开云体育

Concierge medicine started LONG before Obama got involved. It was created (IMO) by the reimbursement system, which encourages "churning" of as many patients as possible through in one day, rather than dealing with multiple (possibly interconnected) complaints in a single visit, which would be more satisfactory for the patient and lead to better care. The reimbursement system was designed back in the days when people only went to the doctor when they had an acute complaint of some sort. Today, high-quality medical care requires MUCH more than that, and is much more complex. Using the old reimbursement system, there is not sufficient added reimbursement for doing all that extra stuff to cover the time required to do it right.

In addition, office overheads for primary care have gone through the roof, and this (IMO) has largely been due to the administrative overhead of dealing with numerous insurance plans, each of which has its own forms and sets of rules, which also change at least annually. This requires much work that is not reimbursed, since it does not occur during a face-to-face visit with the patient and increases staffing needs. By refusing to accept insurance, an office can greatly lower its overhead.

Let me give a specific example. A patient has been on a particular medication for years and it is working well with no adverse effects. Then the insurance plan decides it doesn't like that medication anymore, and sends notification to (maybe) the patient and (maybe) the patient's primary care office. But the letter does not provide any info re which medication the plan would prefer. It is a guessing game. The office must have a person who specializes in dealing with these things and is able to stay on "hold" for protracted periods while trying to do the right thing for the patient.

In addition, if the "preferred" medication is somehow discovered, and the patient is switched to that medication, that may trigger the need for additional expense and inconvenience for the patient. For example, some blood pressure medications can cause alterations to kidney function or potassium levels. Thus a medication switch now morphs into the need for extra labs after the patient has been on the medication for awhile, and an extra office visit to make sure the blood pressure is OK. BUT - the pharmacy insurance company doesn't care about that, because the cost of those things is from a different bucket and it isn't THEIR bucket.

Offices are being encouraged financially to implement electronic health records (at great expense) but there are numerous vendors and none of the systems can communicate with each other, which limits the value of such systems. If a patient is seen in more than one location, it is still necessary in many cases to rely on old-fashioned mail and fax communication, which introduces delays and makes cataloging patient data in consistent ways much more difficult.

The whole thing is so fouled up I despair of it being unsnarled in my lifetime. I believe a single payer system is the only possible solution, but there are too many influential entities that want to preserve the status quo. I have worked for the VA and Indian Health Service systems and the office overhead was much lower. These are the closest thing to "single payer" that we have in the USA. Office overheads for Canadian primary care offices are 25% of those in the USA. That's a big contributor to our higher health care costs.

By the way - I am an IBM retiree who retooled and became an internist, and about 85% of my patients are Medicare. I happen to LIKE taking care of that age group. I think concierge medicine is unethical (I can remember that oath I took on graduation from medical school, one of the high points of my life) but I can understand why it happens.
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