Thursday, May 5, 2011
First, a big thank you to Katharine Van Tassel and the Health Law Prof Blog for allowing me the opportunity to be a guest blogger this month. With so much going on in the world of health care delivery and financing in the United States, it is an exciting time to be both a student and a teacher of health care law. Like all good teachers, I consider myself to be both of these things simultaneously. And besides, everybody around my law school is tired of listening to my rants about health care law and health care delivery reform, so I need a fresh audience.
The New York Times had an interesting article by Paul Sullivan on April 29 about what I call “extreme” concierge medical practices. These physicians treat the very rich, sort of like what we see on the USA Network television show “Royal Pains.” The article noted that the number of doctors practicing concierge medicine has risen fivefold in the last five years, but most of these doctors are practicing the more pedestrian model of concierge medicine, where subscriptions cost in the $1,500 - $2,000 range. The typical concierge practice caters to the upper-middle-class who want same-day appointments, extra time with the doctor, etc. In contrast, “extreme” concierge practices cater to the fantastically wealthy, who, for example, want to have their yachts outfitted with “ready rooms” where a doctor can practice telemedicine remotely on a patient. These physicians charge as much as $75,000 per year to ensure that clients can access their “extensive Rolodex” of medical specialists without having to endure long waiting lists.
These practices raise both legal and ethical questions, even more so than the typical concierge practice. Defenders of these practices, such as the American Medical Association, claim that their existence enhances the number of options for health care delivery and financing for all, although it also recognizes the ethical concerns raised by their existence. And some proponents of these practices appear to embrace a “trickle down” theory of access, claiming that the solutions to access provided by concierge practices will “migrate” to even the poorest people in the world. Others who practice concierge medicine don’t believe that it will have any real effect on the larger policy issues we face in financing and delivery of health care.
I’m not sure where I come out on this. I don’t believe in “trickle down” economics, but then I think of the high-powered fashion editor Miranda Priestly (played by Meryl Streep) explaining to her assistant Andy (played by Anne Hathaway) in the movie “The Devil Wears Prada,” that Andy’s cerulean blue ready-to-wear sweater is the product of “trickle-down” from the prior year’s high fashion trend. The reason that “trickle-down” works in the fashion context is that there are financial incentives for ready-to-wear manufacturers to duplicate what has worked for high-end designers. Therefore, if we want to see the general population benefit from the “extreme concierge” model, we need to provide incentives like the ones that exist in such practices to doctors in regular practice. Why do doctors want to go into concierge practices? They want more control over their schedules, to spend more time with fewer patients, and to be financially rewarded for good outcomes, rather than sheer volume. They don’t want to spend their days handling insurance paperwork. How can we provide these incentives to doctors who treat the rest of us?
The Patient Protection and Affordable Care Act (PPACA) takes baby steps towards providing those incentives, through encouraging and rewarding good outcomes rather than just numbers of procedures performed, but we need to do much more. We need to re-think how we train new doctors, and how we finance their training. Given the public’s reluctance to engage in anything more than baby steps when it comes to health care reform, it will be a long haul. But if we keep thinking about what makes doctors want to engage in “extreme” concierge practices, some good to the general public (other than a new television show) may come out of this model of practice.