"Thomas W. LaGrelius, MD, FAAFP
Delivered May 5, 2008 at SIMPD annual meeting, Las Vegas, Nevada
Good morning SIMPD members and friends! Welcome to SIMPD’s fifth annual meeting here at the beautiful Venetian Hotel in Las Vegas. It’s great to be here with the most independent doctors around. We in SIMPD have lifted a page from managed care and created instead a network of unmanageable doctors, except by our patients. And our movement is growing.
Have you wandered through this place? I’ve been to Venice, Italy, but Venice, Las Vegas may be almost as grand. I hope you all have some fun here, see some shows and not lose too much money.
While you are here, connect with and comparing notes with your colleagues in direct practice from around the country. At this meeting you will find happy doctors who love their practices and know they are doing the best work of their lives. Our doctors take excellent, personalized care of their fewer patients, not just run past thousands of them on a mad dash from room to room to room.
Our attitude toward the practice of medicine is quite a bit different from the attitudes of our colleagues back home that are not in direct practice. Many of them are depressed and disillusioned. Some tell their children not to become physicians. Some look for ways to retire early or use their medical training to switch into non health care or even anti-health care occupations. (Being Medical Director of an HMO comes to mind here.)
We know better. We know the practice of medicine is exciting, rewarding and enjoyable.
I hope this meeting provides you with sessions that inform, inspire and assist you in your own practice goals. That is our purpose. Please fill out our program evaluation forms and tell us how we are doing.
How many of you are at your first SIMPD meeting?
When we first organized we called ourselves “The American Society of Concierge Physicians”.
How many of you were here for that first meeting in Denver in 2004?
By the time of our second meeting in Dallas in 2005 our name had been changed to SIMPD. How many were there?
How about the third in 2006 in Chicago where we spent so much money to hear Tommy Thompson talk, and maybe it was worth it. There were some bumps in the road for SIMPD after that, but we made it through.
Our fourth meeting in 2007 was delayed half a year, because of the bumps, until only six months ago in Washington DC, where Chris Ewin turned over the gavel to me after spending 18 months as president smoothing out the bumps. How many were there?
And here we are in Las Vegas for number five. We are young and small and the organization still struggles to provide services and better benefits to our membership, but a lot of folks outside of our movement are now asking about us who did not before know or care that we existed. Venture capitalists approach us with intriguing ideas to rapidly expand the numbers of direct practice doctors with their capital. The media call fairly often putting SIMPD’s name and web site in the public’s eye and thus bringing patients to you our members. Politicians too now wonder and ask if what we do could really be the solution to our gathering health care perfect storm almost everyone sees on the horizon.
I missed the first meeting in Denver but have attended all the rest. What I learned at my first SIMPD meeting in Dallas allowed me to launch my own direct concierge practice later that year. Without SIMPD my practice would be very different than it is today, and perhaps much less successful. The doctors I met in Dallas that first meeting were an inspiration. SIMPD promises to be an inspiration to all of our profession throughout the nation. SIMPD is a visionary organization. We know that doctors need to work directly for the right people, their patients and not for government, health plans or employers.
Until recently it was unusual to find a doctor present in the room where business people and politicians discussed their plans for our future. We were the forgotten victims of their well meaning but misguided schemes to reorganize health care. But now we are here at the same time and in the same place where dozens of other groups are dealing with all aspects of consumer directed health care. What an opportunity to show them our vision of the future.
I want to thank Transmarx and its CEO Skip Brickly for the hard work developing this meeting and making sure we are here participating with and connecting with business leaders in consumer health. Our thanks also to Walt Tudor our very effective day to day administrator, and all the other members of Transmarx’s excellent staff. Take advantage of this opportunity. Look around at all the meetings and investigate all the sponsor booths here. Talk to the business people here and teach them what needs to happen to save American medicine. Make sure they know that there is now a doctor in the room discussing the future of doctors and patients and not just waiting for the next hammer to drop on our heads.
So, where is American medicine and where is it going?
Modern medical science has made incredible strides in the advance of medicine, but our systems to finance its delivery are falling apart and actually damaging the critical doctor patient relationship.
You have all heard the litany of health care financing problems facing us today. It is said we spend too much money and get too little for it compared with other countries. But I submit that the individual citizens of the wealthiest and freest country on earth MUST have the right to spend more of their own money on maintaining the most valuable asset they have, their own good health. And it is our job to make sure they are really getting their money’s worth.
There are 47 million uninsured. Some say this is a crisis, but there are also 253 million insured Americans whose health plans and whose doctors working under the thumb of those health plans often serve them very poorly. Their doctors are working for the wrong master and in the wrong practice design.
We link 60% of health insurance to our conflicted employers creating gigantic problems for patients and employers that threaten not only health care, but our entire economy. This system is the last vestige of the 19th century “company store”, long ago abolished in every other sphere of human need. Our employers do not buy our food or housing or clothing. They pay us wages and we choose what and how much we want to buy as free Americans must.
Medicare, now covering 15% of Americans, is insolvent and will soon have a trillion dollar annual deficit. Yet some, like Michael Moore, suggest we make Medicare universal, as if that would solve our problems. SIMPD members know that expanding a failed system like Medicare to 100% of Americans will only cause a universal catastrophic failure with a ten trillion dollar annual deficit. We have a better idea.
One proposed solution, P4P (pay for performance) is a joke as administered by government, health plans and employers. Through this idea, health professionals are paid for more paperwork rather than for delivering care, and while our colleagues stare at the papers and the computer screens, medical errors kill 100,000 Americans a year because they do not look at their patients. In this election year, every politician has his or her proposed solution to our difficulties. Most are extremely unlikely to work. Again, we have a better idea.
Our goal is an error free practice, and we come very close to that goal. We have the time and the voluntarily given funds we need to improve the odds of getting to that goal. Because, there is a limit to how many patients a primary care doctor can care for safely and thoroughly, and it is a lot less than three thousand. It is probably less than 1000. It has been estimated that caring properly for 2000 to 3000 patients, the way we do for our more limited panels of patients, would require the primary care doctor to work 18 hour days six days a week. Some have questioned the ethics of concierge medicine. But is it ethical to take on a task one knows cannot be done safely?
In a recent Wall Street Journal op-ed, Dr. Jonathan Kellerman, a popular author and clinical professor of pediatrics and psychology at USC compared modern health plans and Medicare to the Mafia. He convincingly described their premiums as equivalent to payments to a protection racket. He accuses the health plans as being worse than a Mafia protection racket because they not only take money and deliver no value back, but then go further and interfere with the business of medicine to the detriment of both patients and doctors after taking their protection payment. Not even the Mafia goes that far. He makes the argument that less insurance rather than more is the solution to the health care financing plaguing our country. And though real insurance for high cost illness is important, we agree with Dr. Kellerman when it comes to basic health care. Americans should buy it directly and eliminate the meddlesome and costly middle man. That my friends is a much better idea.
The only payer that really values our services today is the patient, but most doctors don’t work for the patient. Last month I spoke to Dr. Katherine Atkinson, a family physician near Boston. The Washington Post had just published an article about her practice. She has a one year waiting list to get into her popular and excellent practice. After getting in for a first visit there is a nine month wait to set up a complete physical examination. She loses $20 a visit on each Medicare patient, but does not turn them away. She works very long hours, approaching those 18 hour days I mentioned. No one should work that hard, but that’s what it takes. Those of us who have tried to do it know it is true.
Nearby to Dr. Atkinson there is no doubt an excellent orthopedic surgeon who also works hard, but there is no one year wait to get into his practice. He earns $400,000 per year. Katherine Atkinson earns $110,000 per year and cannot afford to replace her aging automobile.
It is not that we begrudge the orthopedist or the cardiologist or the interventional radiologist their better pay, they too took a cut, albeit smaller, in real dollars in the last few decades. What we are saying is that the economics of medicine drive students to these specialties and away from the primary care dream most of them had at the beginning of their educations.
We are also saying is that good primary care medical homes reduce hospitalizations 60-85% resulting in huge hospital and high tech care savings. We are also saying is that any society that devalues primary care and attempts to run its health care primarily with specialists and a few overworked primary care doctors doing little more than mass triage will never control its costs or improve its quality of care no matter how many electronic medical record systems and pay for performance programs the third parties demand. If that society also believes health care is an inalienable right to be paid for by other people’s money, it will also go bankrupt.
We must work directly for that patient. That is the only way to restore balance. We must convince society that health care is not a right, but a service and a product that must be paid for, ideally by the consumer of the service/product in a free and transparent market. The consequences for our profession and for our nation of not doing so will be catastrophic.
There is another way. If we had 500,000 primary care doctors each providing a medical home for and average of 600 patients as I and many of you here do, guess what. Every single American could have such a direct practice medical home. Do the math. Half a million times 600 is 300,000,000! Imagine that. We would eliminate medical homelessness, cut hospital days at least 60%, save billions and billions of dollars and prolong and improve our lives. We have the answer to our American health care crisis right here in this room. We have a better idea.
Then we could still have 400,000 sub specialists who would be busy doing half the high tech care they do today. The other half would be prevented and much of it actually managed in the medical home instead of being fragmented into multiple consultant’s offices as we see so often today.
Doctors should apologize for allowing the current situation to exist. We allowed others to control health care economics and run it like Enron and the DMV. Physicians and patients must lead the way to solutions, and that is what SIMPD members are doing throughout the land. We are leading the way to a better idea and a better day for ourselves and our patients. In a way this is a return to the practice designs of our youth. It is in some ways a return to the Marcus Welby kind of practice some of us actually remember.
I grew up in Seattle, the birth place of concierge medicine, in a middle class neighborhood long before Medicare, Medicaid, PPOs, or HMOs were invented. Yet we all had excellent, affordable health care. Our family physician Russell Anderson provided us his home phone number, made house calls, saw us the same day when ill in an unhurried well equipped office with little or no waiting. He became my role model and remains so today. I even build my office from a mind’s eye blue print of his.
His was the equivalent of a modern, “medical home” such as SIMPD members provide. My practice is a “medical home” as are most of yours. What most Americans lack today is not insurance, but that primary care “medical home” with a doctor they can access 24/7 who coordinates all their care. A doctor they can see the same day, on time. A doctor who will care for them in the hospital. A doctor who hands them his cell phone number. A doctor who will spent thirty minutes seeing them in an office visit till their last question is answered. How many Americans today have such a doctor? Our patients do and they now number at least one million. Our goal should be to make that 300 million. That is another very good idea.
Russell Anderson’s practice was also a “direct practice” like ours. He had direct professional, direct prompt access and direct financial relationships with his patients. It was a direct practice, medical home like mine and many of yours, but unlike us he had a lot of company. Almost all his colleagues practiced that way in direct professional and financial relationships with their patients. They were accessible, affordable and affable because they worked for and were responsible to us, not for and to third parties.
Back then emergency rooms were quiet and saw only real emergencies. There was not a six hour wait behind a line of people with colds. We called our doctor instead, and he acted.
And, we were completely uninsured. So were most of our neighbors.
Back then there were 150 million Americans without health insurance, not just 47 million. And we amounted to 90% of the then US population, not just 15%. Being uninsured was the norm. And those who had illness insurance had it only for hospitalization, never for doctor’s fees or basic outpatient care. The uninsured were respected consumers of health services, not problems and opportunities for politicians.
We bought health services directly with little financial strain, just as we bought more expensive things like housing and food and cars. Today in contrast almost everything we buy in health care is funneled through insurance. Money and time is thus wasted while most doctors and patients have endless battles with insurance coverage, rules and bureaucracy for basic, relatively inexpensive care. Often it is easier, and a lot more satisfying, to care for the uninsured.
Our crisis is not really one of un-insurance. It is instead a crisis of “medical homelessness”. That “medical homelessness” is the result of insurance perversions having destroyed the free market in health care necessary to create value sensitive consumers and service oriented doctors. There are too many “third parties” meddling in basic health care.
So in America, doctors are working for the wrong employer. SIMPD doctors work for the right employer. We work for each and every individual consumer of medical services. We offer direct practice medical homes. That my friends, is the good idea SIMPD is all about.
In addition to concierge practices, cash practices with low prices now exist to serve patients and the service can be excellent. SIMPD member Dr. Robert S. Berry, a former emergency room doctor in Tennessee, runs such a practice called “PATMOS, named after the Greek Island where St. John worked and wrote, but also meaning “Payment At TiMe Of Service”. Dr. Berry has been widely recognized, appeared on 20/20 and the Geraldo show and testified before Congress. He was one of the first modern, excellent cash doctors to the uninsured but is no longer alone. His practice design is growing.
And another cash design, SimpleCare which was started in the Pacific North West by SIMPD member Dr. Vern Cherwatenko is another fine example. SIMPD is also the professional society for such cash doctors.
Outstanding, “concierge”, medical home preventive medicine and primary care including all needed treatments at that care level can be bought directly for $100-500 per month in a fee for care practice such as that operated by SIMPD member and founder John Blanchard in Michigan and SIMPD immediate past president Chris Ewin in Ft. Worth Texas and SIMPD member and author Dr. Steven Knope whose new book “Concierge Medicine” is now in the book stores and for sale here. Such retainer care can be purchased for less than most Americans spend on cell phones and cable connections. It costs far less than the amounts spend on food and a fraction of the amount spent on housing. SIMPD is the professional society for such monthly retainer fee for care doctors.
Another SIMPD member and former president, Dr. Garrison Bliss in Seattle just opened the second of seven new Qliance clinics, each with several doctors and nurse practitioners, aimed at caring for lower income Americans and the uninsured. Patients who join pay $39 to $74 a month age adjusted. For that fee they get 100% of all the primary medical care they can use, 24/7 direct access to their personal doctor, same day or next day on time appointments, regular check ups and a lot more. Not one cent of insurance money, government money or charity funds are used in his clinics. The care is paid for directly and entirely by the patients through their monthly fee, bypassing the expensive and meddlesome middlemen. SIMPD is the professional society for such retainer doctors to the uninsured.
Many SIMPD members, me included, offer fee for insurance non-covered services direct practice medical homes. We still bill patients and some insurance companies for covered services, but 75-80% of practice revenue is from a monthly or annual fee for services NOT covered by insurance. The best known national franchise practice with this design is the MDVIP network with some 200 quality doctors. We welcome its member doctors here today. We too offer same or next day appointment, 24/7 direct access, high levels of service and affordable wellness and illness care. Again, these practices provide the same excellent direct medical home environment for patients as do the fee for care practices. SIMPD is the professional society for such fee-for non-covered services direct practice doctors.
Both former SIMPD president Garrison Bliss and SIMPD member and Director Marcy Zwelling are independently negotiating with a major carriers to provide patients wrap around coverage for high-tech and hospital services our primary care doctors oversee but cannot provide alone. These insurance companies can be our friends. They can “get it” and understand what is needed and what is NOT needed.
This coverage will have rock bottom premiums because our patients use less hospital time and less high tech care. Published data, from MDVIP, suggests that such direct practice medical homes can radically reduce medical errors and cut high tech care by over 60%. That translates to better health, saved lives and lower cost. It can no longer be claimed that direct practice doctors do not deliver better health care. We do. And SIMPD must develop reporting tools to prove as MDVIP has done that the care delivered by all our members is better.
This is care like Russell Anderson used to give my family and friends. It is the care all Americans should have, could have and will have if our ideas prevail.
Think about it. There are 900,000 physicians in America. Six hundred thousand of them are sub specialists and their numbers are growing. Three hundred thousand of them are primary care doctors and their numbers are shrinking. It used to be the other way around. When we were children the vast majority of doctors did primary care. Most pre-med students enter college still assume they will do primary care. Why did the outcome change?
Well, one reason is of course that high tech care is much more complex, but that is not the major reason. There is a huge shortage of primary care doctors and a relative glut of sub specialists as we all know. Why does the market not correct this imbalance? The reason is simple. The current third party driven payment systems pay sub-specialists about $400,000 per year for their services while they pay primary care doctors about $150,000 a year for their services. We need to equalize that pay to restore the previous balance that once allowed medical homes to exist all over American. How do we do that? We do it through SIMPD direct practices.
Now, charity for those in need is not optional to us and SIMPD members do more than the average amount of it, but patients who are not in need of charity should take care of their own expenses. That is part of being a free American and it should not be that hard to do. Even with today’s massively inflated, quadrupled prices the average American consumes only $250,000 worth of health care in a lifetime. He consumes $400,000 worth of food.
Furthermore, 20% of patients consume 80% of the care. The healthier eighty percent spend much less, perhaps $50,000 in a lifetime or $100 a month. That is an affordable lifetime expense for most of us. The unaffordable excess risk that infrequently befalls a few of us must be insured. That is what insurance is good at. It is in fact the ONLY thing insurance is good at.
So, can we fix health care? Is there the political will to fix it? Can we defeat the vested interests holding back progress? What criteria should we use to sort through, accept and reject, the various ideas thrown our way?
We need to gradually get people back to buying their own basic care with their own money completely outside the public and private insurance systems. SIMPD will be part of that gradual change. Another part of it is tax free health savings accounts and high deductible personally owned insurance that some of you may already have. Non existent five years ago, today at least six million of Americans use health savings plans. My family does. So do two of my employees. Do yours? Even Medicare now offers such a plan.
We must change health insurance, public and private, so that it covers only expensive chronic disease and catastrophes, not basic care. All but the poorest Americans, who do need a charitable safety net, should buy that basic care through a primary care “direct practice medical home” or through a direct cash practice. With the savings we could easily afford the charity care the poorest Americans need. SIMPD’s goal is to see that day come.
Under our current arrangement primary care medicine is on life support. Most students refuse to enter the field. We must convince 50% of our medical students to enter primary care. Less than 8% went down that path last year. That has to change because primary care is the backbone of medicine. Until we eliminate medical homelessness and make primary care the best kind of practice to enjoy and thrive in as a doctor, nothing else will work very well.
Government does have a role. Insurance, real insurance, once purchased must not be cancelable or up ratable just because of illness. It must be purchased in advance of need. We need strong tax incentives that encourage almost everyone to buy that coverage in advance of need. Creating that playing field is the role of government in a free society. So is encouraging and incentivizing patients to join a direct practice medical home like ours. That is why each of you needs to get involved in organized medicine and politics in your local community. You need to be the voices that stand out and shout our message from the roof tops. And they are beginning to listen to our better idea.
We must means test government programs and promote private charity as better and less costly solutions. Charity care, public or private, must go only to those in real need, and bluntly, most of us and most of our patients do not need other people’s money to pay for routine care.
Health care is different from other critical human needs like food, housing and shelter, which are actually more expensive. Illness is unexpected, confusing, terrifying. It strikes randomly and unevenly. Only recently have we found effective tools to battle and prevent it. We naturally want all humanity to have equal access to those new and effective tools, and in our zeal to accomplish that we forgot that free markets are the best way, the only way, to achieve that goal.
Can we do it? I don’t know. SIMPD has put itself in a position to have a more audible voice in the national debate. Keep the objectives of direct practice primary care medical homes for all paid for directly by the patient, an open transparent market and consumer controlled financing in mind with every action you take. My fear is that health care may crash and burn before the rest of America wakes up and rebuilds it. I hope it is not too late.
We will not solve health care with employer or government based universal first dollar prepaid health plans advocated by some. We will destroy it. Likewise, we must not copy the failed systems of Europe and Canada. We must solve health care in a unique American way.
Winston Churchill said that Americans can be depended upon to do the right thing after trying every other possible alternative first. We have tried or observed the shortcomings of every other possible alternative already. Let us try elevating the individual to his proper role of self reliance when possible, using true charity only when necessary, to care for ourselves optimally, while preserving our national identity.
It is the patient’s health care, but he who pays the piper calls the tune.
Tom LaGrelius, MD, FAAFP
President, Society for Innovative Medical Practice Design
Owner, Skypark Preferred Family Care