On the Transcendent Importance of Retainer Medicine

Posted on January 4, 2008
Filed Under Fixing American Healthcare, General Rationing Issues, Healthcare economics, New business models for healthcare, Primary Care in America |

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For the last week or more, DB has been conducting a lively give-and-take over at DB’s Medical Rants on the topic of retainer medicine. DrRich urges his readers who may have missed this ongoing exchange to take some minutes to acquaint themselves with it.

DB has offered a studied and persuasive apology (in the Platonic sense, not in the contrition sense) for this controversial style of medical practice. In response to challenges and criticisms from several of his readers, DB has not backed down from his position, but rather, has steadily developed his arguments in support of retainer practitioners, and has made those arguments increasingly compelling.

Which is to say that DB is doing quite well in this arena, and does not need help from DrRich.

There is one loose thread that continues to dangle, however, and while DB has addressed it on more than one occasion (the most recent being today), judging from the commentators who have responded so far, DB has failed to convince at least some of his readers that he’s tied the thread off. That thread is this: While retainer medicine may be good for individual doctors and individual patients, if any substantial number of physicians were to adopt this new style of practice, wouldn’t that do great harm to the greater good? That is, wouldn’t public health suffer in order to benefit a few lucky patients and doctors?

As DrRich reads it, DB has answered this challenge by: a) pointing out (correctly) that doctors are supposed to care primarily about their individual patients, and that retainer medicine is perhaps the best way to allow doctors to do this; b) pointing out that doctors who go into retainer medicine would most likely otherwise leave “traditional” outpatient medicine altogether anyway; and c) pointing out that if retainer medicine becomes viewed as a desirable thing by enough patients, more doctors will flock to fill the demand - and we may end up with a means of stemming the great exodus of primary care doctors now being seen in American medicine. (Note to DB: If I have misrepresented your arguments, I hope you will correct me.)

These are all good and correct arguments. But to DrRich’s mind they do not go far enough.

DrRich respectfully offers a different approach to answering the critics’ concern for the impact of retainer medicine on public health. Namely, retainer-style medicine (that is, medical practices where patients in some manner are directly paying their own doctors, and so necessarily become their doctor’s primary customer) is the only conceivable pathway toward rescuing public health. Primary care doctors who continue practicing in what has become the traditional third-party-payment system are, in fact, the ones who most threaten public health.

The fundamental argument that supports this contention has been expounded upon numerous times on this blog. In summary: In the attempt to control healthcare costs (as they have been deputized by society to do), the feds and the insurance carriers have, in uncountable ways, coerced physicians to place the needs of the payers ahead of the needs of their individual patients. That is, they have systematically and purposefully destroyed the doctor-patient relationship, killing medical professionalism, and abandoning patients to their own devices as they attempt to navigate an increasingly hostile healthcare system.

This process has been firmly established. It has been legislated by Congress, embodied in volumes and volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the U.S. Supreme Court, and finally (and most tellingly) sanctioned as being entirely “ethical” by revered medical organizations.

It has therefore become impossible to fight this reality while remaining a “traditional” primary care practitioner. To escape, one must either become a specialist (since outpatient primary care has been the main lever on which the third-party payers have pushed to date), a deep-sea fisherman - or a retainer practitioner. That is, a primary care doctor must either try to survive in a system that ruthlessly pushes them toward an unethical, demeaning, public-health-destroying style of practice, or (one way or another) get out.

To argue that retainer-style medicine - or indeed, any innovation that somehow restores both the professional integrity of medical practice and the patient’s rightful advocate - is unethical is completely wrong. It is one of the few viable pathways toward restoring the foundational (but currently obsolete) medical ethic of always placing the patient first.

To argue that it threatens public health completely ignores reality. Retainer medicine is one of the few viable pathways toward restoring protections that the public is supposed to have when facing a healthcare system that is utterly bent on avoiding spending money on them.

To argue that retainer practitioners are creating a two-tiered healthcare system is ridiculous on its face in a society that gives mere lip service (though, to be sure, plenty of it) to the problem of 47 million uninsured.

To argue that retainer medicine will create a subpopulation of elites (because it provides a mechanism by which some individual patients can escape the deadly obstacles that have been intentionally laid before them), is as absurd as arguing that George Washington was wrong to free his slaves upon his death (or even that New York State was wrong to abolish slavery at about the same time), because it created a subpopulation of “elite” (i.e., free) African Americans; that until all slaves were freed, no slaves should have been freed. But freeing at least some slaves - and forthrightly stating why it needed to be done (see: Declaration of Independence) - was not only ethical, but also showed what was possible, and over time created an expectation that eventually could no longer be ignored, and that, at huge cost, was finally fulfilled.

Finally, we should note that any innovation that can potentially spare patients from some of the harm the healthcare system has in store for them will necessarily be applicable to only some patients at first. That’s how disruptive processes work. They begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers. But if at their core they’re offering something fundamentally useful, they will slowly demonstrate their worth - and eventually all the potential users will see the light, and demand for the product will become explosive. When that happens, the means are found to make the new product affordable and available to meet the demand - often by making significant “adjustments” to the original concept, that nonetheless preserve the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.

It may not be that retainer-style medicine plays the personal computer to the traditional healthcare system’s mainframe. But it is inarguable that what retainer medicine offers to patients - at its core - is every bit as vital and every bit as indispensable. And if a critical mass of the public can be made to understand what is really being offered here, there will be no holding it back.

And that, DrRich humbly suggests, will do a world of good for our public health.

Comments

5 Responses to “On the Transcendent Importance of Retainer Medicine”

  1. James gaulte on January 4th, 2008 2:51 pm

    I do not think I have ever read anything better than that on a blog.Wow.

  2. DrRich on January 4th, 2008 3:59 pm

    To that compliment, especially coming from you Dr. Gaulte, I can only say, Wow Squared.

  3. alexa-blue on January 4th, 2008 4:01 pm

    That’s an outstanding post, Dr. Rich, thank you.

  4. Dr. H on January 7th, 2008 6:33 pm

    As a practicing retainer physician, I couldn’t have stated my position any better than you did,Dr. Rich. Thank you for really thinking about it. It is not easy being a trailblazer.

  5. Lynn Carlisle DDS on January 10th, 2008 11:36 am

    Rich,

    It is good to see the passion you and others have for retainer medicine and saving the doctor-patient relationship.

    We dentists, who practice this way, call it relationship-based or health-centered dentistry.

    What kind of feedback are you receiving on your book?

    A fellow warrior,

    Lynn D Carlisle, DDS
    http://www.spiritofcaring.com

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