From the food for thought file: Two stories from Arizona

A few weeks ago, a Tucson physician was informed that Blue Cross Blue Shield was terminating his provider contract because he also had a private practice which allowed patients to pay for their care directly.

Did the insurance company believe it had complete control over his entire practice, even beyond his care of its members? It might appear so. But its reaction backfired...

One doctor’s story

Dr. Steven Knope, M.D., profiled in an Arizona Republic article this past summer, is among a growing number of doctors looking to break free from the assembly-line patient care they say they're forced to adopt under insurance companies, and to return to the era of Marcus Welby. By not tying their practices to insurance companies and by operating as independent businesses — just as doctors have done throughout history — third party payers no longer have control over their practices. No longer can they be manipulated into compliance with insurer mandates on their practices by the fear of loss of income, he said. By managing their own workloads and freeing themselves of the incessant red tape and overhead, paperwork and restrictions of third party payers, they’re able to provide better, more rewarding, quality of care; give patients more of the time and attention they deserve; and provide care less expensively.

He believes that more doctors could also be encouraged to provide primary care — more young doctors go into medicine and fewer older doctors leave — because they might find, as he has, that being a doctor and caring for people can be more fulfilling again.

But free-market medicine is the first real competition to enter the medical marketplace in years, he wrote on his blog. “Insurance companies want to control the flow of every healthcare dollar that moves through the system.”

Insurance no longer means just coverage for catastrophic medical situations, but has become managed care where both members and providers must comply with insurer directives. Under a third party payer, bureaucrats ultimately determine the care patients receive, not doctors or patients, and doctors must work under its terms and prices. BCBS isn’t the only insurer to terminate the contracts of providers who try to break away and establish independent practices.

The response of the insurer backfired, however, said Dr. Knope. It hasn’t had the intended effect of intimidating doctors to “prevent them from escaping the confines of insurance company contracts” and making him an example of those who dare to practice without them, he said.

Why? Because it didn’t matter and that’s the real story. Because we aren’t working for third-party payers and “because we contract directly with our patients for medical care,” he explained, “being dropped from an insurance plan does not affect us.”

It does not affect our patients. All of my concierge patients can continue to see me, so it does not affect them. When I opened my concierge practice, I did not terminate those BC/BS patients who could not afford my concierge plan. I continued to see them at a financial loss, agreeing to accept BC/BS's low rates, so that they would not have to find a new doctor. The poor reimbursement I've received from BC/BS did not even cover my overhead expenses. By no longer being a "provider" on their panel, my income will actually go up. The sad thing is that these non-concierge patients will now have to find a new "provider" under the BC/BS umbrella...

I'm all for free-market medicine and competition...This interchange with BC/BS is an example of how the free-market sorts things out. Blue Cross has every right to refuse to do business with me. Likewise, I can decline to do business with them. I don't need the government to protect me from "big business." I can simply offer a different kind of medical care and allow the public to choose where they want to spend their healthcare dollar.

But is it ethical for medical care providers to practice independent of insurer contracts? On his blog, Dr. Knope explored this concern that often surrounds a form of free-market medicine, called concierge medicine, which some accuse of being discriminatory. He raised interesting ideas that are so different from what we hear all of the time, they add perspectives that are valuable to consider as we look at all sides of the healthcare reform debates.

The first myth is that “the only ethical way to save our medical system is to create a universal health care system, managed by the government and abandon private medicine,” he wrote. “Nobody is talking about the simple, but important fact, that insurance is not health care.” Everybody talks about the evils of third-party payers, he said, and then wants to create an even more massive third-party payer system, calling it universal coverage, which will only add fuel to the fire.

He also talked about some of the misconceptions that have evolved about medicine in general since the days of Marcus Welby, and about the ethics of standard medical care as it’s practiced today.

Let’s look at the ethics of standard care medicine as well as concierge medicine. Are we to accept that the modern doc-in-the-box who accepts all insurance plans — the guy who sees 30-40 patients per day, spending 7 to 8 minutes with each — represents the ethical gold standard against which concierge physicians are judged? What is so ethical about this practice? Is it good to see so many patients and offer them so little of your time, just to pay your overhead? What about the fact that such doctors sign contracts with insurance companies, agreeing to ration care to their patients, so that Wall Street investors and CEOs can make obscene profits?

Concierge medicine is simply where people purchase their medical care directly from a doctor. But it’s not widely known that concierge medicine is available for as little as $100-$150 per month and many doctors see up to 10 percent of their patients free-of-charge. In fact, as the free market does, medical care is already becoming increasingly competitive:

Dr. Garrison Bliss in Seattle, [for example] has implemented a form of concierge medicine for all, in which patients get same-day service for between $39 and $69 per month and those who cannot pay anything are asked to do several hours of community service for their health benefit. Is this not better and more affordable healthcare than that provided by Medicare? What is so evil about this free-market option?

Some consumers fear that doctors practicing what’s called concierge medicine are only in it for the money and that the poor and middle class will be abandoned. But, according to Dr. Knope, those reactions are based on not understanding how concierge medicine works and how medical care has been traditionally provided. It has a place among the options for Americans, he argues. He rhetorically asks: So, there’s no reason doctors can’t care of patients with multiple medical problems in an eight-minute office visits?

I tried doing this for almost a decade. I was chief of medicine at a 400-bed hospital. I accepted Medicare assignment and took every health plan and every HMO contract in the city. I saw 40 patients per day. For those who believe that a doctor can do an excellent job in this model, I simply disagree... Doctors who like practicing medicine like this are welcome to continue doing so. If doctors feel they are benefiting more patients by practicing in a third-party model, have at it. But I disagree that one size fits all. It didn’t work for me.

If excellence is your goal, it has been my experience that TIME is a necessary ingredient to achieve excellence; time and attention to detail cost money... If patients want to pay their doctor for more time and attention to invest in their health, there is nothing unethical about this. Similarly, doctors who practice concierge medicine are not “unethical” just because you say so; they simply disagree with you.

While mulling over the ideas raised by Dr. Knope, the latest newsletter of the Institute for Health Freedom was released. In it, president Sue Blevins, RN, wrote that she’s also been thinking about the freedom to pay privately for health care. She wondered:

What’s wrong with preserving people’s freedom to choose and pay privately for their health care? Should everyone have to give up their freedom in order to extend health insurance coverage to others? Can’t Americans extend coverage without destroying freedom? Is the push for universal health care really about coverage or control? Are promoters of universal health care trying to coerce everyone into a uniform system? Why can’t advocates of universal health care work to ensure a true safety net for the uninsured, rather than create a trap that locks everyone into a one-size-fits-all system? Such a safety net could be created. But it would mean forgoing the push for socializing or nationalizing our nation’s health care system...

Arizona: 180 degrees from Massachusetts

It turns out that an initiative called the "Freedom of Choice in Health Care Act," also called Proposition 101, is up for vote in Arizona. It appears it might, in part, be in response to what’s happening in Massachusetts and efforts to ensure it doesn’t happen in Arizona and to guarantee that consumers cannot be penalized or coerced into participating in care mandates they don’t choose. The legislation, itself, reads very simply. As Ms. Blevins wrote:

According to the Arizona Secretary of State’s website, the ballot initiative known as “Proposition 101” would amend the state’s constitution to provide that no law shall

* “Restrict a person’s freedom to choose a private health care plan or system of their choice.”

* “Interfere with a person’s or entity’s right to pay directly for lawful medical services.”

* “Impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage.”

* “Impose a penalty or fine, of any type, for participation in any particular health care system or plan.”

Supporters of the ballot initiative want to ensure that no health-reform scheme will strip them of their freedom to pay privately for health care. Opponents are concerned that if the initiative passes, it could preclude mandatory socialized health insurance.

Perhaps, not surprisingly, in reading the various pros and cons written about this ballot initiative, it quickly becomes apparent that disinformation abounds and that to get to the facts, one needs to go to the original source of the legislation. The lengthy FAQ answers various concerns about who and what is behind the proposal, and the unintended consequences of the initiative for different people and healthcare professionals. One key concern, about the morality of such a program, is answered quickly. America will continue to care for the poor and those in need, as the Act will have no affect on Medicaid-Medicaid. Preserving freedoms does not deny them to others. It opens:

Why does Arizona need this initiative?

Efforts in Arizona and around the country are gaining steam to put complete control over your healthcare in the hands of government bureaucrats and appointed 'experts'. Government control means you will have less freedom to make the health care choices that are best for you and your family. Government control over health care means "healthcare-by-lobbyist", not the health care that you believe is best for you or your family. Two hundred and twenty years ago, some founders questioned the need for the First and Second Amendments, and the rest of the Bill of Rights, to be in the US Constitution... Our rights have been preserved by the First and Second Amendments. The Freedom of Choice in Health Care Act will protect the right to health freedom in the same way.

What will your initiative do?

The "Freedom of Choice in Health Care Act" will preserve and protect the rights of individuals to make their own health care and health insurance choices... The Freedom of Choice in Health Care Act will not in any way impact the funding of, or functioning of AHCCCS, our state's Medicaid program. People currently on Medicare will not be impacted. The ability of individuals to choose their health care providers and health care plans will be forever protected... [rest here]

Many of us still hold an image of Dr. Marcus Welby (1969-1976) as the kindly doctor who seemed to have all the time in the world to solve medical ills and who did so with a smile and caring bedside manner, who made housecalls, and never seemed to send a bill. Of course, the television character wasn’t real, but a lot of doctors and patients look back on that era fondly and hope to bring a little of that back into the reality of medicine’s future.