[I was kindly asked to provide an article for Courrier du Medecin Vaudois, the French language journal of the medical society of the canton of Vaud. The article was published as part of an issue on the theme of ‘America First against Obamacare.’ Below is an English version of the piece.]
Health care in the United States: The surprising good news
On the surface, the news from America about health care seems rather grim: cost and dissatisfaction keep rising, reforms are stalling, and, for some, even life expectancy may be declining. If that wasn’t bad enough, President Trump issued a tweet on March 25 predicting that “Obamacare will explode.”
For a small but growing number of doctors and patients, however, the future is surprisingly hopeful. The nascent “direct care” movement is made up of physicians who have decided to step outside the government and insurance system and offer their services directly to patients for a simple fee that is transparent and affordable.
For the time being, the direct care movement is limited to outpatient care. The bulk of this movement consists of family physicians who provide their services for a modest monthly membership fee, typically between USD 50-100. In exchange, patients enjoy a personal relationship with a doctor to whom they have direct access—even at night and on weekends—and with whom they can freely communicate, using all modern forms of telecommunications.
Many of these direct primary care physicians also strive to provide their patients with pharmaceuticals and laboratory tests obtained at wholesale cost. The savings to the patient can be substantial, sometimes as much as ninety percent off the retail price.
Another growing part of the direct care market concerns outpatient surgery: Some surgeons and anesthesiologists are offering to perform a wide range of operations (from simple tonsillectomies to total knee replacements) for a transparent cash fee which is significantly lower than that demanded by traditional hospitals—sometimes as low as one quarter to one third of the prevalent hospital price.
For many patients, the direct care movement offers medical care that would otherwise be unaffordable or even unobtainable. For example, many low-income patients with government-subsidized insurance may not find a doctor contracted with that insurance, or they may need to wait weeks for an appointment.
For doctors working within the government and insurance system, the administrative and regulatory burdens of the last decades have become so great that they find themselves unable to provide patients the attention they need.
Lately, those burdens have included the requirement to use unwieldy electronic medical record systems and the need to comply with potentially penalizing “quality measures.” Oftentimes, these quality measures are thinly veiled bureaucratic attempts to control costs. (Incidentally, recent studies have shown them to be ineffective at improving either quality or outcomes.) These burdens are on top of price control measures that have gradually reduced payments to physicians since the early 1990s.
In order to deal with these burdens, those physicians who remain in the government and insurance system have had to merge their practices into larger operations, or even sell their practices to become employees of corporate organizations. Such organizations can better deal with the regulatory burdens, but at the cost of an increasingly depersonalized and fragmented care.
Within the direct care movement, the interests of the doctors are better aligned with those of patients. For entrepreneurial physicians who choose to serve patients directly, professional autonomy and income are no longer subject to the whims of bureaucrats and administrators, but are in the hands of the patients they serve. This can only promote cost conscious medical care that is nevertheless striving for the best service and quality.
While the direct care movement is still minute compared to the traditional system, its growth in the last few years has been remarkable. In 2005, a survey noted that only 143 physicians had transitioned to direct primary care. In 2014, the number grew to 4,400. How fast will the movement grow and how soon will it also attract specialists and hospitals remains to be seen. For the time being, however, the most hopeful change on the American horizon comes from patients and doctors who have simply said “no” to the government and insurance system.
References:
Katherine Restrepo. “Direct Primary Care: A Simple Health Care Model Designed to Help Patients with Chronic Disease and Disabilities.” John Locke Foundation Policy Report. March 22, 2017. Available online https://www.johnlocke.org/research/direct-primary-care/
Haley Sweetland Edwards. “What Happens When Doctors Only Take Cash?” TIME Magazine. January 25, 2017. Available online http://time.com/4649914/why-the-doctor-takes-only-cash/
Amen, brother.