STRANGERCROMBIE WINNER! This article was bought-and-paid-for in The Stranger’s annual charity auction—which this year raised more than $50,000 for the Seattle nonprofit Treehouse, helping foster kids since 1988. Thank you, everybody!
As a primary-care internist in Seattle for almost 30 years, I’ve
loved every day and most of the patients I’ve cared for. I have also
watched medical care descend into a deep abyss—one in which
quality, access, and cost have all been severely compromised. I think I
may know the way back, and I want to share that with you.
Although I had no patients in 1980 when I opened my practice, I had
bright, energetic partners and was privileged to find staff members who
understood how to care for patients and for me. I dreamed of practicing
until I retired, without distraction or interruption. How wrong I was.
As doctors and as patients, we were victims of a number of
well-intentioned but catastrophic decisions, some made by us and some
by others. Together we have nearly destroyed medical care.
The first error was our approach to health insurance. I have always
been a supporter of health insurance. The idea that people should have
access to the best medical care, even if they are of modest means, is
captivating. When health insurance began to flourish in the 1960s, I
was in favor. Medicare and Medicaid—the pinnacle of the Great
Society of President Lyndon Johnson—held great promise. It seemed
to be the beginning of an era in which we would finally overcome our
class discrimination and care for the elderly and the poor.
What happened to medical care as insurance grew widespread? It got
expensive. For the first time, doctors were sending their bills to
third-party payers, not to patients. The enormous restraint inherent in
a doctor-patient transaction was gone. As prices went up, so did
insurance reimbursement—and insurance premiums. Employers were
paying those premiums, and since American industry was strong, wealthy,
and competitive, costs continued to rise. The era of medical inflation
had begun. It has not ended yet. Doctors were not the only or even the
major beneficiaries of this money grab. Medical technology,
pharmaceutical companies, and hospitals all dived in. The health-care
gold rush was launched. With cost-plus health insurance we invented an
inflation machine, one powered by government and employer money, one
without any brakes. Doctors and patients could order what they wanted.
Insurers would pay. As the money flow expanded, so did
insurance-
company profits. It’s no wonder that health care got
expensive.
The next well-intentioned development in the devolution of medical
care was the mechanism by which medical fees were set, a system called
Resource-Based Relative Value Scale (RBRVS). This was the invention of
Professor William Hsiao, an actuary at the Harvard School of Public
Health. RBRVS attempted to price every item in medical care based on
the resources required to create it. Procedures or devices that were
expensive to make were priced higher. Physicians who required more
training and preparation were paid more. What a dream for insurance
companies—pricing without negotiation. In any industry but
medicine, this would be called “price fixing” and probably be illegal.
Instead, RBRVS was immediately adopted by Medicare in 1988. It has been
a fixture in insurance reimbursement ever since.
Unfortunately, there was a problem with RBRVS—it killed
primary care. Just as bad, it caused a natural migration to more and
more expensive treatments. The primary-care doctors didn’t have
expensive procedures, and they didn’t spend as many years in training
as the specialists. In the RBRVS world, they were nearly worthless. In
real markets, prices are determined by what customers value and are
willing to pay: Too high a price, no sale. In health care, if it is
expensive to produce, we pay more. If you want to understand why
American medical care is dominated by specialists doing expensive
procedures, you need look no further than this. Despite growing
mountains of data showing that medical systems dominated by
primary-care physicians produce better health outcomes at lower cost,
we persist with an insurance system programmed to annihilate primary
care and encourage expensive procedures. We spend the lion’s share of
our waning national wealth on expensive, overpriced, and
often-dangerous alternatives.
As the battle between providers and insurers grew, medical culture
took a turn for the worse. Doctors organized themselves as large
financial units with professional management. We moved further and
further from our role as healers, further and further from our
patients. We were thinking about reimbursement, not medical care. The
now-well-paid proceduralists began to dominate clinics financially. The
primary-care doctors became the ugly stepchildren, allowed to stay
mostly as a source of referrals to the specialists, but vastly
underpaid relative to their high-flying colleagues.
There is one more key element that has moved us toward the brink. We
have come to equate medical insurance with medical care. Insurance
companies do not see you when you are ill. They don’t take out your
appendix. Every politician and health strategist in this country talks
about ways to enlarge health insurance when we should be talking about
ways to promote health care. Health insurance is a mammoth middleman.
It is a key part of a health-care system, but it cannot and should not
enclose and manage that system. It is not the answer. In the case of
the least expensive and most critical aspect of health
care—primary care—it is the prime barrier to care.
What should you take away from my journey?
It matters if your doctor works for you or for your government,
employer, or insurance company. If you want better medical care, then
make sure that the money for your care goes through you—whether it comes from your wallet, a health savings account,
your insurance company, or the government. You need to be the customer,
and you should be making the decisions.
If you are a doctor, don’t sign contracts that hand over medical
care and pricing decisions to any third party.
Medical costs need to be appropriate for patients, not for insurance
companies. Physicians need to rediscover what “reasonable” prices look
like.
Technology is nice, but it is not a substitute for access to a
doctor with the time to take care of you and a keen awareness that he
or she works for you and only you.
If you don’t have a primary-care physician, you should get one.
Consider decoupling that care from insurance. Pay with your own money
(it won’t cost you much). Insist on access and service.
The new administration has pledged to reform our broken health-care
system, and it has built an excellent team to complete this important
task. I hope it will listen to some of us old-timers. 
Dr. Garrison Bliss is a Seattle-based board-certified
internist. In 1997, he led the
second-ever conversion of a medical
practice in the United States to a direct-practice model, in which
physicians are paid a low monthly fee directly by patients instead of
seeking and accepting payment from insurance companies. He is now chief
medical officer of Qliance Medical Group and continues to see patients.
Dr. Bliss can be reached at thestranger@qliance.com.
There was an article in Harper’s this month, on a similar theme (behind a subscription wall, unfortunately). It ended on a fairly pessimistic note, though.
um, guys, do you realize that this way of thinking about healthcare is totally in line with what the folks on the right side of the political spectrum have been saying for years–that managed healthcare systems do more harm than good–you might want to rethink supporting politicians, say, like Obama, when in fact you don’t actually agree with their policies
With all due respect to the man and the care he has given to people over the years, I find it odd that the beginning of this piece makes promises about solutions, but the promises end up with something like, “Pay cash.” I realize that there was some other options in there as well, but Dear The Stranger, get someone who has actually thought out some solutions to the problem. Being a doctor does not qualify an individual to wax philosophic on all things related to public health.
I have used national healthcare systems in Europe on three different occasions. They work, for less money.
It is impossible to me that someone would write an article on the problems with healthcare and not mention the 25% profit that is skimmed off of the top for the insurance companies.
Now I get it, the Bliss family medical practice purchased the opportunity to push their own practices. Interesting.
I’m curious why you say “push their own practices”. They are a business – with an interest in promoting it – and it happens to solve an issue by creating an alternative for people that may not have the ability to receive healthcare otherwise. I would say they are far from being “pushy”, they are simply outlining the benefits and highlighting the VERY real problems with the current healthcare system.
As for the person who says there is no solution except to “pay cash”. What’s the problem with that? Right now you have to “pay cash” to access healthcare – and it happens to be a significant amount more cash. The solution isn’t just to pay cash – it’s to create a relationship with a doctor where you are a client, and you are treated like a client. Imagine if we went to a grocery store and there was a person walking you through the grocery store rushing you – pushing you along, and dismissing you before you got every item on your list. Would you buy from that store? NO! We have an expectation of quality customer service everywhere EXCEPT for our healthcare providers. They’ve gotten a golden ticket to shuffle us through their offices at mach 3 speed and often with only one problem at a time solved. This provides a solution to that problem.
And as for the person who says this is aligned with conservative ideology: I’d like to ask you where you get that notion. Conservatives and liberals alike agree there is a problem with healthcare. Conservatives favor deregulation and little oversight of the industry which then perpetuates the problems we see now.
I don’t want to be the person who stands up for insurance companies. However, when I read articles that don’t go beyond bashing insurance companies it only shows how much ignorance there is about the enormity of the healthcare issue. It’s easy to hate insurance companies and get those to be on your side, but there are not-for-profit insurance companies as well that aren’t trying to screw society. Don’t forget we live in a litigious society in which we sue and point at those that we can find any sort of blame upon in which forces doctors to pay for expensive medical insurance to protect themselves and create more admin costs for things like HIPAA which ultimately increases the cost of care. And what about paying 10 times the cost for same prescription meds as you can get in other countries that are the essentially the same chemical compounds found in the drug (generics)?? You really don’t think the hip scientists down in South Lake Union have no hand in that so they can market and advertise their brand products for more money? Or the major drug companies that can charge more in their own country so they can fund their lavish annual meetings in Switzerland and support special-interest groups to buddy up with the FDA and politicians to get their drug approved all at the same time making people thinking they are helping the world with their innovation? Does the media not try to frighten us with reports over a massive bird flu, flesh-eating diseases, and a mosquito virus that will decimate millions of us in a week that gets people running to their doctors further increasing costs and expense? Remember that health insurance is a product. It is an expensive product due to many variables. You don’t have to buy it… and then try to blame someone when your doctor’s invoice arrives for the heart surgery caused by your pack-a-day cigarette habit, television life, and pizza diet.
I think this Qliance stuff is generally a great idea, but I take issue with Dr. Bliss on a fairly big omission: why not mention managed care? Mentioned it zero times. What is up? Managed care is not cost-plus, and you can’t get whatever procedure you want, on demand with managed care. I’m not saying that managed care is better than what Dr. Bliss is promoting, I’m just saying WTF, why didn’t you bring it up at all? It’s weird.
Managed care is also partially based upon actuaral costs. Group Health was considered a Model for the Clinton adminstration for the entire country, and when they squeezed that to the limit, they needed something else to justify rate increases. We have had managed care, by and large, for a long time already, and costs still go up. Especially since 1998. Coincidence? I think not.
Actuary’s are the fuel for the insurance companies denials, policies, and rates, NOT indivdual needs. They are a primary reason private health care insurance companies in the US have a directconfict of interest, when immediate costs are more important than indiviual outcomes. Ironic, as doing it right saves money in the long run, but not when you are thinking about next quarter’s profits.
Dr Bliss seems well intentioned but the bottom line is that he runs a “boutique” medicine clinic that does not accept insurance and is based upon people paying for their care completely out of pocket; this is just not a real solution for our country’s healthcare problems (though it would be from the side of the docs as they wouldn’t have to waste so much time on paperwork and get shitty reimbursements from insurance comps). His argument for boutique care is not one that will make healthcare obtainable for people of “modest means.” I can not afford to join Qliance or pay for my primary care visits out of my pocket (maybe to Dr Bliss $115 is not a lot to pay for a primary care visit but it is to me and I’m grateful my insurance comp pays for the majority of it), and I do not feel that this is any way diminishes my respect for the place of the primary care provider in public health. I don’t have a solution to this issue, nor do I love having to deal with my insurance company when billing gets screwed up (as it inevitably always does) but I am one of those people of modest means who is grateful their employer provides health insurance. Until we get a national plan where everyone is covered, there is no way I’m paying for anything out of pocket unless it is my deductible or co-pay.
Let it not be said that “Bliss is ignorance…..”
…wise words of scenery.
Bravo Dr Bliss! Eloquent and persuasive as always.
As president of SIMPD, the Society for Innovative Medical Practice Design, the professional society open to all concierge and other direct practice doctors (of which Dr. Bliss is a member and past president) I want to confirm that the reason health care is so fragmented and disrupted today is the lack of excellent primary care America once had. That fact in large part results from the devaluation of primary care and its extremely low pay status under the third party and Medicare dominated payment system under which we suffer.
The concept of “medical home” is a critical one. Every American needs one, a place they can access top notch primary care immediately and fully like one can access a concerned family member. And they need to buy that home directly, not with other people’s money. When they do so the cost can be very low to the patient and the benefits very high to patient, primary care doctor and society.
The only payer willing and able to pay what a medical home will cost is the patient. Interest in concierge medicine is therefore rapidly growing. Starting with the first such practice about twelve years ago in Seattle and growing exponentially, there are now thousands of such practices in the USA, some are associated with franchises though most are independent. No mater what the government does, that is where the action will be in the future as our numbers grow from the current thousands to tens of thousands to hundreds of thousands.
Direct practice doctors and those who wish to adopt the direct practice model can join the society and get many benefits including up to 55% discounts on malpractice insurance, practice marketing help, national care networks and many other services. Our society is rapidly growing its membership. Direct practice doctors have much more time with their patients, make a better living, and virtually never get sued. That is why we get huge malpractice insurance discounts.
Patients can go to SIMPD’s web site at http://www.simpd.org for information and to find such a doctor in their own community at the “find a physician” link. This is the ideal way for patients to get personalized, prompt, excellent primary medical care in a unhurried, pleasant setting. Money is actually saved on patient care in such practices because emergency room visits and hospitalizations are drastically reduced due to of the personalized, immediate, detailed care we deliver. The cost of concierge care, which averages about $150 per month, can be as low as $40 per month. This is affordable for most Americans, while the fragmented primary care most are now getting through employers or government third party interference in the doctor patient relationship is penny wise and pound foolish.
SIMPD believes most Americans can eventually be cared for in such direct “medical home” practices resulting in far better care. This will result in lower overall cost and a return of interest in primary care by students who now shun the field as undervalued, underpaid and undesirable compared with other medical specialties which for the same or lower levels of training and effort often pay double and tripple what primary care pays inside the insurance system.
If any of you have further interest please contact me through the SIMPD web site. I answer all emails through that site personally.
Thomas W. LaGrelius, MD, FAAFP President, SIMPD http://www.simpd.org
Owner, SPFC Torrance, CA http://www.skyparkpfc.com
@ Germaine Jackson
The money needed to run a national system where everything is covered is going to come out of your pocket.
I am currently living in a socialist country with a “universal” healthcare system. Almost 50% of my salary goes to taxes, and about 80% of the taxes I pay go to fund health care. In addition, I pay for most of my care out of pocket anyway, because if you go to a state run clinic you’re treated like a box on an assembly line.
I would love if I could opt out of the national system and instead go to a “boutique” clinic like Dr. Blisses for primary care and buy my own insurance for emergencies, etc. But its not allowed here, because people like me who work legally and full time are expected to support all of the unemployed (many of whom actually are working but aren’t reporting their income) and the retired, etc.
Don’t get me wrong, I think that there should be programs to help people get healthcare who can’t afford it, but forcing americans who have access to quality care now into a nationally run “universal” system where they would likely get worse coverage is absurd.
Look at everything else our government runs–the schools, the prisons, and ask yourself if a state run hospital would look any different.
I just need to say that you can find Qliance’s fees on the following page:
http://www.qliance.com/fees.html
Unfortunately they cannot take Medicaid or Medicare because those require you to bill them. They do not have this ability, as they have no other need for the expensive overhead of the billing/insurance staff; They do not bill insurance.
You will notice that you pay per month, with practically unlimited visits (there are only so many hours in a work day). “You may be asked to pay additional fees for items such as prescription medications, laboratory tests and outside services such as x-ray interpretation if needed.” However, they know up front what your cost for these should be and you can still bill prescriptions/laboratory tests to other insurance. I believe you have to do this yourself though.
The deregulation promoted by Republicans points more in the deregulation of insurance. In the state of WA, we (under Gov Chris Gregoire, democrat) fought very strongly to require insurance companies to cover certain items/procedures/standards. This, of course, made insurance more expensive but also drove out all the insurance companies that did not want to provide those services (it wasn’t profitable enough). Deregulating this would probably end up in crap insurance for ridiculous prices/moderate prices.
Although I’m not sure if they mention it on their website, Dr. Bliss also advises getting catastrophic insurance (emergency room visits, surgeries) because they are primary care not ER docs or surgeons. These procedures are costly (maybe not quite as costly as they should be) because they require extra staff and proper conditions.
I have been a patient of Dr Bliss for the past 26 years. He was, before Qliance, edxtremely hands on as a physician. After Qliance, my fanily’s experience has improved even where no improvement was needed.
With our monthly out of pocket for his services, it still costs less for our medical care than previously.
We are lucky enough to have medical insurance through my employer, however when we did not due to self-employment, it cost less then also.
Do not think that me4dical care in this country cqn survivr through the right wing pandering and the insurance companies, we need to “socialize” our medical care…if we do not provide adequate care to all Americans, where is our next generation going to be? Dumb and sick?