Dr. Villarreal has had a different experience. His business model frees up time for him to see more patients, he said, without the added costs that come from filing insurance claims. He still sees 40 to 60 patients a day, he said, 20 of whom tend to be new to his practice.

“To me, there’s no other way I would practice medicine,” he said. “You feel like you’re a doctor again.”

One of the perverse results of the structure of US health care is that it takes doctors away from the kind of care they wanted to do when they entered the field. Replacing insurance with concierge medicine will not only reduce the bureaucracy, distortions, and over-spending that comprehensive insurance introduces into our system, it will also allow doctors to live their vocation more richly.

But there’s a catch here, as the article points out. Concierge medicine isn’t a new trend—we’ve covered it here before. But now that Obamacare is swelling the ranks of the comprehensively insured, doctors who don’t take insurance are increasing the pressure on the system. There’s a hint in the NYT piece that other doctors think it’s irresponsible for their colleagues to stop taking insurance just as the Obamacare rollout promises to strain practices and hospitals past capacity. This bias against innovators is what happens when federal legislation cements a dysfunctional system in place. Doctors who want to experiment with new models of payment face social pressure to abandon these experiments because of policy choices made in Washington.

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  • Andrew Allison

    “Doctors who want to experiment with new models of payment face social
    pressure to abandon these experiments because of policy choices made in
    Washington.” Wrong, they face social pressure from a (medical, in this case) guild dedicated to maintaining the status quo ante. I find it ironic, not to say hypocritical, that doctors who complain that they are not being allowed to do provide the care they want to, are utterly opposed to a solution which solves the insurance overhead problem.

    • Maynerd

      Most doctors I know don’t give a rip about the AMA or any other medical society. These organizations sold out long ago to government rent seeking interests.

      The majority of primary care doctors are now employed by large hospital systems and have lost their autonomy. The remaining minority are innovators bucking this trend and are largely impervious to social pressure. However, they will be stymied by laws and regulations that prevent this model.

      • Andrew Allison

        Absent some concrete evidence, I simply can’t believe that “The majority of primary care doctors are now employed by large hospital systems and have lost their autonomy.” A quick look at the Yellow pages suggests otherwise. The issue, surely, is whether the Guilds (AMA, etc.) actually represent the profession.

        • Maynerd

          The Yellow Pages are misleading. Many practices maintain their original name and location but have sold the practice to a larger hospital system.

          FYI KC Star 12/13

          December 28

          BY ALAN BAVLEY

          The Kansas City Star

          In unprecedented numbers, America’s doctors — those most entrepreneurial and fiercely independent of professionals — are trading in their autonomy for regular work hours and a hospital paycheck.

          Quickly and quietly, hospitals across the country have been buying up hundreds of doctors’ medical practices and hiring thousands of formerly independent physicians.

          Since 2000, the number of doctors on hospital payrolls nationwide has risen by one-third, according to the American Hospital Association.

          In the Kansas City area, fully 55 percent of physicians are now employed by hospitals, Blue Cross and Blue Shield of Kansas City estimates. That includes virtually all cardiologists and most cancer specialists.

          Read more here:

          • Andrew Allison

            As a supposed professional, please explain the relevance of “hundreds of doctors practices” and the hundreds of thousands of individual practices.

          • rheddles

            Yeah, that’s not concrete evidence.

          • SongDog

            Andy my boy, I have seen it first hand and the trend is accelerating.

          • SongDog

            Roger that, that’s what my wife’s group did. But, with the passage of time, their independence is eroding. A business bureaucracy, like any other, reaches to control what it can.

  • Maynerd

    The concierge model is the great hope for those of us trying to avoid the inevitable one size fits all single payer system. For those who disagree, I would suggest reviewing the Veterans Administration Hospital system. It’s the inversion of Churchill’s praise of the “Battle of Britain” British pilots. The VA version is – Never have so many done so little for so few.

    • Andrew Allison

      Maynerd, there’s already an alternative to the one size fits all single-payer system: all those extant. All of them permit private insurance for those who want (and can afford) a larger size. The concierge model is simply a reflection of that.
      I don’t disagree that the VA is a disgrace, but would suggest that this is result of government delivered, as opposed to paid for healthcare.

  • Boritz

    blah blah blah blah……”but the ACA threatens to quash their innovation.”

    You don’t need to be so specific. We get it.

  • lhfry

    Is there a nationwide list of doctors that don’t take insurance? An association that represents them? I’d like to find one in Virginia. I have Medicare, but it’s hard to find a GP you would want to visit who accepts its payments. Particularly if you are a healthy old person who doesn’t need a lot of drugs, tests, and procedures.

    • Maynerd

      The Feds regulate the Medicare patient population like no other. You may be able to find a concierge doc that will focus and preventative care and help guide you through the byzantine health care system when you get sick. Typically concierge docs ask for a flat annual fee for the additional TLC. In my opinion, it’s a bargain. Ask every doc, nurse, health care worker you know and eventually you should be able to piece together your local medical community.

  • rheddles

    Bureaucracies don’t innovate. They apply rules mindlessly.

    • Andrew Allison

      Wrong. They seek to expand endlessly,

  • SongDog

    All heavily regulated systems tend to stifle innovation. You are much easier to regulate if you do things the same way everybody else does.

    • Andrew Allison

      You may be right, but here’s an alternative viewpointis that the purpose of regulation is to force everybody to do things the same idiotic way.

  • cloud_buster

    Check out Simple Care:

  • PapayaSF

    The doctors don’t take insurance, but is there anything to prevent the patients from sending proof of their payment to their insurance companies and getting reimbursed?

    • Jeanne_DeVoto

      That’s how indemnity insurance works, but I have yet to see an Obamacare “Qualified Health Plan” that’s indemnity insurance. All of them I have seen thus far are HMOs, PPOs, or a variation: a network-based plan that restricts care to certain doctors and hospitals. If you have such a plan, going to a doctor who doesn’t accept any insurance won’t allow you to be reimbursed.

      (Indeed, it’s possible that there’s a regulation or a piece of the law that outlaws indemnity medical insurance, although I don’t know for sure.)

  • get2djnow

    I love that there are naysayers here. I don’t deny you your right to have an opinion, but I do deny you any right to impact my ability to deliver patient care to the patients who want my services at the rates I charge and that they are willing to pay. There are docs willing to accept anything from King Ovomit. Many of us are not. I, for one, won’t mind moving my practice mostly underground to make it work around your system.

    • Andrew Allison

      You are absolutely correct in so far as your patients, rather than their insurance companies or the taxpayer, are paying your fees. Might I however suggest that taking your practice underground would require that patients to pay the full price. Good luck with that!

      • get2djnow

        Given the penchant for government to slow down delivery of services (a feature, not a bug) in the hopes that my patients will die before they get what they need, I won’t have a problem with that. Thanks for the well-wishes.

  • free_agent

    The discussions I’ve seen are of “direct primary care” physicians that target the more affluent, and they compensate for spending more time with each patient by seeing fewer patients. That’s not reducing the cost-per-patient. I can’t tell if the cases this article discusses reduce the cost-per-patient either, but I’ll note that my primary care physician is paid $50 for an office visit, just like the direct care physician discussed in the NYT article. The difference is that mine is in Boston and the other is in Laredo, where the cost of living is a lot cheaper.

  • CincinnatiRIck

    This is essentially the healthcare system in the UK. Those who can, pay their own way and for everyone else, there is a pitiful National Health Service. So everyone is covered…sort of like Animal Farm…all the animals are equal.

  • Andrew Allison

    Don’t know how I missed this when posted but by encouraging the restriction of networks in order to reduce costs, ACA encourages concierge medicine. Not that I think it should be encouraged: it’s essentially scam based on the presumption that the services required will be less than the monthly premium.

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