One of my coworkers showed me a letter she had gotten from a local internal medicine physician, who explained that he was converting to what is often called "concierge medicine". In the letter, he complained that Medicare was not paying him enough for the work he did, and also that he spent long hours into the night doing insurance paperwork instead of being with his family. His solution is to stop taking Medicare and other insurances, and instead charge patients $100 a month (to be paid every 6 months in advance as $600). This would not cover any labs, medications or hospital bills, just his personal services. Furthermore, he is only going to accept the first 350 patients who contract with him-- I guess the others will have to scramble for another doctor. I don't know how many patients are in his practice now, but many doctors have a few thousand patients-- this could be a big problem in Huntsville with our current shortage of doctors accepting new patients.
My co-worker felt this was a fair thing for him to do, because he deserved to be able to make good money and have time for his family. I don't dispute his needs-- but I pointed out that this would bring in $420,000 yearly for him, even if these 350 patients didn't need many appointments. Typically a physician keeps 40% of total income for personal profit, but the percentage would likely be far higher in this case, since none of it would be used to purchase medications or vaccines, and his practice will not have to pay for insurance billing personnel. Probably not as much for clinical staff either, with such a reduced patient load. Patients who could afford these up-front fees, I suspect, would likely be wealthy and thus more likely to be healthier. Even though we might think they would want to come for more appointments, having already paid for them in advance, I doubt that these higher earners would really want to take too much time off from their work and leisure activities when not sick.
I believe this particular form of concierge medicine is unethical and unprofessional. First of all, regarding income-- the large part of a physician's medical education cost is actually borne by the public, through tax money distributed to medical schools and hospitals. Our tuition doesn't come close to covering the actual costs. To me, that means we owe a debt not only in terms of student loans but also to our communities. I feel quite sure this doctor was not dumpster diving for his groceries, although it is probably true that there were things he wanted that he could not afford (like all of us). Is the income a person makes really based on what she deserves, on the hours or effort expended? If this were true, public school teachers would make as much as surgeons-- their work does not end when the school bell rings, either. The truth is that our incomes are based on what people are willing to pay for our work, not on what we deserve. And as professionals, we are obliged to consider not only what people are willing to pay but also what they are able to pay.
As physicians, we are held to professional standards which go beyond market economics. We are to be compassionate towards our patients. The word compassion comes from the Latin for "to suffer with". Right now, our patients are suffering from healthcare rationing-- many completely unable to afford medical care, and many more unable to afford sufficient care to meet their needs. The professional response to this is first to be willing to suffer somewhat ourselves. I do not propose that we dress in rags, only that we do not attempt to profit at the expense of our patients having decent medical care. Once we have agreed to that, it is perfectly reasonable to speak out for in favor of fairer and more reliable physician payments-- and even to enlist the grateful help of our patients in doing so.
There are actually ethical methods of refusing to deal with insurance companies. For instance, there are doctors who work on an affordable fee for service schedule but who have a sliding scale for the poor. A way to do this on a concierge basis would be to maintain the same number of patients in one's practice, while charging a higher monthly amount to higher income patients and perhaps nothing to those who can't afford it. And the way I advocate is to convert to a publicly funded national health insurance-- an improved, expanded Medicare for All. This would also significantly reduce physician paperwork (note the word "improved"). By putting all of us in the same boat, it would push well-off patients to insist on proper physician payment, so that they could continue to have access to quality medical care.
An Alabama physician, Dr. Robert Bentley, is running as a Republican for Governor of Alabama-- one of his campaign promises is that he will not draw a salary until Alabama has sufficient jobs for its citizens. I do not like Dr. Bentley, who espouses some very regressive ideas. But would that he had issued a similar call to physicians not to increase their salaries by turning away patients who need care.