The Dying Doctor-Patient Relationship

​Healthcare in the United States is an industry like no other. Consumers of health care services and the providers of healthcare services are drifting farther and farther apart as well-meaning employers, insurers, and governments inject themselves into what should be one of the most intimate and closely guarded relationships. 

In any other business, goods or services are exchanged for money. The exchange often occurs at the time of service with the consumer at least somewhat aware of how their money is being spent. Only in the US healthcare system are goods and services bought and sold without a clear understanding of cost (on the part of the patient or the provider), and constantly subject to negotiation and denial by third parties only to be paid sometimes months (or years) later. 

Most large third-party payers, i.e. insurance companies, are for-profit enterprises. These are often publicly traded companies whose combined annual profits are measured in the billions of dollars. In order to be profitable, or even financially viable, they must deny more claims than they pay. In other words, they make money by refusing care--the interests of the shareholders are placed above those of the patient. 

Must is said about the rising cost of healthcare yet few talk about why they are rising. While certainly a multi-factorial problem, a significant driver is the effort to ration limited funds by governments and insurers alike. This is accomplished by denying service, or less visibly, reducing payments for services or cutting them entirely. In order to protect their own profit margins, healthcare providers respond by increasing the quantity or complexity of charges which triggers payers to make additional cuts. It is a self-perpetuating problem; one where no one wins, certainly not the consumers caught in the middle. 

Is there a way to break the cycle? Is there a way to restore the long-held "doctor-patient relationship"? In order for this to happen, patients must be empowered to make educated decisions on how they spend their money and healthcare providers must be able to clearly communicate the costs of common services. Prices must be fair and transparent. There must be competition and innovation to hold those prices in check. This may be difficult to do in a hospital setting where services are more complex and medical needs often emergent but we can start by requiring this sort of transparency in the services that we seek most often such as primary care. Enter DPC (Direct Primary Care) or what is often referred to as "concierge medicine". 

A DPC or concierge practice is essentially a subscription service. With a fee of $50-$75 dollars per month, an individual can typically access unlimited office visits, 24-hour phone service, and deep discounts for ancillary services such as laboratory studies and imaging. The motivation for the practitioner is to provide better, more efficient care rather than to generate billable encounters. 

A cash-based fee-for-service practice would be difficult for clinicians to maintain due to lower and inconsistent revenues. A subscription model, on the other hand, allows a practice to shift the focus from a transactional relationship to more of a stewardship with shared responsibility. With less concern for what each encounter generates in terms of revenue, a subscription-based practice can focus on providing value to the patient and working to improve both immediate and long-term health outcomes.

Third-party payers are not accepted in DPC practices though some sort of "catastrophic coverage" is still encouraged for those hospital, ambulance or specialty-based services not covered by the DPC. This shift helps to return health insurers to the business of insuring against disaster rather than directing every aspect of care. It restores them to the realm of financial products rather than health-related ones. 

Clinicians appreciate the freedom that direct primary care promises. No longer are treatment decisions directed by the insurer. The hours of tedious documentation and paperwork are drastically reduced. Mandates to adopt expensive and cumbersome electronic records all but disappear. Patient visits become opportunities to bond and heal and not to generate a bill.

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