• Access is more than just insurance

    Many of my friends believe that money is the key to the highest quality care in the United States. The truth of the matter is that it’s sometimes necessary, but rarely sufficient. What really matters is access, and by that I mean an insider.

    The most expensive doctor is not always the best. You need someone inside the medical field to really know who’s good. And, even if you have the best insurance, you will often find that the waiting time for a specialist appointment can be months. That is, unless, you know someone like me.

    My friends know that they can call me anytime to get personalized pediatric care. I’ve been known to make house calls, and often welcomed friends to bring their kids to my house for me to check them out. There have been numerous times I’ve dropped an email to a colleague asking them to squeeze a friend into a visit, which has shortened the wait from weeks to days. I’m happy to do these things for those I care about. It’s part of being a good friend, and I know how hard it is to negotiate the health care system.

    But everyone doesn’t know someone like me. What are they to do? Some, with means, turn to concierge practices:

    The recession has not stopped some South Floridians who value personalized medical care from paying $1,500 a year or more to guarantee a same-day appointment with their favorite doctor.

    Frustrated with long office waits and feeling rushed during examinations, many pople have switched to concierge practices that charge an annual fee for what they consider top-notch care, including minimum 30-minute physician visits and access to the doctor’s cellphone number.

    Although some have criticized these boutique practices as medicine for the elite, others say they are the logical result of the deterioration of U.S. health care, with doctors forced to see many patients and perform lots of procedures to stay solvent.

    So, patients pay the hefty fees to get same-day appointments without long waits, thorough physical exams, 24-hour availability and doctors who are less stressed. They still need health insurance for hospital stays and specialists.

    I want everyone to have high quality health care in the United States, not just those who can pay extra. My clinical practice, although small, serves people on Medicaid or without insurance almost exclusively. I believe that we provide the best care we can, but there are limits. Getting an appointment is hard, and if you want an sick visit, it’s almost never with your doctor. Getting a specialist appointment can take months.

    In the past, I’ve often been a bit down on concierge medicine. It felt like we were creating two tiers  of practice, and that this would only make things worse for people with less money. But, recently, I’ve been thinking about how my friends basically enjoy concierge care because they know me. Is that fair?

    Moreover, I’ve been thinking about my parents. They live thousands of miles away, and I can’t do for them what I could do if they lived close by. But since they’ve paid for concierge care, I know they can get a same day appointment when they need to. I know their doctor answers their phone calls quickly. I know that if they need something, they will get it.

    I wish everyone could have such service, but it’s not possible in today’s health care system. We don’t have enough doctors. It’s why we are seeing retail clinics pop up. And it’s why concierge medicine is gaining steam.

    We have two choices. We can make it so that everyone can get really timely care, or we can expect the market to find ways for those who can pay extra to get it preferentially. And while I find the latter less preferable, as long as I continue to help those closest to me get better access, I can’t fault others for trying to do the same.

    • I’m going to keep citing Kaiser Permanente as an example. When I was insured through them, I did have 24/7h access to urgent care. The results would have been communicated through the electronic medical record to my PCP (and I had a couple of urgent care encounters in my first year). I could also email my PCP and usually get a timely response. While I wasn’t able to get same day appointments with my PCP, I could usually get one pretty quick. When my wife needed to see a specialist, she was able to get an appointment in the same medical center, same day.

      Not quite the same as $1,500/yr concierge medicine, but close enough for me.

      I have never worked for KP, by the way. I keep citing them because of my good experiences. I don’t think we need to go the full closed panel HMO route (actually KP is not fully closed panel and will reimburse partially for out of network care). However, there are things we can learn from them, and organizationally, I think building larger medical practices could help in ensuring quick access to physicians, all else equal and assuming you could hire competent administrators. The larger the practice, the more you can spread the relatively fixed costs of administrative staff and electronic records.

      • Hey, I’m not saying it isn’t possible to create a system that works. I’m saying it’s not happening. We have a doctor shortage, which is exacerbated in many regions. You can build Kaiser in California, but not everywhere.

        Moreover, what are people to do while the government sits on its hands and practices and hospitals are resistant to change?

        • Ah, but I’m not saying that we necessarily need to build KPs everywhere – although I think Americans should strongly consider doing so. What I am saying is that, all due respect to your profession, physicians need to get less enamored of independent practice. They need to organize. They need to hire competent administrators. They need to create integrated practices with flexible hours, including access to off-hours practitioners. It doesn’t have to be KP. But it has to be better than the status quo.

          Meanwhile, I’m going to occupy my local small physician practice with their incompetent administrative staff.

    • Excellent post. Paying for access is far more fair, impartial, and honest than a system where folks leverage insider connections to achieve the same ends.

      It’s also worth noting that once you eliminate third party payors and all of the flawed incentives that arise from that from the equation you can get access to primary and preventive care for less than the price of a monthly cable bill.


      (I have no affiliation with qliance)

    • Kaiser is not the answer. It can be adequate if you know how to work their system and are not elderly. When my mother needed an oncologist they managed to delay access until treatment was no longer possible. When my symptomatic 80-year-old and otherwise totally healthy father needed a colonoscopy (his gatekeeper at Kaiser had never ordered colon screening) they refused the specialty procedure. I brought him out-of-state to where I do have inside leverage, and he was diagnosed with colon cancer. In the office where I work we do provide same day service for illness to all our patients; we do leverage other providers as necessary ot get necessary care for our patients. It is not hard but you have to have staff that consider it important. Working through the obstacles of other offices who can’t be bothered is that hard part.