letters

Contemplating Robin Hood practice

After completing rounds at two nursing homes and a hospital and watching my daughter's soccer game all on a Saturday morning, I found time to review FPM (a testimony to FPM's relevance). After reading about Dr. Forester's successful nonprofit concierge practice ["A New Model of Charitable Care: The Robin Hood Practice," February 2008], I felt a tinge of practice envy at first.

After all, I have a practice with more than 6,000 active patients and, along with an invaluable full-time physician assistant and a part-time nurse practitioner, work 24/7 to meet the needs of these patients while maintaining a busy personal life (with four growing children). I could replace this hectic lifestyle with one that is more relaxed and just as profitable simply by selecting several hundred "benefactor" patients who could afford to make the yearly payments a concierge practice requires, and then I would have the time and resources to provide charity care to uninsured patients as well. Yet, I would have to say goodbye to the several thousand patients who are stuck with the usual third-party payers or Medicare and can barely afford their co-payments and deductibles.

When a similar concierge practice opened in a neighboring (and I might add more affluent) community, I searched my own heart and mind to see whether I would, or should, follow their lead. Thus far, the answer has been a resounding "no." To find my answer, I simply considered the many hardworking middle-class patients in my practice who have sought me out because of the quality of care my practice provides. It would be difficult to open a practice that excludes my friends who are schoolteachers, hospital employees, construction workers and neighbors simply because they are neither rich nor poor enough to fit into my practice model.

Perhaps as my energy level dwindles, I will reconsider. Dr. Forester's practice sounds like a comfortable and rewarding lifestyle.

John T. Littell, MD
Kissimmee, Fla.

The article on St. Luke's Family Practice was outstanding! What a vision! Thank you for the encouragement.

Marty Sineath, MD
Sumter, S.C.

Patient vs. "customer-owner"

The article "Transforming Your Practice: What Matters Most" [January 2008] was well done, but I take issue with one point. The authors, in discussing what the business is about, say: "It is about human beings. Alaska Native people are not just patients; they are customers and owners of the business. As such, we refer to them as 'customer-owners.'" The implication is that the people are more than "just" patients; "customer-owners" is more inclusive.

I think the authors have it backward. The term "patient" is defined in Webster's dictionary as a person who is under medical care. This concept is not anathema, though we are being conditioned to think so. If a physician is seeing a person as a patient first, the physician will be respectful, compassionate and intent on relieving suffering or assisting in the cure of the individual. This approach is not about business; it is about resonating with vulnerable human beings who need our care.

Until we remember to treat the human first and the business second, the public will continue to complain about our profession's insensitivity and the way doctors are no longer "connecting." Think about the last time you were treated for a medical condition with sincere compassion, communication and competence. I'll bet the first thing that came to your mind was not whether you, as an owner and customer, were being delivered a core product.

Edward Thompson, MD
Middletown, Md.

Evaluating the RUC

I'd like to commend Kent Moore and the other authors of "What Every Physician Should Know About the RUC" [February 2008] for an illuminating and insightful article on the fundamental assumptions, biases and mechanics that underlie the financing of Medicare.

All too frequently we collectively moan about the decline of applicants in our noble and altruistic specialty and the economic headwinds facing medical school graduates. It is not by accident that graduates of American medical schools are fleeing primary care. The RUC ensures this. As the article points out, there are only five votes out of 29 on the RUC advocating for primary care, and it requires a two-thirds majority to alter relative values. Is it any wonder that primary health care is undercompensated? Indeed, when insurance payment mechanisms were initially constructed a century ago in Minnesota, surgical interests made certain their reimbursements were at the top of the scale. Their assumptions and policies remain largely unchallenged.

We will never have meaningful realignment of our health care priorities in this country unless we dismantle this arcane paradigm of "one vote per specialty or subspecialty" and confer on primary care its full economic benefit. The AAFP would do well to promulgate this.

James Wedell, MD
Fair Oaks, Calif.

Curing Baumol's disease

I found Dr. Bobby Newbell's opinion piece on "Baumol's Disease" [November/December 2007] interesting, but any significant relationship between this "disease" and escalating health care costs is not supported by any data. I agree that "we should avoid the temptation to look for a single, simple explanation" of rising health care costs, but this should not prevent us from recognizing that the major drivers are higher-priced services, rising drug costs, the aging population and technology innovation.

The lack of increased efficiency in primary care cannot be the basis for concluding that "rising health care costs may be with us indefinitely," as if we are mere victims of the system. Regardless of our degree of productivity, there is much we can do to slow the escalation of health care costs: We can educate ourselves and our patients about the costs of diagnostic and treatment options; we can prescribe generic medications and refuse gifts from pharmaceutical companies; we can provide patients with the care they need - not the care they want; and we can reduce the medical spending occurring during the last six months of life by utilizing a hospice organization and ensuring that all patients have advance directives.

We may never have a direct way to affect Baumol's disease, but unless we become better stewards of our finite health care resources, the ultimate cure for our sick health care system will undoubtedly be imposed on us by politicians, insurance companies, employers and individuals who are unwilling and unable to pay for what they perceive as a health care "product" that is too expensive.

Allen Horn, MD, MBA, CPE
St. Cloud, Minn.