Thursday, September 19, 2013

All People Great and Small

An ancient symbol of cyclical regeneration and renewal, the phoenix seemed an apt if not particularly original blog title of my personal and professional story of hope and rebirth.  I am a forty-something family/general physician living in Texas in the United States of America.  I graduated from medical school over 20 years ago, studied surgery and later primary care medicine, and started my own medical practice in early 2001.  It was a "traditional" model, working with insurers like Blue Cross/Blue Shield, Aetna, Humana, United Healthcare, and Medicare and Medicaid to provide services to over 8,000 patients over almost 10 years.  I created, in cooperation with GE Healthcare, a model of primary care efficiency that, even today, I reminisce on wistfully.  The personal price of that exacting life lead to a self-destruction of sorts, from the ashes of which I am now emerging, to find a new and satisfying way to make a difference.

Today I began investigating concierge medical practice.  The phenomenon, likely present for decades, has been gaining momentum in the United States in the past 10 years in response to thematic patient concerns about a combination of slow access to care, perfunctory attention by professionals, and skyrocketing costs.  The emperor is naked, my friends, and everyone but the doctor knows it!

Concierge care -- sometimes referred to as boutique medicine -- is a cash-only healthcare delivery model.  To physicians, it appears deceptively simple and clean, without the hassles of working with insurers, with their deductibles, copays, EOBs, and denials.  I like the fact that it brings one more face to face with the true value of the service.  How much are folks willing to pay for my services?  But it is likely not as easy as it sounds.  The business of medicine, like medicine itself, has never been easy.  This is a discussion for another post, I think.

I worry most that I will marginalize those who need but can't afford my care.  It very easily could become care for the super-rich.  Costs are over and above what folks already dish out for insurance, and who can afford that?!  I have tried to placate my conscience by reminding myself that, with all of the savings, I will have time to give to indigent care clinics.  Of course, if I am not already giving there now, why do I think I will do so then?  This also is an issue to ponder in a future post.

Patients aren't happy.  The aforementioned delays in care, lack of meaningful relationships with clinicians, and costs that betray the true value of the experience, together with inundation by medical information are some of the reasons for this.

Clinicians aren't happy.  Long hours, Brobdignagian bureaucracy, plummeting remuneration, and a growing disillusionment in being able to establish clinical cause and effect all conspire to a resignation to the status quo.  Many wonder if they really are making a difference any more.

Payors aren't happy.  They are trying to meet both parties at some middle ground and all they seem to get is vilified.  Of course, they do raise prices, increase bureaucracy, and, not infrequently, engage in the practice of medicine, typically in the guise of cost-control or preventative care.  I could build a bonfire from the letters any ONE of them sent me, while in private practice, admonishing me to do this test or that, for their client's well-being.  And, not long ago, the CEO of United Healthcare took home in one year 132 million dollars (without stock options).  Who is worth that much?  Especially with the "healthcare crisis" looming.

The government, of course, wants to make everyone happy.  I don't think that new rules and regulations can assure this, not, at least, without more attention to personal responsibility.  We need to re-align our expectations of what healthcare can and should do for us.  This is definitely a topic for future elaboration.

In the end, our healthcare dilemma just doesn't have to be this hard.  The more complex a thing is, the more simple its themes.  When I graduated from medical school, and, later, residency, I was persuaded to rely on tests and x-rays to make clinical diagnoses.  Years later, however, I realize that one does not need all of this testing.  Most of the time, the patterns are evident to those who recognize them, and testing only increases cost with the benefit of increased patient anxiety.  Any job is like this:  we mature in our understanding of what is important.  Have we over-complicated healthcare?  Another exposition in the wings.

So here I am.

I worked for two years, after leaving my private practice, with a large group of physicians, the only job from which I was ever fired.  The hours were oppressive; the pay, insubstantial; and the sense of reward, absent.  The firing left me devastated beyond words.  Subsequently, I worked for a retail-minded purveyor of male hormone replacement.  Here the money was great; but the job, tedious and unfulfilling; and the sense of ethos, lacking.

So I quit.  And that was two weeks ago.

The phoenix.   There has to be a better way to get everyone happier with healthcare.  Is concierge care the answer?  Not as I have too often seen it done, a service to the very affluent.  Hopefully I can find something that obviates the usual payor structure though, but is still attainable by most, and satisfying to all.  There are no good roadmaps for this path, but this blog will record the path I took.  "I shall be telling this with a sigh somewhere ages and ages hence..."

Hoping, on the eve of Obamacare, that I can make a different difference, I will give you

All my best,

Dr. P

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