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An amazing way to practice primary care

October 18, 2008

Dr. Keenan shares a remarkable model for practicing primary care.  From the description, it sounds like he is providing what is now being called “concierge medicine” (and what used to be called simply “medicine”) for a $12 per month charge (which is above and beyond health insurance premiums).  For a moment, let’s presume this is how we all want medicine to be practiced–well, at least how the doctors and patients want medicine to be practiced.  (The insurance companies don’t really have a model for how they envision medicine.  They just want it to be profitable.)  What is the logical conclusion of all primary care docs adopting such a practice model?

1)  Reduced insurance premiums–Now, in order for this to be a consequence of this practice model we are going to have to make several assumptions.  The first assumption is that this model will lead to better quality of care and healthier patients.  This doesn’t seem too far out of the realm of possibility.  More comprehensive and better coordinated care has been shown to improve health outcomes.  The second assumption is far less plausible.  In order for the insurance companies to pass on the savings they are getting from healthier patients, they have to say “no” to more money.  I think we all know that this is unlikely.  A more plausible consequence may be that premiums don’t rise year-over-year and outpace inflation as they have been for the past decade.  Bottom line, patients could see lower health insurance costs under this model.

2)  Physician shortage–Most primary care doctors currently carry patient panels in the thousands (typically around 2,500).  This model calls for reducing those panels below 1,000.  Given the shortage we are currently facing, this would only exacerbate the problem.  There only two ways solve this problem–make more doctors or import doctors.

As far as making more doctors, the medical schools in our country aren’t chomping at the bit to increase their enrollment.  Why not?  It seems many schools are running at capactiy and would have to undergo capital improvement projects to increase their capacity.  Unfortunately, most schools are too busy constructing new research facilities to win fat NIH grants.  Med school administrators face a not too difficult decision in terms of economics–build labs that will generate hundreds of millions of dollars in NIH and private research dollars OR build some classrooms and cadaver labs which will probably lose money because tuition payments rarely cover the actual cost of educating a medical student.

Importing doctors is a viable option and one that has worked for many years.  Unfortunately, this has dire consequences for global health.  Essentially, we are stealing doctors from countries with far greater health needs.  AIDS has ravaged much of Africa due in large part to a shortage of health care workers who have left their native countries to work in industrialized nations that promise higher wages.  This is unacceptable.  More importantly, we can’t “import” our way out of this problem.  This is only a short term solution.

3)  Happier doctors–It seems plainly obvious that this model represents how most doctors want to practice medicine.  Doctors, especially primary care physicians, practice medicine because they enjoy spending time with patients and getting to know them on a personal level.  Having happier doctors may, in the end, solve the physician shortage problem.  More bright and capable young people will go into medicine because they will hear stories about genuine doctor-patient relationships and not the horror stories of five-minute patient visits and mountains of paperwork.  Regardless, doctors work very hard just to become physicians.  I think any model of care that could make their work more enjoyable is the least we could do as some token of appreciation for their sacrifice.

The most remarkable aspect of Dr. Keenan’s model is the reasonable cost of these services.  Most “concierge” practices charge in the hundreds of dollars per month.  Do the economics of Dr. Keenan’s model really work out?  What differentiates his practice from that of the typical “concierge practice?”  Are other practices offering similar services at much higher rates just greedy?

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