Can Boutique Medicine Save the Health Care System?

Boutique medicine (or concierge or retainer medicine) is one of the newer developments on the political and medical horizon. Most physicians consider it a mere blip on the radar screen of medical economics. But is that true? It requires the patient to pay a retainer fee for the services of a primary care physician, who then drastically limits the size of his medical practice to provide a more personal and dedicated service, usually including house calls, ED visits, hour-long appointments for health maintenance, and same-day scheduling when needed. In short, it is the ultimate in primary care. Many physicians believe this a passing fancy, or perhaps just a type of care that will occupy a tiny niche of physicians' practices. Others think it is about to be smashed by a Congress dedicated to the fair treatment of all persons. Is it an insult to Hippocrates and perhaps even to our founding fathers to consider the possibility of different levels of care for persons of differing financial capabilities? After all, isn't health care a right for all Americans, guaranteed by our citizenship in this blessed and wealthy nation? Boutique medicine flies in the face of this government entitlement mentality. The prevailing thought among the public is, unfortunately, that health care is a right guaranteed by citizenship. This belief in medical entitlement (as with other entitlements) has become ever more popular over the past four decades of increasing government activism. It has in fact become such a popular and ingrained belief that neither political party has the will, guts, or stamina to attempt to correct it. I suppose that some actually don't believe it needs correcting. Perhaps I believe in America more than the average politician. I believe that capitalism is inherently superior to communism or socialism at all levels. I believe that no matter how benignly it starts or how gradually it is introduced, socialized medicine is still socialism. I cannot, like some people, say that “socialized medicine is a wonderful concept, but we cannot afford it.” If it is a wonderful concept, then we should pursue and achieve it, and show the world that America has the best socialism in the world. If it is ethically and morally right, it will work. But just like the right to free government housing (which failed to do more than help create ghettos), free health care is not just unaffordable, it is wrong. The guarantee that we have a “right” to medical care for which the government will pay is wrong at several levels. First, the government does not pay for anything, people do. Government merely taxes the working class at higher and higher levels, and then creates more bureaucrats, more pensions, and more inefficiency to provide a service that usually was already present. Second, the idea that anything is a right, other than “life, liberty, and the pursuit of happiness” presupposes that such a right does not infringe on the rights of other persons. Every time a person presents to my emergency department and wants a “free” CT for his headache (for which Medicare or Medicaid or public assistance must pay), they infringe on the rights of thousands of individuals who work hard to pay their taxes and meet their bills. The sum total of these “free” medical tests, which these poor and often uneducated persons believe are their right, costs American taxpayers trillions of dollars. In fact, I daresay it would be possible to balance the budget simply by eliminating all this waste. At the very least, the likelihood of Draconian measures being required to save Medicare for the boomers and the gen-xers would be drastically diminished. Enter the concept of boutique medicine. I cannot say for sure that this is the solution to our budget crisis, but what if it did succeed? What if it became the standard of care? I believe the public, the politicians, and AARP would all be fighting for its success if they really understood the implications of this development in private practice financing. If some patients paid for more and better primary care, there would be less needless and costly ED visits and specialist referrals If boutique medicine becomes generally successful, it would immensely enhance the status and calling of primary care physicians. This, most everyone would agree, would be a positive development. If we have more primary care physicians with better knowledge of and better relationships with their patients, we will have healthier patients. Many studies have proven the benefit of primary care in health maintenance. In addition, this close relationship, the house calls, and immediate physician availability would prevent millions of needless ED visits at a savings of many billions of dollars. Over the past several decades as the government and insurance companies have rewarded procedures over diagnostic skills, they have ensured the costly boom in procedural medicine that now threatens the solvency of the system. They have paid for millions of cataract surgeries on elderly and debilitated nursing home patients, and hundreds of thousands of coronary bypass surgeries on obese, sedentary smokers who change none of their risk factors. They pay billions for emergency department “dumps” by primary care physicians who are seeing thousands of patients in their patient panels “just to survive,” and are consequently too busy to see their patients when they are actually sick. The patient who could usually have been seen and treated for under $100 in a private physician's office is instead seen an evaluated by a stranger in an ED who usually feels obligated to run thousands of dollars in medical tests to avoid any potential for malpractice and to meet the “higher standard of care” of the ED. The ultimate cost of our ineffective provision of care is likely in the trillions. The alternative is that if patients as individuals pay for more and better primary care, there would be less needless and costly specialist referrals, (which could, of course, mean a higher percentage of appropriate referrals), and less expensive and redundant testing with CT and MRI. The era of “test everything to please the attorneys” could finally give way to the era of reasonable discussion between patient and physician. The physician in a boutique practice has the time to discuss the risks and benefits of procedures and referrals. Trust and reason can prevail, and primary care can finally rise to the level of its calling. If retainer medicine is successful, we take one giant step away from socialized medicine, away from the seeming inevitable bankruptcy of Medicare, toward fiscal solvency. Of course, to do so we must finally admit that there is nowhere in law, ethics, government, or the constitution, the guarantee of medical care. If a society chooses to care for its indigent, it does so at a cost, and this cost must be thoughtfully addressed and evaluated. The cost must not be so high that the entire system is in jeopardy. As we accept the possibility that we are not living in a socialist state, we can then accept the possibility that those who earn an income may choose to spend a portion of that income on medical care that is above and beyond the basic level provided to the indigent. This is their right. This formula has been successful in most societies and throughout all the ages. Those who can afford better automobiles, better steaks, or better medical care have the right to purchase it. To refuse to allow this is in itself unconstitutional. This is a two-tiered system, and it is ultimately the only fair and reasonable approach to medical care. If we can accept the inherent fairness and reasonability of this concept, then there may yet be hope to avoid the bankruptcy of the American medical system. The future may belong to boutique.

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