I know there are some HMO "Hells" out there. But even the worst of them is better than what we would get under universal coverage.
That is not my concern, personally. It's a concern politically, and for the system, in general, but not for my own access. My primary care physician doesn't participate in any plan and I pay her out of pocket. More and more doctors are opting out of programs that require them to accept assignment--whatever the carrier pays for a particular service without making additional claims on the patient.
Here is a clip I saved that explains the problem. I no longer have the source although I think it was the Federal Medicare site. Sorry for the ugly formatting. At the time I researched this, Senator Kyl was trying to get this changed but was unsuccessful.
<<Charge limits for physicians who do
not take assignment
Even if physicians do not agree to accept as-
signment, there are limits on the amount they
may charge you. All physicians who treat
Medicare patients are bound by all Medi-
care laws and rules:
• They must submit your bill to Medicare and
they must do so within one year of the date
of service. They may not charge a fee for
filing your claims.
• They may not charge you more than 15%
above Medicare’s approved amount. (In
Minnesota and New York State, the limit is
5% above Medicare’s approved amount.
Massachusetts, Pennsylvania, Rhode Island
and Ohio do not permit physicians to charge
anything above Medicare’s approved
amount. And Vermont and Connecticut do
not permit charges above Medicare’s ap-
proved amount for seniors and people with
disabilities with low-incomes.)
Note: Physicians do not have to treat Medi-
care patients. However, if they agree to treat
you, they must comply with all Medicare laws.
If they say that they do not “take Medicare,”
this means only that they do not accept Medi-
care assignment. They still must submit the
bill to Medicare. They are also still bound by
federal and (where applicable) state limits on
the amount they may charge.
Special agreements with your doc-
tors: They are not always binding
Some doctors who do not accept Medicare
assignment ask their patients to sign statements
(“waivers”) agreeing to pay the doctor in full
for services for which Medicare denies or re-
duces payment. In most cases, these waivers
are not binding.
For example:
• If you sign a statement agreeing to pay your
doctor whatever is charged—even if the bill
exceeds legal limits—you are not bound by
this agreement. In fact, your doctors are le-
gally obligated to charge no more than what
federal law permits and may be fined if they
willfully overcharge you.
• If you sign a statement agreeing that your
doctor will not submit your bill to Medicare,
you are not bound by this agreement. More-
over, doctors may not charge you for com-
pleting the Medicare claim form>>
Here is an article on boutique care I clipped it a while back.
---------------
Boutique Doctors Cater to Patients' Needs
Christine Wiebe
[Medscape Money & Medicine, 2001. © 2001 Medscape, Inc.]
Fed up with the pressures of managed care, a small cadre of physicians is forming "concierge"-style practices that offer top-notch accessibility and service - at a price.
Imagine getting in to see a doctor the same day a medical problem arises, or being able to call the doctor's cell phone at any hour for a consultation or prescription. Imagine a primary care physician accompanying a patient to a specialist's office in order to coordinate their care, or actively managing a patient's weight-loss program.
About a dozen or so doctors in a few pockets of the country are working to make that version of medical utopia a reality. Fed up with the harried and depersonalized approach demanded by managed care payers, a small number of doctors have formed new "concierge"-style practices that offer that a high level of accessibility and service.
The services offered through these practices don't come cheap, of course. Physicians are able to offer them by reducing patient loads and charging extra service fees. Although the medical concierge trend is still fairly new, these doctors have been successful enough that they are spreading their vision across the country, enlisting other doctors to follow their lead.
Meanwhile, critics have lobbed harsh accusations of greed and elitism at this physician cadre. They argue that America should be closing the widening gap between the insured and the 40 million uninsured, rather than adding yet another tier of medical care.
"It's adding an obscene third level to the way we deliver health care in this country," declared Martin Solomon, MD, a prominent Boston internist and instructor at Brigham and Women's Hospital. He was solicited by the largest group, called MDVIP and based in Boca Raton, Fla., but he remains unpersuaded.
"I did not go into medicine to just take care of rich people," he said.
Doctors involved with these special-services practices take issue with that characterization, however. In fact, the prices and range of services vary considerably, from the most exclusive, called MD2 (pronounced MD-squared), which costs $20,000 a year per couple, to the more affordable services of MDVIP - "the cost of a latte a day," as backers like to say.
Serving Different Clienteles
There's a reason why the price of latte is bandied about: The medical boutique trend started in Seattle, where a daily expenditure for coffee is considered the norm. Founders of MD2 believe they were the first to design and promote a boutique practice in 1996 that provides first-class service to an elite clientele. In 2000, they opened the first "franchise" across town, and are planning to expand across the country.
"Most of these patients are incredibly mobile people, with multiple homes," said Duane Dobrowits, chief executive officer. The company is in discussion with 30 practices across the country, seeking to build a network that could provide services wherever its clients travel.
An annual retainer paid by patients covers the costs of all primary care, but they are expected to carry insurance for hospitalizations, he explained. Physicians care for a maximum of 50 "family units," and they do not deal with any managed care restrictions or insurance claims. "We simply don't go there," he said.
Dobrowits is unfazed by charges of elitism just because the company provides special services to its clients.
"There is a niche of people who want this access," he said. "These are the same people who send their children to private schools. We're simply filling that demand."
Although the MD2 clientele is undoubtedly wealthy, other service-oriented practices are catering to the middle class for much lower fees. Services range from priority phone lines to broader preventive care, and clients still carry medical insurance and are responsible for co-pays and deductibles, in addition to the annual service fees.
"Patients interested in our practices are definitely different than the ones paying $20,000," said Ed Goldman, MD, president of MDVIP, a group of eight Florida doctors that charges $1,500 a year for non-insured services.
"By charging for these services, we're able to generate enough income to reduce the patient size of the practice," he explained. Patients wait less than two minutes on average for their appointments, which usually are scheduled the same day they call.
Doctors have enough time with patients that they can focus on preventive care, which is only given lip service in most traditional practices, Dr. Goldman said.
"I see this as being a niche for patients who are interested in preventive care and for physicians who are interested in providing that," he said. The group is planning to expand and eventually could include 100 or so doctors nationwide. Doctors who have expressed interest in joining tend to be older, locally prominent and pro-active in preventive care, "and they are not happy with what they're doing now," Dr. Goldman said.
Physicians wishing to join must close their existing practices and start over, with no financial guarantees and with severed ties to the majority of their patient population. Some patients have complained about being "abandoned" in the process, and have even complained to Medicare officials, prompting probes by state officials and legislative debates.
Discontent Spurs Patient Interest
Increased scrutiny by regulatory agencies has been an unwelcome surprise, Dr. Goldman said. But the high level of patient interest in the program has exceeded his expectations. "I had totally miscalculated the level of discontent with the current health care system," he said.
In Boston, two internists sparked public attention recently when they announced they were forming a service-oriented practice, scheduled to open in April, with two more doctors joining the group shortly. They will charge patients $4,000 a year for special services not covered by medical insurance.
"What we're selling is the fact that we're far more available and we can provide a higher level of service coordination than is available in other practices," said Steven Flier, MD, one of the founders. He compares the additional fee-for-services with other non-medical costs patients often incur, such as parking fees at hospitals, or paying out of pocket for elective procedures such as lasik eye surgery or cosmetic surgery.
The level of media attention spurred by his announcement has surprised Dr. Flier, who views his new practice simply as one doctor's solution to shortcomings in the existing health care system.
"We aren't doing this to be trend-setters," he said. "We're doing this because we see a need for changing what we do relative to our patients."
He has also been surprised by patients' reactions; some who he expected to oppose it have actually enrolled, while others have switched to another doctor.
One patient accused him of catering to the wealthy. Dr. Flier pointed out that the patient's two-pack-a-day smoking habit cost him about the same amount annually as the medical service fee.
"No one goes around saying that smoking is a habit only for the wealthy," Dr. Flier said. "People do make choices in that range of dollars."
Overall, subscriptions for the first year have exceeded the doctors' expectations, he said, and they now will turn their attention to satisfying patients so that they will re-enroll next year. In the meantime, he welcomes the public debate about problems with the current health care system.
A Catalyst for Change?
Even critics of the new VIP practices hope the trend will force greater public discussion about health care in this country, particularly the question of whether quality health care is a privilege for some or a right for all. The trend could even put pressure on the existing system to provide better service to all patients.
In Seattle, competition introduced by the concierge-practices drove one medical center to create its own special-services unit. The Virginia Mason Medical Center initiated its program, called the Dare Center, after losing some of its patients to the MD2 practice, said John Kirkpatrick, MD, who fostered Virginia Mason's program and now cares for patients who pay the annual $3,000 fee.
As an employee of the medical center, Dr. Kirkpatrick does not benefit directly from the revenue generated by the program, but the medical center has used the extra dollars to support its free care of the poor.
"I'm very confident that this has helped the overall organization," he said.
Patients in the program vary from those who are very demanding and expect lots of attention, to those who simply do not want to spend their time sitting in waiting rooms, he said. Patients can call his cell phone day or night, seven days a week.
"It would be nice to be able to give everybody this kind of service," Dr. Kirkpatrick said. But the government and private insurers simply cannot afford everything that Americans demand in health care, he said.
"This is not the answer for everything," Dr. Kirkpatrick said, "but it may be a partial answer to get more people who can afford it to put more dollars into the medical system."
The notion of some people getting better care than others, however, deeply disturbs critics.
"It's contrary to what American medicine has stood for," said Boston physician Dr. Solomon. He believes that catering to patients' unrealistic demands will drive an even bigger gap between levels of health care.
"Not everybody needs to be seen the day they call," he said. "It's a total luxury."
Advocates of the new service-oriented practices insist, however, that both doctors and patients can benefit from the arrangements, and that they are simply one alternative to the traditional health care system.
Boston internist Dr. Flier asks: "If providers and patients are dissatisfied and want something better that works, why would anyone oppose that?"
Christine Wiebe is a freelance health and medical writer who lives in Providence, Utah. She can be reached at cewiebe1@attbi.com. |
