Happy – They don’t collect the same $ for the same services. My uncle was a cardiologist in a small town. He was paid half what cardiologists 15 miles away in the big city were paid. He asked around. Other docs started talking to their associates in the city to learn what they were being paid; the result was that all doctors in the small town moved their practices to the city. By driving 15 miles, they doubled their incomes.

The insurance companies will pay 10 doctors in the same town 10 different fee schedules. Fees may be off by up to $10 a code eitehr way for office visits. The insurance companies have a take it or leave it attituted when dealing with solo doctors or small groups of 2-3 physicians.

“The free market works – look at the success of retainer medicine.”

That’s like saying the auto industry is in fine shape because people are still buying Lexuses.

I think one large problem with advocating retainer medicine is that it is only good for primary care where there are few procedures. It does not at all provide an alternative to any type of health care where specialist are involved, procedures are necessary, or care gets complicated; it can only provide a supplement to insurance.

It does not follow that a free market will lead to more decision making by patients or an improvement in care. Free markets work well when buyers and sellers of products and goods compete freely for services/products in a transparent market where knowledge is open to both buyers and sellers at a place where transacations are once and done deals, and where the products/services are produced by the seller and consumed by the buyer. In medicine, patients don’t know what they want or need (that’s why they need doctors), care can be ongoing, and costs can escalte quickly even when pursuing the most conservative treatment strategies. Free markets in medicine work with patients who have expendable money and in areas that are “lifestyle” procedures (i.e. Lasik, cosmetics). Insurance works in part because it spreads financial risk; the question for medicine in the US is how to contain costs (if it did not cost so much, the political will to change medicine would not exist. Most other discussions, including the compensation of physicians, overal public health, would not have enough political force.) Politics will always make a difference in medicine– no other large first world country has delivery of medical care outside of government control, either directly via single payer or indirectly via tight regulation and control of insurance markets.