The DIY Healthcare Revolution

Whoever gets elected President this Fall, it’s a safe bet that healthcare reform will probably be on the to-do list.

ByErik Goldman

If the U.S. puts a Democrat in the White House, the proposed healthcare reform will likely take the shape of “Universal Coverage.” That’s because most Democrats, like most Americans, have come to believe that it is impossible to have healthcare without health insurance. Hence, the only way to solve the healthcare crisis is to make sure everyone has health insurance coverage.

If we end up with…dare we say it…another Republican, odds are we’ll hear a lot of blather about unleashing market forces to rouse good ol’ American competition between insurance companies, which will drive down costs so regular folks can afford insurance. Employers won’t have to buy it for them anymore because tax credits, according to Republican candidate John McCain (R-AZ), will enable working families to buy it for themselves.

Like the Dems, most Repubs share the unspoken belief that insurance equals healthcare. They somehow conclude that having insurance corporations dictate what you can and cannot have healthcare-wise, is a far more American solution than having “the government” dictate the terms.

Problem is, American physicians—the people who actually do the actual healthcaring—don’t agree. For the first time, a majority of American doctors say they’d prefer a single payer national healthcare system to the fragmented for-profit insurance-based fustercluck we’ve got now. The Annals of Internal Medicine (March 31, 2008) just published data from a University of Indiana survey of 2193 physicians across the nation, the largest study of doctors’ attitudes on healthcare financing ever undertaken.

The survey found that 59% of doctors support a single-payer system (that’s the Canadian style thang) that would eliminate or reduce the role of private insurance plans. Support for single-payer exceeded 50% among all medical specialists with the exception of surgical subspecialists, radiologists and anesthesiologists—procedure-based specialties that sit at the top of the financial pecking order in insurance-dominated medicine.

These findings represent a major sea change in attitude. For decades, doctors have been strongly and vocally opposed to “socialized” medicine. But insurance plans have pinched, pushed and pummeled them to the point where they’re feeling they couldn’t be any worse off with a single payer plan.

A small but definitely growing number of doctors are making their feelings known by getting out of the insurance game. They’re joining “concierge” practices, in which their patients pay yearly membership fees in exchange for more or less on-call access. Or they’re starting medical spas. Or they’re converting their practices to good ol’ American cash-on-the-barrel fee-for-service. Or they’re starting up house-call businesses. Or anti-aging/aesthetic practices.

Some are dropping out of medicine completely and going to law school. A few, taking a “can’t beat ‘em, join ‘em” view, go to the Dark Side. They get MBAs and become health plan administrators.

The upshot of it all is that by the time the politicians figure out how to make sure every American has health insurance, there may not be enough doctors around to treat them.

Submitted for your approval (cue “Twilight Zone” music): The State of Massachusetts, where a Republican governor—some guy named Romney—succeeded in passing a first-of-its-kind, state-level universal health insurance bill. Everyone in the state now has or by law should have health insurance.

But what happens when they try to use it? They have to wait a looooong time to see a doctor, that’s what.

According to a recent New York Times article (“In Massachusetts, Universal Coverage Strains Care,” April 5, 2008) detailing the crisis in Massachusetts, the number of internal medicine doctors accepting new patients has dropped by half in the last year. The average wait time to see a general internist was 52 days in 2007, up from an already dreary 33 days in 2006.

Dr. Patricia Sereno, the president of the state’s branch of the American Academy of Family Physicians, told the Times’ reporter that her daily caseload has hit 22-25 patients, up from 18-20 in the previous year. Since she can’t put more hours into a day, it means shorter visits and hastier care.

Steadily declining insurance reimbursement for primary care services has made primary care a dicey career prospect for young doctors. Nationwide, the number of med school grads going into family medicine training programs has dropped by 50% since 1997. The fall-off isn’t quite so severe for internal medicine, but the number of newly minted internists who go into general medical practice (as opposed to subspecialties) has dropped from 54% in 1998 to 24% in 2006.

Young medical grads are choosing more lucrative specialties like dermatology, where competition for training slots is fierce. Only 61% of candidates whose first choice was dermatology last year were able to get training spots. The Times reported in a separate article that there are now about 64 applicants for every one dermatology residency slot. High-paying, procedure-oriented specialties like plastic surgery and otolaryngology are drawing grads with the highest medical board scores. In short, the young doctors are going where the money is.

Massachusetts’ legislators, scrambling to manage the primary care short-fall, are considering a bill that would forgive med school debt for doctors willing to practice primary care in underserved areas. But that’s not going to help the older doctors already in practice and trying to survive.

The Concierge or “Boutique” model, though still in its nascent stages, has a lot of traction with primary care doctors. Concierge networks, taking cues from the highly successful MDVIP (which stands for “Value in Prevention” according to the company), are springing up all over the country.

The core idea is pretty simple: Patients pay doctors an annual fee—which varies from region to region, plan to plan—to be a member of a doctor’s practice. In exchange they have more or less unlimited access to their doctor for a carefully-defined set of preventive, wellness oriented services. Short waits, luxuriously long visits, and personalized attention make it an appealing prospect for many patients.

Concierge programs do not replace the need for insurance on the patient side; most require members to carry some form of high-deductible major medical insurance plan. But they largely eliminate insurance hassles for the doctors, hence their strong appeal. Concierge groups like MDVIP, MD2 (pronounced, “MD-squared”), Signature MD, and Concierge Choice offer their doctors marketing and practice management support, in exchange for a cut of each patient’s annual membership fees.

I know several primary care doctors who’ve gone the concierge route, and so far they’ve got nothing but good things to say. For one, it all but eliminates the paperwork headaches that plague insurance-based practice. This, in turn, reduces practice overhead (kiss those billing clerks goodbye!). It affords them more time with their patients, and enables them to practice prevention-oriented care. Since they’re paid a fixed annual fee, they’ve got incentive to keep their patients healthy.

Other pluses include more control over their schedules, more time with their families, a smaller patient pool, and an end to the “treadmill” atmosphere of insurance-based practice.

The concierge model clearly has downsides, especially if you’re a patient and your doctor decides to “go concierge,” and you cannot afford the annual fees to stay in the practice. Critics argue that it is “boutique” medicine for well-off folks who can afford to play beyond the margins of conventional insurance. And since the annual membership fees only cover a circumscribed set of wellness services, patients can still end up racking up serious bills if some serious condition lands them in the hospital.

Then, there’s the scary prospect that once the concierge networks fatten up enough, the insurance companies will always swoop in and buy them. For the moment, though, the movement seems to be thriving as a viable way for doctors to practice prevention-oriented primary care, and to restore a healthier relationship with their patients. While clearly not a definitive answer to the nation’s healthcare crisis the concierge model seems to be a good solution for some doctors and some patients, a haven from the hell of insurance-based “care.”

Some doctors are completely dismissing insurance-based medicine and going exclusively fee-for-service. Though the transition can be rough, especially for patients who are used to having “someone” pay for everything, the end result can be wonderful.

Case in point is Dr. Brian Forrest, a family physician in Apex, NC. Several years ago, Dr. Forrest radically transformed his practice after realizing that, like other primary care doctors in his area, it was costing him roughly $50 in overhead for every $39 he earned via insurance reimbursement. That’s because he had to pay several billing staffers just to chase his money. He was working harder, earning less and staring helplessly as his relationship with his patients eroded.

So he dropped out of all insurance plans, and shifted to fee-for-service. He says the move has been very positive. He was able to drastically reduce his practice overhead, which lowers the costs to patients who pay a flat $45 fee per visit. He can spend 50 minutes of every hour with patients, and he breaks even after the first four visits of the day.

Dr. Forrest is certainly not alone. Doctors all over the country are moving back to fee-for-service. There are even companies like Modern Med (www.modernmed.com), founded by Scottsdale-area physician Jami Doucette, MD, and Seattle-based Precura (www.precura.com), started by a frustrated patient, which help doctors make the transition out of insurance-controlled practice, assist them in finding patients willing to pay, and in some cases help patients find health-savings accounts from which they can pay the doctors’ fees.

Call it DIY(do-it-yourself) healthcare reform—rather than waiting around for political solutions that will only give us more of the same, doctors and patients are starting to work together to find a healthier, less expensive, and more sane way of doing healthcare. I think that’s a very promising trend, and one our industry should support. After all, most health insurance companies never seem to see the value in covering nutrition-based, prevention-oriented natural healthcare. Doctors who move off the grid, so to speak, have greater incentive to keep their patients healthy, to say nothing of the fact that many of them are looking for fresh revenue streams to keep their practices fiscally healthy. Patients who opt out of insurance-based medicine surely have incentive to optimize their health.

In the spirit of empowerment and self-reliance, the DIY healthcare revolution has much in common with the natural medicine movement, and there is considerable overlap between the two. Leaders in the natural product field would be wise to keep a close eye on these trends.NW


New Conference: Erik Goldman is the editor of Holistic Primary Care-News for Health & Healing, a quarterly medical news publication covering the field of holistic which is holding its first conference, called “Heal Thy Practice: Transforming Primary Care” on Oct. 31-Nov. 2, 2008, at the Westin La Paloma Resort in Tucson, AZ. Concierge care, fee-for-service medicine and other trends described in this article will be among the topics discussed at the meeting. For more information about Holistic Primary Care or the “Heal Thy Practice” conference, visit www.holisticprimarycare.net or e-mail erik@holisticprimarycare.net.