Friday, May 20, 2022

Concierge Medical Care

Medical Care in America you some of the best in the world and yet it seems to benefit no one.

I mentioned before that our doctor passed away unexpectedly a few years ago. She was a great doctor, General Practitioner or GP, which is the hardest job in the world, I think. If you're a specialist, I think it might actually be easier, as you are always doing the same procedures and seeing the same symptoms and diagnosing the same illnesses. But a General Practitioner has to be a jack-of-all-trades and be able to pick up on a subtle cues as well as handle very mundane things like infected toenails and whatnot. It's hard work and it doesn't pay very well to be a GP.

We looked around for a new doctor after our old doctor passed away and somebody suggested we try this young cardiologist who was accepting patients for General Practice. I kind of felt like we were using a Ferrari to drive to the grocery store. He was highly specialized in cardiovascular care, but we needed somebody to help us with more mundane things like, well, infected toenails.

When the only tool you have is a hammer, every problem looks like a nail.  So the first time we went to visit him, we both ended up having a stress test, and I end up in the hospital having a heart catheterization procedure to install stents which turned out to be totally unnecessary. I had zero stents installed but my doctor did make medical history by finding a heart in a lawyer.

He warned me that if I continued with my current lifestyle, I would be in a world of woe by age 70. And he may be very well right about that. He was, however, pushing a all-vegan agenda, which I thought was a bit extreme. He also rides his bike like 50 to 100 miles a day in the streets and I warned him that that was probably more unhealthy then my carnivore lifestyle. And sure enough, during one of his rides, he fell off and punctured his lung and broke several ribs. He's lucky he wasn't run over by a car.

We decided to find someone who was a GP, and found a young woman who had a practice locally. I say "young woman" as she was in her 30s and pregnant at the time. That seems very young to me now. I remember my Dad mentioning that you know you're getting older and all your doctors are younger than you are.   And he was right about that.

She seemed like a good doctor and things seem to be going pretty well, although she seemed a bit distracted by other elements of her practice. Then one day we get a notice in the mail that she is leaving the practice of the hospital and opening the concierge practice on nearby rich people's island.

What is a concierge practice? Simply stated, it's a practice where you pay a monthly fee to become a patient of the doctor. The doctor does not accept insurance or any other form of payment such as Medicare or Medicaid but only cash. If you want to be reimbursed by your insurance company, you have to take the receipts and submit them yourself, fill out the forms, and wait for reimbursement.  However, since your doctor is now out of network, very little of the expenses are covered compared to in-network care.

There was a $100 fee just to apply to become a patient in her practice in a $250 per month fee to remain a patient.  That's $6000 a year, even if we never get sick. Obviously, this was not in the cards for us but aimed more at the people who live on rich people's island, or more specifically the people live on really, really rich people's island. To give you an idea of what those folks are like, John Travolta used to have a house there at one time.

We're just poor white trash living in a State Park and dependent on Obamacare. Concierge Medical Practice is not for us.

I'm not angry or disappointed at our doctor for doing this, however. It seems that our medical system is unsatisfactory to everyone involved, both doctors and patients alike. I noted before how our original doctor had a room full of files and clerks to keep track of all the records and more importantly file claims with insurance companies. The insurance companies then pay 30, 60, or 90 days later.  In the meantime the doctor struggles to keep the lights on. Once you have a steady stream of patients coming in, you can develop a pipeline of cash flow. But it also means that maybe you have 10 to 15 minutes to see a patient which makes the practice even more stressful.

The concierge model eliminates all of these problems. No longer does the doctor have to deal with insurance companies but just with the patients. As long as the patients are rich, this model works very well. But for the rest of us who have to rely on insurance or some sort of government medical program, it's not a very workable plan.

In addition, the doctors can charge what they considered reasonable fees for their services. With most insurance plans and also government plans, procedures are capped arbitrarily. So, for example, you have an office visit, the insurance company might pay $50 or $100 or so, which really is a loss leader.

With more extensive procedures, prices are also capped, with the patient being on the hook for the balance. However, oftentimes the patients can't afford to pay this balance and so the doctors, or more often, the hospitals have to eat this loss.

For more extensive procedures, the problem is even more acute. Since the insurance companies and government agencies limit the amount paid out for these procedures, it encourages doctors to become proficient on an assembly-line basis. I noted before that my doctor who performed my colonoscopy had patients lined up in an assembly-line fashion. There was very little bedside manner or chit chat. In fact during the last procedure - which I hope will be the last procedure I have in my lifetime- he spent barely 60 seconds with me after the procedure, saying that I was "fine." He was about to leave and I asked him for more details since I have a history of diverticulosis. He replied, "Oh you have poly-diverticulosis, you're large intestine is riddled with pockets." I was kind of shocked and then he said people with my condition rarely have serious problems and then turned around and left. I was left with more questions than answers.

But given the way the medical billing system works, there is very little time for bedside manner and chit chat. Get them in, get them out, get them billed, get paid. We've turned the art of medicine into a business.

So I understand why my former doctor wants to start a concierge practice. It's not just a bald cash grab, but an attempt to de-escalate and depressurize the practice of medicine. With a concierge practice, the doctor no longer has to worry about medical billing and insurance companies, but can actually practice medicine the way they want to, and take their time with their patients and reduce the amount of stress in their lives.

In a way it's what I did with my own law practice. While working for a law firm, I had to constantly bill, bill, bill. Every minute of the day had to be accounted for and we had to basically bill 8 to 10 hours a day just to make our billable hour quota., particularly since not every hour we build ended up being billable.

I quit the associate rat-race and it's mythical partnership track and started my own practice. I' eventually reduced this to working from home and taking on far fewer clients while being able to spend more time with clients counseling them and doing quality, contemplative work. Maybe I didn't make as much money as before, but I was able to control my own life better.

Of course, the downside to this concierge medical practice is that very few of us patients can afford it. In addition to paying the application fee and monthly concierge fee, I'm signing a blank check as to open-ended costs should I have any medical issues. Concierge doctors are considered out-of-network, so my insurance will cover a very little of their costs. Simply stated, the risk is too much for me to take.

Of course, some of our friends overseas will say that this is an example of how the American medical system is broken. In England or Canada they go to the doctor and never even receive a bill. However, I understand is there are physicians in private practice in countries with socialized medicine, and that people who have the means can engage private physicians and avoid the lines at National Health. In a way that is similar to concierge practice.

We have an appointment to see a new (conventional) doctor in June, and we'll see how that goes. We are fortunate that we are fairly healthy at this stage in our lives and haven't had any major health crises. Unfortunately, that seems to be the best healthcare plan we have in America: don't get sick.