Correspondence
Luxury Primary Care
N Engl J Med 2002; 347:618-620August 22, 2002
- Article
To the Editor:
The article by Brennan on luxury primary care (April 11 issue)1 was of particular interest to us as patients of a physician who notified us only two weeks in advance that he would eliminate us from his practice unless we joined MDVIP at a fee of $1,500 per person per year.
Our reaction went from surprise to shock to indignation. For the most part, the services being offered were no different from those we have been receiving — that is, prompt responses to our telephone calls, timely appointments, and adequate examinations and consultation times.
We cannot believe that this kind of medical practice is legal. As Medicare patients, we are entitled to access to our physicians with nothing more than a 20 percent copayment. Without a doubt, if this practice is allowed to continue, we will have a two-tiered medical system in our country. How sad.
1 ReferencesBeverly Sharfstein
2275 South Ocean Blvd., Palm Beach, FL 33480Sunny Adler
9198 Heathridge Dr., West Palm Beach, FL 334111
Brennan TA . Luxury primary care -- market innovation or threat to access? N Engl J Med 2002;346:1165-1168
Full Text | Web of Science | Medline
To the Editor:
I have been practicing “luxury” primary care for many years, since I am accessible to all my patients 24 hours a day, 7 days a week, and I do not even charge an annual fee. I allow such access because I strongly believe in practicing patient-centered medicine with joint decision making.
Granted, my practice is small. I am not part of any health maintenance organization, because I do not fit into the mainstream of contemporary medicine. My annual well-woman examination with a pap smear may take up to one and a half hours because I discuss with the patient any health-related concerns she may have. I want my patients to leave my office with all their questions satisfactorily answered and all concerns addressed.
Financially, I am not a huge success. Even as a practicing obstetrician-gynecologist many years ago, my largest gross annual income was less than $200,000. Today, I supplement my income from my office by working elsewhere, and my gross income is about $100,000 per year. But what is money? Serving my patients well is very important to me. Surely, I am not in the minority. I do not want to be in the rat race.
Yasuo Ishida, M.D.
6744 Clayton Rd., #302, St. Louis, MO 63117To the Editor:
Brennan inadequately addresses the association of many luxury primary care programs with teaching hospitals, where new doctors learn professional ethics and where standards of evidence-based medicine are developed and taught. The general public contributes substantially, through state and federal taxes, to the education and training of new physicians. Should those physicians limit their practices to the wealthiest fraction of our citizenry, when 43 million Americans lack health insurance, our country ranks near the bottom among Western nations in life expectancy and infant mortality, and racial and wealth-based disparities in access to care and outcomes abound?1 For teaching institutions to promote luxury primary care in the face of these problems is to erode fundamental ethical principles of medicine, such as equity and justice, and such promotion will engender cynicism among trainees and the public.
1 ReferencesMartin Donohoe, M.D.
Oregon Health and Science University, Lake Oswego, OR 97034
martin.donohoe@verizon. net 1
Donohoe MT . Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med 1998;158:1596-1608
CrossRef | Web of Science | Medline
To the Editor:
As physicians in the center of the controversy over luxury primary care, we were particularly struck by the absence of the patient's voice in the review by Brennan. The current system of primary care is the creation not of doctors and patients, but of those who pay for care — in general, insurance intermediaries acting on behalf of employers or governments. Since this system is not designed by or for the patients we serve, it is not surprising that there has been widespread dissatisfaction with the results it delivers. When those who pay for services are different from those who receive those services, problems arise. Some patients want something different, and we have responded to that desire.
Our practice is not an answer to the problems of the uninsured, nor is it offered as a solution for all patients or all doctors. Our practice is an answer to the needs of specific persons — patients and doctors — who have felt inadequately served by the system as it exists. We have risked our livelihoods and our reputations in an effort to prove that a better and different way of practicing medicine is possible. We believe that free choice and the marketplace of services and ideas are better alternatives than the status quo. Our success will be measured by our ability to deliver on our promises, as determined by the patients who choose our care.
Steven R. Flier, M.D.
Jordan Busch, M.D.
Nancy H. Corliss, M.D.
Personal Physicians HealthCare, Chestnut Hill, MA 02467
sflier@personalphysicians.net To the Editor:
Brennan sets out to “examine the . . . ethical issues that arise with [luxury primary care] practices.” His chief concern is access, and he concludes with the prescriptive (as opposed to descriptive) statement that “as physicians we have a commitment to the equitable distribution of health care.” What is the basis for this statement? Certainly, most people believe that food and shelter are more important than medical care, yet there is no expectation that builders have an obligation to provide for the equitable distribution of housing or that supermarket chains have an obligation to provide for the equitable distribution of food. The origin of Brennan's assertion lies in the concept, beloved by certain policy makers and health economists, of medical exceptionalism. Again, however, beyond the assertion that “medicine is different,” there is no argument to sustain such a belief. The distribution of resources belongs in the political arena, and ethical physicians of all stripes can advocate for whatever scheme they are committed to, but clearly equitable distribution is not a problem for the individual physician, no matter how guilty he or she can be made to feel.
Stephen Bohan, M.D.
Brigham and Women's Hospital, Boston, MA 02115
jbohan@partners.org To the Editor:
I take issue with the definition of luxury care given in Brennan's article. Luxury is a subjective term that hints at extravagance, exclusivity, and exclusion. It troubles me when this term is used to describe activities that until recently were considered to be quite ordinary — in fact, the standard of care. The half-hour office visit may be a thing of the past, but it seems wrong to regard it as a luxury. In many instances, particularly in the case of an elderly patient with multiple medical problems, more than 15 minutes of a physician's time is a necessity and not a luxury.
I think that the problem that is leading to plans such as “luxury primary care” is the woeful inadequacy of reimbursement for office-based medical care. The current standard for office visits of 15 minutes or less is not a matter of choice, but rather a matter of financial survival. With reimbursement rates as low as they are, a physician has to keep patient turnaround time short in order to keep a practice financially viable. The situation is made worse by the tendency of government to balance its budget at the expense of the medical practitioner. This year, Medicare cut payments to doctors by 5.4 percent, and additional cuts totaling 17 percent are anticipated during the next three years.1 Meanwhile, overhead costs for medical practices continue to climb. For instance, medical-malpractice insurance premiums throughout the country are rising at an average annual rate of 30 percent.2 Where will it all lead? Nowhere good, I'm afraid.
2 ReferencesBasil K. Lucak, M.D.
New York University School of Medicine, New York, NY 10016
basmed@cyburban.com To the Editor:
I think you should comment on some other losses in the population of physicians who are practicing standard medicine. Could you comment on the ethics of physicians who choose to leave clinical medicine to earn master's degrees in business administration and become physician-executives? Could you comment on physicians who subsequently attend law school and practice law? Could you comment on physicians who retire before becoming enfeebled or incompetent or 65 years of age? Finally, could you comment on the 13th Amendment to the U.S. Constitution and its applicability to persons holding the M.D. degree?
When I attended medical school, the teachers repeatedly articulated the concept that my fellow students and I acquired a special responsibility to society by attending a state-subsidized medical school. In exchange for life-and-death responsibility and hard work, society would offer us respect and remuneration substantially higher than that afforded the average worker.
My perception is that lawyers and bureaucrats have dismantled the implied social contract that was described to me when I was a medical student. Production pressure has diminished “the calling” of being a physician. It comes as no surprise to me that some physicians have found novel ways to support themselves.
James R. Niederlehner, M.D.
Anesthesia Associates of Roanoke, Roanoke, VA 24018
jnieder@roanoke.infi. net Author/Editor Response
Dr. Brennan replies:
To the Editor: Bohan and I disagree sharply. I believe that our ethical commitment to patients does create a responsibility to address the distribution of health care resources in the political arena. Medicine is different from other forms of commerce — we adhere to an explicit set of moral principles that give rise to professional responsibilities, including, I believe, the responsibility to address policy issues.
Unlike Flier et al., I do not believe that luxury primary care is a simple matter of choice for patients and doctors. I see it as part of what I believe is a long-term trend toward segmentation of the medical market into the haves and the have-nots. I think that the profession simply cannot tolerate structural inequalities in the ways in which sick people are treated and must resist libertarian, market-driven changes that create such inequities.
Troyen A. Brennan, M.D.
Brigham and Women's Hospital, Boston, MA 02115
tabrennan@partners.org - Citing Articles (4)
Citing Articles
1
K Umeshita, S Satomi, M Monden. (2005) Present condition of liver transplantation and future problem. 2. Various problems on living liver transplantation donor.. Kanzo 46:6, 306-309
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Hiroshi Imamura, Norihiko Kokudo, Yasuhiko Sugawara, Keiji Sano, Jun-ichi Kaneko, Tadatoshi Takayama, Masatoshi Makuuchi. (2004) Pringle's maneuver and selective inflow occlusion in living donor liver hepatectomy. Liver Transplantation 10:6, 771-778
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Yasuhiko Sugawara, Masatoshi Makuuchi. (2004) Advances in adult living donor liver transplantation: A review based on reports from the 10th anniversary of the adult-to-adult living donor liver transplantation meeting in Tokyo. Liver Transplantation 10:6, 715-720
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Antonio Lopez-Navidad, Francisco Caballero. (2003) Extended criteria for organ acceptance. Strategies for achieving organ safety and for increasing organ pool. Clinical Transplantation 17:4, 308-324
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