How much is your doctor worth to you? For most people the answer appears to be, “Not very much at all.”
In the current rapidly changing health care environment patients are seeing their insurance coverage change on a regular basis. Their in-network physician can become an out-of-network physician overnight. Continuing under their physician’s care then results in additional charges for each visit. These charges are typically in the range of $30-$50. The vast majority of patients are not willing to pay the additional fees and therefore switch to a new physician. For healthy patients who do not have a well-established relationship this makes sense. Why pay extra to see a doctor you have only seen once or twice for a head cold?
For patients with chronic illness and who have more complex issues the decision is more significant but the outcome is seldom different. In the minds of many patients doctors are like any other product they would purchase at the market. The name on the package may be different but the basic product is the same. They see no reason to pay more for something when they can get the same thing somewhere else at a lower price. Even when a doctor has provided exceptional care there is little extra value perceived.
Several years ago I had an active senior citizen come to me saying that he was getting more fatigued with exercise. He had no chest pain or pressure but I asked the appropriate questions and felt there was a significant chance of coronary artery disease. Although the symptoms were not classic I referred him to a cardiologist for an urgent evaluation. Further testing revealed significant blockages of his heart arteries and he underwent angioplasty. It is not an exaggeration to say that my thoroughness may have averted a heart attack. A few months later he learned that I might not continue to be covered by his health plan and that in the coming months he might have to pay an additional fee. He changed doctors immediately. I may have saved his life but I was not worth an extra $30 a visit.
For physicians who truly care about their patients this can be very discouraging. Last year I made a change in my schedule, lengthening routine appointments by 33%. Patients appreciate the time and attention and I think it has greatly improved the quality of medical care I provide but at the end of the day the percentage of patients willing to pay more for the extra time, attention and quality is discouragingly low. We live in a world where people who pay $5 for a cup of coffee, $15 to see a movie and $150 a month for cable TV are unwilling to pay more than the minimum to see their doctor.
This is part of the reason many doctors have converted to concierge practices, models in which patients pay an upfront fee to be a part of a quality practice. For fees of up to $3000 a year or more patients are guaranteed same day access, rapid telephone and email responses, and lengthy appointments. Patients get high level service and physicians get patients who value their time and expertise.
While concierge practices have much to offer they are out of the reach of the vast majority of patients. As appealing as the arrangement is from a financial perspective I cannot bring myself to closing the access door to longstanding patients of modest means. For the moment I plug along doing the best I can at current reimbursement levels, knowing that my current strategy of providing the highest quality care and service I can may not be sustainable in the long term. My hope is that over time more of my patients will grow to appreciate the value of the service we provide. If not, we will all have difficult decisions to make.