Concierge Services

There's a growing movement, more in the US than in Canada, but it's popping up here too, where physicians - typically family physicians - charge individual patients directly for their primary care needs. In exchange for a yearly or monthly charge, patients get a litany of services, often including basic lab work, imaging, and physiotherapy, in addition to their routine doctor visits. Insurance is essentially taken out of the equation.

In Canada, this is technically against the rules in many respects - physicians are forbidden from charging patients for their care while also charging the government for that care. It happens, but either the providers just hope the regulatory colleges don't get wind of their actions, or they add on extra services and claim the charge is for those extras (it's legal to charge patients for services not covered by government insurance).

In the US, however, it's perfectly legal and becoming increasingly popular. Family doctors love the set-up, as they get to spend more time with each patient. In addition, they have no real incentive to order more services for a patient (actually a bit of a disincentive to do so) and overall, their incomes seem to go up. Many patients like these set-ups as well, as they get more dedicated time with their physicians.

The downside is cost. Seeing fewer patients for more time each while earning more money means that without significant increases in efficiency, concierge medicine is more expensive than traditional fee-for-service or insurance-based care. In the US, there is one major source of increased efficiency - lower administrative costs. Most estimates I've seen put direct administrative costs in the US at about 15%, well above that of other countries. The mishmash of various insurers and their interest in reducing payouts accounts for a good portion of that. By eliminating all or most interactions with insurers, US physicians can save themselves a lot of time and money, which can go towards more time with patients, lower costs for patients, or higher incomes for themselves.

These cost savings appear to be significant. While initial concierge services were incredibly expensive, available only for the super-rich, emerging clinics seem to be charging in the range of $1500 a year per patient. This is still beyond the ability of low-income individuals to pay, but after regular insurance payments (now mandatory due to Obamacare statutes), middle-class patients may be able to manage these costs. If insurance companies discount their prices to account for concierge services, as some are, they may become more affordable. At the moment, however, the majority of patients in concierge practices are quite wealthy.

$1500 is also a substantial sum for primary care alone. Per person healthcare costs in the US and Canada are well above that, but are concentrated on a set of high-intensity patients who receive a substantial amount of non-primary care. If the US were to spend $1500 on every person's primary care - or even only $1000 - their overall healthcare costs would skyrocket above their already immense values.

In Canada, the situation is more clear-cut. With universal health insurance, concierge services are by definition an extra, with extra costs associated. There's virtually no room for increases in administrative efficiency, as one major benefit to universal health care is low administrative costs. That may seem surprising, given the stilted bureaucracy of Canada's health care system, but most of the money ultimately does go to providing care.

It will be interesting to see how the situation evolves as time goes on, especially in Canada. Currently colleges are cracking down on known instances of concierge medicine, but sporadically and often only in response to complaints. More importantly, while our public universal healthcare is well ingrained in the culture of the public, many physicians would prefer being able to work outside the system, or believe that private care has a role alongside public care. There may be pressure to allow for parallel private medicine in Canada, including concierge services.

How Healthcare Views Obesity

I'm on vacation (well, was when I started this post) and I finally get to read some real books. On the flight, I quickly got through Dr. Brian Goldman's "The Secret Language of Doctors". It's a worthwhile read. I've read or listened to some of his work before and while I always tend to find a point or two I disagree with, on the whole he's done a great job making medicine accessible to the wider public.

A major part of this book concerns how healthcare professionals view certain patient populations and how those views translate into their speech, sometimes towards patients, but most often towards each other about patients. Frankly each one of the patient populations he describes deserves a post, but I'll focus on one in particular - the obese.

Obese people face discrimination, in medicine and out of it. They are perceived as being lazy, negligent, or at fault for any medical conditions they might have. They're made fun of by healthcare providers of all types. There's a prevailing attitude towards these patients in medicine that can seriously prevent them from getting optimal care.

However, obesity is a medical condition associated with numerous negative outcomes, at almost all stages in life (being somewhat overweight - but not obese - may be protective for elderly individuals, but that's still an ongoing topic of research). For the sake of someone's health, it's something worth addressing in most if not all patients. Obese patients are also considerably more difficult to treat. Every procedure, from simple venipuncture to complex surgeries, has additional challenges in obese patients. Diagnostic tests, particularly imaging studies, are harder to obtain and less reliable in obese patients. All other things being equal, an obese patient is a more difficult patient. When someone makes your job more difficult, it's natural to be a bit less enthusiastic about helping them.

Still, there are plenty of other patient populations who make clinicians' jobs more difficult as well. Cancer patients, for example, are considerably more difficult to treat than non-cancer patients, even for conditions unrelated to their cancer. Bringing up venipuncture again, I'll much rather try to draw blood from a typical obese patient than a typical cancer patient. Yet, with a few unfortunate exceptions (ie those with lung cancer), clinicians are often more than happy to go the extra mile for cancer patients.

The defining factor seems to be a sense of responsibility on the part of the patients. Obese patients are believe to be obese because of their own actions, while cancer patients have cancer through unlucky chance. And there's a degree of truth to that - after all, those who exercise frequently and eat well are generally slim, while those who never exercise and chow down on fast food tend to be obese. Yet, people are typically products of their environment - if you were raised rarely going outside and eating junk, it's very hard to change those habits, even with the best of intentions and considerable effort. Adult environment contributes too. A person's income and where they live are good predictors of likelihood to become obese. Obesity is also self-entrenching. Someone who has always had a BMI of 25 will have an easier time maintaining that weight than someone who once had a BMI of 35 and got it down to 25. Our bodies' compensatory mechanisms have a preference for retaining fat once it's acquired. Genetics come into play as well. While the current epidemic of obesity was not caused by genetics - after all, the human genome really hasn't changed in the past 150 years, yet obesity has skyrocketed - but it does explain why some individuals stayed slim and others put on the pounds, as the changing world environment preferentially affected those genetically predisposed to obesity.

I think the recognition that obesity cannot be assumed to be the fault of obese individuals is necessary when treating these patients. There are modifiable factors than should be addressed, but even then, making those modifications won't necessarily lead to the kind of weight reduction desired, even with highly compliant patients. We should keep negative perceptions about obesity to the condition itself, not to the person with the condition, even if it is at times hard to separate the two.

Travelling

Limited blogging (likely) continues as I am currently overseas on a short vacation. I may make a quick post or two now that I have some time off to think and read some interesting books. Actually have a number of topics worth discussing right now that I would love to write about, but we'll see how well that works on a phone through unstable wifi.

All I can say now is that if you're in medical school or about to, make time to travel! Some people take the whole summer off and I don't think I could do that (too long not being productive isn't good for me in any way), but after putting myself a bit through the wringer this past month, even a few days away from major respnosibilities is just amazing.