Wednesday, June 18, 2014

Whither Direct Pay Medical Surgical Care?

Whither goest thou?

John 13:36

Quo vadis?

Latin saying 

Where is the direct pay movement,  led by independent direct pay primary care and direct pay ambulatory surgical centers,  headed?   

 Is it a whimper or a wave?   

Is it the start of a two-tier health system – one for paying private patients and one for government-subsidized-and –entitled citizens?

No one can say with certainty.   We simply do not have enough knowledge at this point.   Nor do we know if ObamaCare has sturdy enough political legs to stay on the 10 year course it has laid out for itself.

But, based on the current mood and developments,  we can reach certain tentative conclusions.

·         There exists a high level of dissatisfaction among American citizens and physicians over the status of the present system.

·         ObamaCare has yet to deliver on its promises of lower costs and higher quality and more standardized care for all.

·         People are looking for alternatives to ObamaCare,  which has resulted in often unpredictable  and  higher premiums and deductible for many, and given  growing physician shortages, increased coverage under ObamaCare does not assure increased care with physicians' increased reluctance to accept patients under Medicare, Medicaid, and  ObamaCare-sanctioned health plans.

·          These alternative include going “bare” without insurance,   care at retail and walk-in clinics,   care by alternative practitioners,  and  direct care delivered at the marketplace by independent physicians and surgeons.

·         Many citizens are seeking more personal,  confidential,  convenient, and timely  relationships with personal physicians,  and many physicians yearn to  deliver this kind of care.

·         Market and cash-based care faces formidable political obstacles  from those who believe everyone has a right to receive government-subsidized care  and from those who have a vested interest in preserving  the current 3rd party managed system.

·         A large school of thought and a huge management apparatus exists and is growing that says  health care and quality  cannot be entrusted to physicians acting in their self-interest  to deliver care to vulnerable, insufficiently informed patients: in other words, only large organizations, including government, can be trusted to deliver reliable, high quality care.

·         The American health care system is the most expensive in the world and much of this expense can be attributed to the regulatory and management systems.

        Direct ambulatory patient care at doctors’ offices and decentralized  care centers  without insurance or 3rd party management and involvement  lowers costs of care.

·         Transparency of prices, when displayed on the Internet, especially when coupled with bundled pricing known in advance,  appeals to cost-sensitive consumers and to self-funded employers who seek to lower costs and to make them more predictable.

·         Predictions and fears that concierge/direct pay medicine would  divide health care into two tiers – one, the affluent who could afford to pay, and two, the poor who could not afford to pay – have proven to be unfounded: those choosing to avail  themselves of these direct services include the uninsured, the insured, and those seeking  more personal,  predictable, convenient, and, in some cases, more affordable care.

The case for government-controlled-directed care  has yet to be made nor  has the case for free market-based care.   Future care will be a mix of the two.  It  will depend on intangibles such as the yearning for individual freedom and choice  and business and political models that slow the rise of health costs and produce better health outcomes.

In the end,  the availability of consumer-drive,.  market-based, direct-pay, medicine and surgery boils down to these questions.

·      Do consumers have the right to select doctors of their choice?  I think they do.

·     Can government sanction what doctors, and under what  economic conditions, can deliver care?  I do not believe can enforce sanctions to make consumers and physicians to behave for the best interests of  government.

·      Do qualified, certified doctors have the right to charge cash for their services based on a mutual agreement with patients?   I think they do if the amount expended is mutually agreed upon.

·       Are independent, market-based  medical and surgical services feasible and moral when consumers and doctors agree these types of practice offer better care? In a capitalistic system,  in which marketplace transactions guide every other transaction,  market-based  health transactions are both feasible and moral

·       What is the place and role  of government  and under what conditions, should government  play in free market –based care?

·       What should government do to strike the right balance between government-controlled and consumer –driven care?

Government should  take off its ideological blinders and acknowledge that consumer-driven care has a place at the health reform table.

It  should acknowledge that financial incentives play a major role in consumer behavior.    Entitlements lead to demands that cannot be met by centralized government.   Patients spending more of their own money,  having “skin the game,”  are circumspect about what they will spend and what doctors they will choose.  Employers know first hand that worker holding plans featuring  health savings accounts spend less for care than those who are members of traditional HMOs and PPOs.

It should acknowledge that certain business models,  such as that of the Oklahoma Surgery Center,  which posts its prices online for all to see and guarantees a set price inclusive of all services,  have dramatically lowered prices for  consumers,   self-funded companies, and government agencies with no sacrifice in quality.

It should acknowledge that greater coverage for the uninsured and underinsured does not necessarily produce greater access to care, and indeed, may lead to greater dissatisfaction because of longer waiting times, rationing of care, and irr4itating bureaucratic impediments.

It should acknowledge that American businesses are leery of increased costs and requirements of  ObamaCare.   These costs and requirement  have stymied economic growth and led to part-time employment on a massive scale.   One way to reduce  and change this business behavior is reduce costs by  having  businesses contract directly with directly with direct-pay physicians and their direct pay outpatient surgery centers , thereby reducing the administrative costs of the middlemen.

It should acknowledge that consumers directly spending their own money are very smart people  and generally know what is best for themselves and what  ehy can afford. 

What should  government’s?   It should provide for tax-free health insurance for all. It should not restrict shoppers to a government run market as the only means of getting health insurance. It should require insurance for financially catastrophic care, say anything above $300o for an individual for a family earning $50,000.   It should provide transparency about the quality of care of providers of health care and their prices.   It should not dictate how the money is spent.  It  should subsidize consumers who cannot afford care. It  should provide medical savings accounts for all Americans. It should promote health plan competition across state lines.  And it should vigorous support tort reform.

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