Insurance Free Medicine

I never thought I would be in academic medicine for so long. When I was hired about 12 year ago, I figured I would stay in academics for a few years and then join a private practice Internal Medicine group. Now, I can't even fathom that idea. One of the reasons I have stayed at my institution for so long is that I love teaching and the academic environment. However, a second reason is that the "real world" for primary care medicine is a scary one. As a salaried employee in a large practice, I am somewhat sheltered from the harsh realities of running a business in the current health care environment. Yet, I hear horror stories from my colleagues in the community that are struggling to survive. With reimbursement rates from insurances so low, and administrative burdens so high, many older physicians have retired and younger physicians have adopted new models of delivering care. These have various names such as "concierge medicine" or "boutique practices".

Though I have no intention of leaving any time soon, I know that (assuming there are not major changes via health care reform) the current model of a small group of primary care physicians who accept insurance is simply not sustainable. Yet, I have a hard time imagining myself practicing in one of these new models, or even attracting patients to my practice. Retainer medicine is one model, where primary care physicians are able to see a much smaller panel size (and thus increase access) by charging patients an annual fee, which ranges from hundreds to thousands of dollars. Though the model makes financial sense, the word "retainer" sounds too legalese for me and likely not easily understood by the lay public. I would prefer something like "membership fee" similar to something would pay to join a club. However, "membership medicine" or "club medicine" just doesn't seem to have a good ring.

"Boutique" practices often use a retainer model, but boutique can also refer to primary care physicians who charge for extra services such as laser hair removal or botox injections. There are many primary care physicians who still take insurance that have started using these kind of practices or have found other ways to meet their bottom line, such as selling nutritional supplements. Though there is no question that the public has a demand for these services, providing them for a fee as a primary care physician seems to carry some conflict of interest, since none of these services show any benefit in overall health. "Concierge medicine" is another term used with retainer models and boutique practices. This implies some sort of preferential treatment, but also usually is associated with "executive physicals" and a battery of unnecessary testing and high technology that again provides little in the way of proven health benefits.

Some physicians have continued to practice normally, but simply do not accept insurance. They have figured out that they can sustain a primary care practice if they simply refuse to accept the substantially reduced rates that insurance companies give them. These are often referred to as cash only practices. Yet, the term "cash only" seems to imply (at least to me) something shady or under the table. In addition, most patients who see cash only physicians, pay for these services using a credit card, making the name somewhat illogical.

However, the reason that all these new models of medicine exist boils down to one single reason: health insurance. Rates from insurance companies are so low, that the only way a primary care physician can make ends meet is to increase volume to the point that both access and care delivery suffer substantially. In addition, the administrative headaches which include fighting to get tests/medicines covered and arguing over claims once submitted, make the practice of medicine less than enjoyable. The often quoted study (that I co-authored) showing that only 2% of medical students are interested in primary care internal medicine, is often used to support the argument that primary care physicians need to be paid more. While the need to substantially reduce the growing income discrepancy between primary care physicians and specialists is critically important, the study actually showed that educational experience, nature of patient care and lifestyle were the primary factors influencing career choice, not income. This was regardless of students' medical school debt. In other words, it was more about the hassles of primary care medicine and less about the how much money they would make, that led students away from careers in primary care.

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care (in blogs, media, etc.) is "insurance free medicine." In my opinion, the term "insurance free medicine" captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance. Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like "boutique," "concierge," and "cash only" might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. In a previous post on KevinMD, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies. With a more frequent use of the term "insurance free medicine," patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

Though I have no immediate plans to leave the world of academia any time soon, I could certainly see starting an insurance-free practice if I ever did.