Friday, June 09, 2006

The Capitalization of Medical Services?

One morning last week I was rudely awakened by the blaring news report coming from my radio alarm about a private medical practice offering, for an extra charge, preferential patient treatment that would include services such as next-day appointments, three-minute return phone calls, and real-time access to a doctor by cell phone or email. I was horrified. If some patients pay extra fees for priority service, isn't response time and level of service for patients who can not pay extra fees necessarily de-prioritized and slowed? My jaw dropped a little further when I heard the doctor speaking for the practice rationalize the idea by explaining that without the extra revenue derived from premium services, his practice would be out-of-business within the next year or two.

I was immediately reminded of an issue I worked on when I was an advocate for artists and cultural organizations. In 2001, the United States Immigration and Naturalization Service (now the U.S. Citizenship and Immigration Services) implemented a $1000 premium processing fee for non-immigrant visa applications. This service worked in favor of businesses who could pay the fee to have the applications of new foreign employees processed in 15 days, but it significantly lengthened the time it took to process non-premium application (to as much as 120 days). As a result, the visa applications of international artists who could not pay the fee were delayed enough that some missed their own performances in the U.S. and many cultural institutions experienced booking difficulties.

I was a little groggy when I heard this news and I had missed the first half of the story, so I later Googled around for a matching news article with the information I missed. I didn't find an exact match, but I did find a number of other articles about the phenomenon—that is, concierge medicine or “pay-for-care” services. Concierge-style medical practices charge an annual fee of anywhere from $700 to $6000 for the patient conveniences mentioned above, and additional per-visit fees of $50 to $200 depending on the service provided. Many patients who utilize concierge medical services claim that these fee-based conveniences save them aggravation in obtaining care, provide them with better quality health care, and save them money and time in the long-run. Many of these patients also keep their regular health insurance to cover major and emergency medical needs.

I couldn't help but wonder, if I as a patient could pay the extra fees, why should I, on principle, have to pay anything on top of what I'm already shelling out for health insurance and copays, just to get decent service? Furthermore, would it not be selfish of me to opt for premium service knowing that medical care resources are limited and I would in effect be taking away a level of service from patients who can not afford extra costs?

Should a line be drawn between different kinds of services, those for which premium service is stratified by cost and those for which levels of service must be prioritized by something else? I thought to myself, it's one thing to charge extra fees for a service that does not directly infringe on the rights of an individual. I don't have a problem with the idea of stratefying cost according to speed of package delivery, as it is unlikely to affect any critical aspect of my life (like my health), and the use of premium services do not strain the resources of the delivery company. Health care services are sometimes prioritized by urgency of medical need, for example, in the emergency room, or when my physician will give me a same-day appointment because I have been running a high fever for several days. But once someone else can out-prioritize me by paying more, medical urgency goes out the window.

It then occurred to me that it may be more ethical to run a purely pay-for-service practice, as opposed to a practice that offered fee-based services for those who could afford them but still accepted patients who could not. (I'm not sure exactly how the practice on the news operated.) Some doctors who run concierge-style medical practices in fact claim that they are better able to care for their patients because they see fewer patients without sacrificing revenue and save time by not having to submit health insurance claims for patients. Declining rates of insurance reimbursements for providers was also cited as incentive to run concierge practices.

Still, the existence of a few concierge-style medical practices creates the potential for skew in who gets the better medical care and an environment of “you get what you pay for.” I can imagine that as things currently stand only a very small percentage of the population could or would be willing to pay several thousand more dollars a year for medical care. I am reminded of a conversation I had with a Philadelphia-based psychotherapist about the administrative and cost issues of insurance supplementation for mental health services: she told me that many of her colleagues had chosen to move their practices to Main Line areas, where patients would be likely pay for services not covered by insurance. This was not to suggest that those therapists were not aware that they were potentially contributing to an overall situation of better care for the “haves,” but that they had perhaps had made a very difficult personal choice, an ethical leap, that the benefits to perhaps themselves or their families or the future of their practices outweighed the issues (and their abilities to operate within them) presented in today's landscape of psychological and medical care in the United States. Though I certainly do not believe that the idea of concierge medical practices or psychological services available only in economically advantaged areas is a viable solution to the critical issues of a medical care coverage system that is groaning under its own weight, I do believe that it is worthwhile considering the idea that concierge medical practices are a valid development, or an ethical/pragmatic response to the current landscape of medical care coverage. This also forces consideration of the fact that, as things now stand, U.S. citizens are hardly on a level playing field in terms of medical coverage and quality of care, and I can't help but wonder that if pay-for-care medical service was the norm, things might not be that much different than they are now.

Some interesting news stories about concierge medicine:

and from the Miami Herald.