Today's NEJM includes many letters about - "Luxury primary care". Since most readers do not have a subscription, I will quote liberally. If you have access - Luxury Primary Care.

The article by Brennan on luxury primary care (April 11 issue)1 was of particular interest to us as patients of a physician who notified us only two weeks in advance that he would eliminate us from his practice unless we joined MDVIP at a fee of $1,500 per person per year.

Our reaction went from surprise to shock to indignation. For the most part, the services being offered were no different from those we have been receiving — that is, prompt responses to our telephone calls, timely appointments, and adequate examinations and consultation times.

We cannot believe that this kind of medical practice is legal. As Medicare patients, we are entitled to access to our physicians with nothing more than a 20 percent copayment. Without a doubt, if this practice is allowed to continue, we will have a two-tiered medical system in our country. How sad.

All threats to the doctor patient relationship are sad. The patients quoted here refer to medical care as an entitlement. Is your choice of physicians an entitlement? Are Medicare's reimbursement and regulations an entitlement? These are very difficult questions. We do not know why the physicians made this decision. It may just be monetary, or it may be more.

As physicians in the center of the controversy over luxury primary care, we were particularly struck by the absence of the patient's voice in the review by Brennan. The current system of primary care is the creation not of doctors and patients, but of those who pay for care — in general, insurance intermediaries acting on behalf of employers or governments. Since this system is not designed by or for the patients we serve, it is not surprising that there has been widespread dissatisfaction with the results it delivers. When those who pay for services are different from those who receive those services, problems arise. Some patients want something different, and we have responded to that desire.

Our practice is not an answer to the problems of the uninsured, nor is it offered as a solution for all patients or all doctors. Our practice is an answer to the needs of specific persons — patients and doctors — who have felt inadequately served by the system as it exists. We have risked our livelihoods and our reputations in an effort to prove that a better and different way of practicing medicine is possible. We believe that free choice and the marketplace of services and ideas are better alternatives than the status quo. Our success will be measured by our ability to deliver on our promises, as determined by the patients who choose our care.

This is a straightforward, honest response from doctors. Do I necessarily agree with them - no, but I emphathize with their point. They do emphasize a better way of practicing medicine.

Brennan sets out to "examine the . . . ethical issues that arise with [luxury primary care] practices." His chief concern is access, and he concludes with the prescriptive (as opposed to descriptive) statement that "as physicians we have a commitment to the equitable distribution of health care." What is the basis for this statement? Certainly, most people believe that food and shelter are more important than medical care, yet there is no expectation that builders have an obligation to provide for the equitable distribution of housing or that supermarket chains have an obligation to provide for the equitable distribution of food. The origin of Brennan's assertion lies in the concept, beloved by certain policy makers and health economists, of medical exceptionalism. Again, however, beyond the assertion that "medicine is different," there is no argument to sustain such a belief. The distribution of resources belongs in the political arena, and ethical physicians of all stripes can advocate for whatever scheme they are committed to, but clearly equitable distribution is not a problem for the individual physician, no matter how guilty he or she can be made to feel.

Very interesting ethical points made in this letter. Is medicine really different? Having chosen medicine, does that give me an unusual responsibility to society, beyond my own sanity, health and financial stability?

I think that the problem that is leading to plans such as "luxury primary care" is the woeful inadequacy of reimbursement for office-based medical care. The current standard for office visits of 15 minutes or less is not a matter of choice, but rather a matter of financial survival. With reimbursement rates as low as they are, a physician has to keep patient turnaround time short in order to keep a practice financially viable. The situation is made worse by the tendency of government to balance its budget at the expense of the medical practitioner. This year, Medicare cut payments to doctors by 5.4 percent, and additional cuts totaling 17 percent are anticipated during the next three years.1 Meanwhile, overhead costs for medical practices continue to climb. For instance, medical-malpractice insurance premiums throughout the country are rising at an average annual rate of 30 percent.2 Where will it all lead? Nowhere good, I'm afraid.

Points very well made. This echoes (and states better) points I have discussed frequently over the past several months.

When I attended medical school, the teachers repeatedly articulated the concept that my fellow students and I acquired a special responsibility to society by attending a state-subsidized medical school. In exchange for life-and-death responsibility and hard work, society would offer us respect and remuneration substantially higher than that afforded the average worker.

My perception is that lawyers and bureaucrats have dismantled the implied social contract that was described to me when I was a medical student. Production pressure has diminished "the calling" of being a physician. It comes as no surprise to me that some physicians have found novel ways to support themselves.

Agreed!

I think that the profession simply cannot tolerate structural inequalities in the ways in which sick people are treated and must resist libertarian, market-driven changes that create such inequities.

The author of the original piece responds. He declares himself anti-libertarian - and implies a need for greater bureaucracy.

If we accept a bureaucratic system, a one class system, will we get the best and brightest to become physicians? Why do expect the medical system to provide one class care? Certainly, one could argue that we should live in a one class world - equal housing, food, clothing, legal advice, etc. But communism does not work. You would not reward me as a basketball player or movie star. What makes physicians so different? Why shouldn't we allow payment for special attention? We are not willing to pay for everyone to get that care.

These are difficult issues. We must keep the debate focused on the problems of adequate care. We should not accept inferior care for all. Perhaps we can use this model to "fix" the entire system.