A growing medical menace

The Baltimore Sun

A new and disturbing trend in the medical field is gradually eroding access to primary care physicians: boutique medicine.

In medical practices that "go boutique," a provider's patients are asked to pay an annual fee - generally between $1,500 and $2,000 - to remain in the practice and to receive enhanced, more personalized care. Although this allows the provider to dispense with an intrusive insurance system, the patient still has a need for health insurance, as this retainer only covers primary care, not hospital or specialty care or prescription medications.

Unfortunately, the majority who don't want to pay this retainer, or can't afford it, lose the ability to see their trusted primary care provider. This sounds, at first, like a mild inconvenience at worst; after all, these patients are generally fully insured. The problem is that in more and more areas of the country - including much of Maryland - the number of primary care doctors is quickly shrinking. And because the typical practice of 3,000 patients decreases to 500 patients once it has gone boutique, for the deserted patients of boutique medical practices, having health insurance coverage does not equal access to health care.

There are significant problems with the current insurance system that have led some primary care physicians down the road to boutique medicine. Doctors are required to submit vast amounts of patient information via complicated forms, requiring the hiring of personnel in most physicians' offices dedicated to such tasks. And reimbursement rates for time-intensive primary care visits are significantly lower than those for specialty care visits, resulting in drastically lower incomes for primary care doctors compared with specialists. When you take into account that educational debt is $150,000 for the typical medical school graduate, it is no surprise that less than 2 percent of recent medical school graduates report that they are going into primary care. Hence the growing dearth of primary care doctors in many areas of the country.

The Hippocratic Oath admonishes physicians to "first, do no harm." Although their motivations are understandable, doctors who go boutique are harming their communities by seriously decreasing the availability of primary care. Access to this type of care is absolutely imperative if we are to get a handle on the major causes of illness and death in this country: chronic conditions such as heart disease, diabetes, high blood pressure and cancer. Primary care physicians can identify these conditions early enough to limit severe health consequences; it is through primary care physicians - who take into account the whole patient - that the vast majority of these chronic conditions are managed.

What are the solutions? Two entities must respond: private insurers and Medicare.

Private insurers in many parts of the country are already starting to feel the consequences of the trend toward boutique medicine in terms of shrinking numbers of primary care physicians available to join their groups. Without sufficient providers, insurers will be unable to offer participants access to appropriate care. To counter this problem, insurers must do two things: increase reimbursement rates to primary care doctors and drastically streamline their administrative requirements.

Medicare also must address the problem. Because most private insurance reimbursement rates are tagged to what Medicare pays for that service, Medicare can help push private insurers by increasing primary care reimbursement rates too. In addition, because the residency programs that train medical school graduates in whatever field they desire to enter have historically been funded by Medicare, the Medicare program must work to increase the number of primary care residency training programs in the country, in order to increase the supply of primary care providers to necessary levels.

Only by addressing the dwindling supply of primary care physicians can we curtail the trend of boutique medicine and - more important - maintain Americans' ability to access the primary care services that are vital to our nation's health.

Dr. Peter Beilenson is the health officer for Howard County and the founder of Maryland's Health Care for All initiative. His e-mail is pbeilenson@


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