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On the Third Hand: Concierge medicine

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Rep. Pete Sessions, R-Texas, and Sen. Bill Cassidy, R-La., have introduced a Patient Protection and Affordable Care Act (PPACA) change bill that is full of interesting ideas for modifying the PPACA commercial health insurance provisions.

See also: Sessions-Cassidy PPACA overhaul bill, dissected

Some of the ideas in the Sessions-Cassidy proposal might be worth considering even if the current PPACA commercial health insurance framework stays more or less as is.

One section, for example, would beef up insurers’ defenses against healthy consumers who intentionally go without health coverage. Consumers in that situation could still sign up for major medical coverage during an open enrollment period, without going through medical underwriting. But they would have to pay more for their premiums.

Another provision would let some low-income, low-asset consumers buy limited-benefit health insurance rather than full-fledged medical coverage. The provision would protect the holders of that coverage by limiting health care providers’ ability to sue the limited-benefit coverage insureds for re-payment.

One drawback is that the major medical-limited-benefit divide might push some health care providers to discriminate against the patients with the limited-benefit coverage. One advantage is that the provision might do something about the reality that PPACA coverage seems to be a much better deal for hospitals than it is for moderate-income, poorly subsidized exchange plan buyers.

Still other proposal provisions would encourage doctors to start and consumers to use concierge medical practices.

A typical concierge medical practice charges a consumer a flat annual fee in exchange for a year of access to primary care services.

The proposal would let a health savings account (HSA) user tap HSA funds to pay the fee for a concierge practice.

Another provision states that a concierge practice service package “shall not be treated as offering health insurance coverage and shall not be subject to regulations as such coverage” under the federal Public Health Service Act and the Employee Retirement and Income Security Act (ERISA).

I think the provision raises a really important point: It’s very easy for professionals of all kinds to turn themselves into accidental equivalent of a bad, 1980s-style HMO: an organization that’s promised to provide all the services a customer needs, for a flat annual fee, without either the seller or buyer understanding why that cute little promise is actually absurd.

On the one hand, of course, some health maintenance organizations (HMOs) are fine, and many doctors run efficient, adequately staffed offices that have more than enough capacity to provide whatever primary care the enrollees need.

But if a big “Walking Dead” zombie epidemic strikes, that epidemic will knock out health care provider and health care finance organizations of all kinds.

On the other hand, a one-doctor office that’s promised members “unlimited access” to primary care get overloaded a lot more quickly than a big HMO, and the one-doctor office may not even understand what exactly it’s really promised the patients.

What if the doctor in the one-doctor office suffers a disabling illness or injury, or gets fed up with practicing medicine in the middle of the year and runs away from home?

What a concierge practice uses a contract that does set reasonable care access limits, but the patient and the provider get in a dispute over how the contract is being interpreted?

If concierge medicine is going to become a major source of medical care, not just a rare experiment, then the doctors, consumer groups, insurance regulators and others need to get together to come up with a framework for concierge medicine that minimizes hassles for the providers but keeps doctors from over-promising and protects the patients against doctors who are unable to deliver the kind of care promised.

Some ideas:

  • Create a database of regulator-approved concierge practice model patient contracts, so the practices have an easy time keeping their promises reasonable and the consumers’ expectations realistic.

  • Require concierge practices to make arrangements for backup care. One approach might be to have a concierge practice buy a new type of business interruption policy. The policy would reimburse the practice patients for primary care if the practice shut down and the patients had to get care elsewhere. 

  • Promote the use of Yelp and similar public and private websites as mechanisms for helping patients identify concierge practices that are not living up to expectations.

See also:

Continuing care retirement communities: What could go wrong?

The Medical Home: Dream Castle Or Just A Buzzword?


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