Boutique Medicine Will Not Save Health Care

Editor: Dr. Neal Mack (“Can Boutique Medicine Save the Health Care System?” EMN 2003;25[10]:5) offers a false remedy for the problems and contradictions of our present health care system. Dr. Mack states that the government “taxes the working class” to create “more bureaucrats, more pensions, and more inefficiency to provide a service,” and cites government housing as a failure of an entitlement program. He states that free government housing “failed to do more than help create ghettos.” Contrary to Dr. Mack's beliefs, for many people who live in it, government subsidized housing did and does work. It does so via the division of government known as Housing and Urban Development. Does this make us a socialist country? We think not. It may be true that some areas of government are inefficient, but Dr. Mack's generalization also does not apply to one of the largest federal entitlement programs, Medicare. While the average administrative costs of private insurance companies range from 16 percent to 30 percent annually, Medicare administrative costs are a mere three percent per year. This cost difference is astounding. In fact, our country can afford a universal health care system. This nation spent 13 percent of its GDP on health care in 2000, far above that year's international average of eight percent, more than any other nation in the world, and more than the amount allotted for the U.S. defense budget.1 The number rose to 14.1 percent in 2001. According to a recent analysis in Health Affairs, our level of spending per capita is 44 percent higher than Switzerland's, the country with the next-highest level of spending per capita, yet we do not provide more health services than any other nation.2 In addition, our health outcomes are not superior to nations who spend far less and have national health care systems. Our money, as shown by the uncontained administrative costs of the vast number of private insurers and high prices for goods and services, is simply not being wisely spent. One of the problems with the “boutique” or “concierge” medicine that Dr. Mack promotes is that elderly patients (the largest and fastest growing segment of our population) are at risk of being excluded from such practices because Medicare likely will not pay for the higher costs of these plans. Unfortunately, many physicians across the country have pulled out of the Medicare market, refusing to see patients covered by Medicare due to what they feel are inadequate reimbursements. Concierge medicine will only exacerbate this problem. Dr. Mack aims to reduce the number of unnecessary ED visits by improving primary care for patients, and this is a worthy goal. His argument that boutique medicine will help to do so is misguided. The patients to whom boutique medicine caters are not those who typically fall through the cracks of the health care system and end up in an ED, late in the stage of an illness they hoped would self-resolve or needing medications they could not pay for. Instead, the problem lies largely in the inability of the uninsured and underinsured to access primary and preventive care. How will creating smaller practices for self- and physician-selected groups of patients help to diminish the number of ED visits? It won't. Instead, it will shift the care of even more people who cannot afford health care into the hands of fewer doctors. The group of doctors to whom Dr. Mack refers in his article, the doctors who are “too busy to see their patients when they are actually sick will become more overburdened, as boutique doctors eliminate more and more people in this country from their networks of care, necessitating excluded patients to seek care elsewhere. One can be sure that contrary to Dr. Mack's opinion, this shift also will place greater stress on emergency physicians and other staff. What else will concierge practices do? They will allow the wealthy in this country, if they choose, to pay even more for primary care. This will cause already uncontained health care costs to rise even more. Instead of looking to blame doctors who care for large, diverse patient populations, and “poor…uneducated persons” who believe “free medical tests…are their right” and ask for a “free CT” (a phenomenon we have not experienced from the uninsured patients in our practice) for our country's health care crisis, Dr. Mack must examine some basic facts. The denial of health care to a large subset of the population is a serious infringement on the rights of us all, and the consequences resonate throughout our society. It allows for the spread of infectious diseases such as tuberculosis, HIV, and hepatitis. It burdens our hospitals with acute illnesses that could have been prevented had adequate public health measures been available to these individuals. It results in significant loss in productivity amongst the uninsured ill members of our workforce. We all share the burden of an expanding population of medically neglected citizens. According to recent IOM data, the U.S. loses $65 billion to $130 billion dollars annually “as a result of poorer health and earlier death experienced by the 41 million Americans who lack health insurance.3 In addition, not all of the uninsured and underinsured are “indigent” or “uneducated.” About two-thirds of the uninsured are employed workers and their families.4 Many are hard-working people with full-time jobs who make too much to qualify for Medicaid but whose employers do not offer insurance. To qualify for Medicaid, one must be at or below the federal poverty level: $8,950 annually for an individual and $12,120 annually for a family of three. If one does not qualify, a basic insurance plan runs $300 to $600 per month, arguably unaffordable for those making even double the poverty level.5 The problem affects all ages. From 1995 to 1996, 23.1 million children of the 70.1 million in the U.S. were without insurance for at least a month. In 1999, almost 30 percent of young adults 18 to 24 were uninsured. Boutique medicine, contrary to solving any of these problems, would simply exacerbate them. It would make our system even more exclusive and doubtless put a higher premium on primary care for patients who can afford to buy in. All people should be entitled to some basic level of care, from both an ethical as well as a financial standpoint. A recent study published published in the New England Journal of Medicine estimated health administration costs in the U.S. amount to $294.3 billion annually, accounting for 31 percent of our nation's health care expenditures, almost double that of Canada.6 A universal health plan can save lives and money, and the only way to accomplish this is through restructuring our current system. Central to Dr. Mack's argument in favor of boutique medicine is his staunch support for a “capitalistic” rather than “socialistic” method of health care delivery. The right to basic health care for every citizen is implicitly expressed within the very words of the Declaration of Independence he quotes: what kind of life and what kind of liberty do we have without our health, and how do we pursue happiness in a debilitated state? To challenge this basic tenet is contradictory to the foundation of our profession. Although Dr. Mack asserts that health care should not be a human right, there are a growing number of physicians who believe a universal health care system is an appropriate solution to accomplish the goal of providing health care for all of our nation's citizens. This is evidenced by growing membership in the organization Physicians for a National Health Plan (PNHP), which has more than 10,000 members nationwide. Maria Raven, MD, MPH Craig Smollin, MD New York, NY

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