The Covert Rationing Blog

Smile When You Call Me Optimist

April 14th, 2008 by DrRich

In a previous post, DrRich gave his thoughts on the distressing condition of the American primary care physician (PCP), and described how the feds, the insurance companies, and the currents of history are conspiring to fundamentally devalue and disrupt their once-honored profession. Further, he attempted to describe some options that disaffected PCPs might explore which might possibly open the door to new, more sustainable business models.

This posting has generated a robust commentary, for which DrRich is grateful, as he thoroughly enjoys engaging in give-and-take with his readers, whose thoughtfulness and intelligence invariably challenges him to bring his analyses into sharper focus.

And based on this most recent commentary, DrRich finds that there is indeed an issue that clearly needs more focus - that of his purported optimism. It seems that some readers, in perusing the previous post, came away with the idea that DrRich is saying something like this: While history is demanding that PCPs must suffer a great disruption, history also points the way to their salvation; that, indeed, PCPs merely need to jump in the boat, and the currents of history will sweep them into the promised land.

To the extent that he created any impression that the transformation he’s proposing for PCPs is likely to be automatic, or straightforward, or easy, or without significant hazard, or (least of all) universal, DrRich most humbly apologizes.

He would like to set the record straight.

Here’s what history dictates: As long as there are free markets, the “final solution” being embraced by the insurers and the feds - that of a dumbed-down, malleable population of front line medical practitioners (whether made up of indoctrinated younger physicians, “broken” older physicians, ascendant nurses, or some combination of these) who will provide all basic medical services and control access to more specialized services - will ultimately not prevail. The large number of patients who have needs that will not be met by this solution will create an irreducible demand that the market will somehow conspire to meet. That, if anything, is the “optimistic” part of DrRich’s synthesis.

PCPs are in an unique position to fulfill much of this demand, and DrRich tried to describe two general pathways that might be explored for doing so (there are almost certainly others). But he certainly did not mean to imply that this would be easy to do, or that more than a minority of PCPs would embark on such a path, or would be able do it successfully. Indeed it seems likely that most PCPs will take the course of least resistance, as they seem to be doing now, gradually allowing themselves to be absorbed by the diminished model now being offered by the insurers and the feds, complaining about but not really fighting their fates, and all the while hoping for early retirement.

History reveals this to be the general rule. Most persecuted Puritans did not migrate to the New World (where they faced hurdles arguably even more off-putting than the threat of malpractice suits and specialist-dominated credential committees). Most Goths, upon being overrun by the invading Huns and facing the choice of absorption or migrating to territory occupied by somebody else, did not move south to sack Rome. Most PCPs will likewise accept their fate, and simply try to make the best of it.

Any pioneering PCPs who attempt instead to blaze these new trails will face huge hurdles, and they’re hurdles anyone (including DrRich) can see very clearly. They include the strong opposition (to put it mildly) PCPs will get from specialists as they explore ways to encroach on their turf; the attacks they’ll suffer from malpractice lawyers as they undertake to perform services traditionally done by specialist physicians (lawyers being the specialists’ great allies in this instance); the steady resistance of the insurers; the notion dearly held by most of the public that people shouldn’t have to pay for ANY of their own healthcare; and the parallel notion dearly held by many government officials that people shouldn’t be ALLOWED to pay for any of their own healthcare, and that any attempts to arrange for people to do so should be met with the most extreme prosecutorial wrath.

So, while DrRich believes history helps to explain what’s going on in the world of the American PCP, and helps (at least vaguely) to point the way for some of them, history rarely unfolds easily, or quickly, or without pain, bloodshed, tragedy and travesty. Generations (or centuries) can pass before a resolution is reached.

But if some insist on characterizing this as optimism, who is DrRich to object?

Posted in New business models for healthcare, Primary Care in America

4 Responses to “Smile When You Call Me Optimist”

1. Keith wrote on 04/15/08 at 2:22 pm :

   Just to add more pessimism to the story, I worry that some legislator may get a call from the insurance PAC crying that they don’t like concierge medicine (indeed they don’t).
   Next step, congress outlaws concierge medicine as some version of independently operating insurance provider or some such trumped up claim.
   Yeah, it’s gonna be painful or at least interesting

2. Cheshire Cat wrote on 04/15/08 at 8:26 pm :

   As long as there is a “free market,” eh?

   A free market exists, even in Soviet Russia. It just involves looking for cops before you make your transaction.

   If we go to all-out socialized medicine, a black market for healthcare will spring up pretty quickly. It did in USSR, Vietnam, Canada (ask the head of the CMA) and a bunch of other overregulated places.

3. anonymous wrote on 04/16/08 at 8:01 am :

   i love the blog, but geez, i can’t digest my food after reading your blog because i have to think so hard to understand what you are writing. do you have a comic book version or something?
   are you going to hrs? can you autograph your books?

4. DrRich wrote on 04/16/08 at 10:03 am :

   Keith,

   This is already happening. An all-out effort is being mounted to declare concierge practitioners to be both unethical and illegal. Any model where patients pay for their own healthcare will be anathema to the kinds of “solutions” now being proposed to fix the healthcare crisis. Concierge doctors will have to be terminated with extreme prejudice.

   Cheshire Cat,

   Great minds think alike. I have written about black market healthcare, and why we need it, here:
   http://covertrationingblog.com/new-business-models-for-healthcare/black-market-medicine-staying-off-the-grid-2

   anonymous,

   I don’t plan to attend HRS this year. Autographed (and even personalized) books are available from here:
   http://publishorperishdbs.com/buy-the-book

   If reading my blog wrecks digestion (writing it certainly does), I will look into marketing it as a weight loss program, which truly would lead me to the promised land, at last.

   Rich

TrackBack URI

Leave a Reply