A provocative response on retainer medicine

I think someone who was a pure free-marketeer would see concierge practices as the free market version of means-testing — that is, those who had more, paid more.

Right now, my private, employer-provided health insurance sometimes reimburses *less* than Medicaid. Even though I would be in the “have more” camp compared to the median income in the US, I am often in the “pay less” camp anyway. Where’s the free market in that? So in some cases it seems that whether a person has private insurance or Medicaid/Medicare, the end result is that the doctor gets paid less for the service than it costs to provide, regardless of whether the patient is rich, poor, or in between.

The problem with “free-market driven” solutions to the problem (which I will define here as “providing adequate and timely healthcare to those who need it regardless of their income in such a way that it keeps them from dying or suffering in ways that could be alleviated by appropriate medical care”) is this: in a free-market driven solution, there’s no guarantee that revenues taken in by practices who charge more will be redistributed to aid the practices of those who charge less.

Each year I encounter this at my Church as we consider Lent. Lent is a Christian tradition that comes from the Middle Ages which encourages Christians to fast and give up luxuries in the forty days preceding Easter, both to encourage humility and to provide for the poor. In Europe in the Middle Ages, eating less during the early spring did mean that some people who might have nothing to eat may in fact have something to eat. However, for someone like me, just because I give up Ben & Jerry’s will not do anything to get a person who has less to have more of what they need. This is why many local churches encourage “service Lent” where instead of giving up luxuries, members of the congregation give up time to volunteer or money to charity.

Without any business relationship between a concierge practice and a general practice, what may happen is what happens today in the area of housing. Today, we see more and more “McMansions” being built, because this is what gives builders (who, in their defense, have a risky business that is not always guaranteed to return them a profit) the most reliable return on their investment.

However, McMansions are not generally what the society as a whole needs to be added to the housing stock, and profits from the sale of McMansions does not automatically go to build more affordable housing — it builds more McMansions. As a result, there are fewer affordable places to live for people who make the median income in that region, which has the effect of making housing prices rise overall, which makes everybody pay more for housing and causes some people to be homeless or suffer other privations because of the cost of their housing.

Free markets won’t automatically provide what we (consumers or citizens) want, despite the mantra of “choice” that is often trumpeted by its supporters. In many cases, what happens is that the suppliers in the market will all chase after the most profitable niche in a winner-take-all competition that bankrupts many of the suppliers and leaves many of the consumers with nothing available for them to choose that they can afford or want.

Ultimately, as citizens we may want different things for ourselves and our society than the free market may provide, and if we had a free market in healthcare or any other good which has effects on the quality of life for the society, we may want government to step in to curb the excesses and failures of a free market to provide those things to us. Both voting with a ballot and with your wallet count.

I disagree completely with the statement “Unless the economics of generalist care improve, you will see either a decrease in access or a decrease in quality.” Access can always be maintained by keeping open the floodgates to international graduates who often can begin medical residency after 5 or 6 years of prior training because they are not required to get a full four year undergraduate degree before starting medical school in their home countries. In addition, in many of these countries medical school is much lower cost than in the United States. Therefore, these foreign physicians are in a better position to be able to go into low paying primary care jobs in the United States as the pay and life here is still an improvement compared to their home countries. I would probably jump at the chance to come here and be a primary care doctor if I were in a similar situation. In addition, many of these foreign physicians are superb doctors and I see no data to support the assertion that there will be a decrease in quality. The bottom line is that access will be maintained by the influx of foreign physicians as well as the increased used of lower paid nurse practitioners and physician assistants. I would bet that your current UAB internal medicine residents from University Cayetano Heredia (Peru), University Pernambuc (Brazil), All India Institute (India), King Edward Medical College (Pakistan), Maulama Azad Medical College (India), NKP Salve Institute of Medical Science (India), and American University of Beirut (Lebanon) have nowhere near the 100K median debt load of US medical school graduates. The future primary care physicians is this country will be predominantly international medical graduates.

RG Lacsamana’s understanding of the term “free market” seems to be woefully inadequate. The reason that the “boutique” medical practices can charge high prices is because there are so few of them. If EVERY physician in the country set their own prices, competition would drive the overall costs down — a la the pre-medecaid era. IMO it was not fee-for-service healthcare that caused the huge rise in healthcare costs. It was 3rd party payors and “usual and customary” charges that led the way.