October 24, 2002
To the editor:
Mr. Enthoven is right that employers need competition among alternative delivery systems in healthcare. However, his suggestion concerning “health-insurance exchanges” will have little impact on the “high costs and inefficiencies that plague [this] market.” Where I live, one third-party administrator’s service costs only about one percent of the claims it pays. Savings from Mr. Enthoven’s suggestion, it appears, will not likely affect overall healthcare costs very much.
As a frontline physician, I believe that significant savings can be achieved by eliminating third-party payment altogether for the routine medical care that occurs during the hundreds of million visits to primary care practitioners annually. Administrative overhead for such clinics usually runs between 50 to 60 percent. Much is wasted in purchasing and updating computer billing systems, in submitting and re-submitting claims, in negotiating and re-negotiating contracts and fee schedules with insurance carriers, and in complying with billing regulations such as the monstrously complex, expensive, and intrusive HIPAA that looms on our horizon.
All this expense and hassle have been heaped upon the doctor-patient relationship ever since physicians unwittingly agreed to do their patients’ billing several decades ago. Now they do managed care’s bidding. Not so with new point-of-care payment clinics such as ours. Stripped of the baggage that comes with co-administering and co-financing health plans, these clinics serve their patients free of bureaucratic entanglements at costs that typically run between an “oil change and a brake job” – an apt analogy in this new era of HRA’s and savvy healthcare consumers. In the near future, healthcare’s Hondas will likely be patient driven.
As more Americans grasp the implications of the new pre-tax, tax-deferred personal and family medical accounts, they – not their employers, managed care providers, or even doctors – will decide how money for routine healthcare will be spent. Healthcare’s insurance oligopoly will be replaced by millions of primary care consumers busy searching out the best value for their healthcare dollar.
Primary care practitioners will readjust. Until now relatively few physicians, out of principal, have refused contracts with third parties so as not to compromise patient care and confidentiality. In the future for economic reasons, more will shed these obligations or risk the fate of 1970s’ “Detroit’s gas guzzlers.” They will differentiate themselves among the new healthcare consumers on the basis of quality, cost, and convenience – the usual forces operating in a free market. Innovations to satisfy patients’ demands in this new environment will profoundly change the delivery of healthcare, with more routine care taking place over the Internet via email and ecam using medical debit cards.
For those who resist such improvements, there will probably always be third-party payment clinics. For everyone else, payment will take place at the point of care (perhaps even in homes and offices). Health insurance will once again be applied to that which it was originally intended – catastrophes. Patients will manage their own care, triaging themselves away from overburdened ER’s for minor illnesses or injuries to clinics such as ours that are more cost-effective. Even the uninsured (whom Princeton policy wonk Uwe Reinhardt once called “expendable people – mostly low income, hard-working stiffs, socially and politically marginal”) will find primary medical care more available and affordable (as they already have at our clinic where they are welcome along with all point-of-service payers).
Americans might yet ignore the siren songs of universal healthcare – so beautiful and noble in conception, so ruthless and hypocritical in administration. A new wind of freedom and fairness is stirring in healthcare today – more personal as is befitting a relationship in which one bears his or her person to another. Patient-driven healthcare is more than just a new vehicle for change. It is shaping into a grassroots movement that will forever rearrange our priorities and perspectives.
Robert S. Berry, MD
President & CEO of PATMOS EmergiClinic
President of Health & Care for the Uninsured