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	James L. Holly, M.D.

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Letters - The Flaw in Subscription Healthcare, James L. Holly, MD, Medical Home News, August, 2013

By James L. Holly, MD
Medical Home News
August, 2013

The fundamental flaw to “subscription healthcare” is that most of SETMA’s patients cannot afford a $5 co-pay. How would they then afford a monthly payment of $60 or more? Ten years ago, SETMA went to our major HMO and asked them to reduce the co-pay for primary care visits to zero. Our analytics of outcomes measures by payer class shows that our Medicare Advantage patients, who have no co-pay to see primary care, have better outcomes than Fee-for-Service Medicare beneficiaries who have to pay 20%. By implication, we think, this has to do with a financial barrier to care.

The proposal by Mr. Tolbert will work with patients who can afford care, but will not with our patients. We believe that capitation will answer the problems of escalation of healthcare costs and that payment for quality outcomes will allow providers to be rewarded for their efforts at transformation.

From a public policy view, healthcare should be a human right (Dr. Don Berwick). This is another way of expressing Senator Hubert Humphries, 1977 “Moral Test of Government”, which states: "The moral test of government is how it treats those who are in the dawn of life, children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped."

Mr. Tolbert makes the same mistake that others have in assuming that a personal, financial relationship between a healthcare provider and a patient creates a patient-centric dynamic of care. It doesn’t. Medical Home works to transform a practice to benefit all patients. Concierge medicine artificially limits the size of a practice to give better care, but only to a few patients. Medical Home attempts to increase access for all patients, while concierge medicine significantly decreases or eliminates access to care for the majority.Medical Home attempts to make care more sustainable by decreasing the cost. Subscription medicine adds to the cost of care by the subscription fees are pain in addition to insurance which is not eliminated. There is no structural basis for a patient to be dismissed from a Medical Home but if a patient can’t pay their subscription fee, they apparently will be dismissed from the concierge practice.

The greatest fraud of concierge medicine is the pretense of being patient-centric. The problem is they are patient-centric only for the patients left after they impose a tax on being a part of the concierge practice and after abandoning patients unable or unwilling to pay the tax, many of whom they have cared for for years. NCQA, AAAHC, URAC and the Joint commission should not allow concierge practices to apply for PC-MH recognition or certification. If these organizations allow concierge practices to receive their approval, they will have abandoned any moral imperative they have as accrediting bodies. There is nothing in the mission of medical home, in the Triple Aim or in ACOs which allows for the exclusion of people who cannot afford a financial premium upon their care, or for the exclusion of those who have complex, chronic health conditions.

The plaque arrived on April 23, 2013 and read: ‘Texas Physician Practice Award presented to Southeast Texas Medical Associates, LLP for Providing Exceptional Preventive Health Care Services using Health Information Technology.’ Awarded by The Texas Physician Practice Quality Improvement Award Committee, the committee is made up of the TMF Health Quality Institute (Texas’ CMS Quality Improvement Organization), the Texas Medical Association and the Texas Osteopathic Medical Association. The Committee commented further, ‘Congratulations on this significant accomplishment, which illustrates your commitment to delivering quality care to all patients. Your award demonstrates that SETMA has an exceptional team.’ ‘Quality care to all patients’ is one of the major goals of healthcare reform and one of the foundational principles of medical home.

Conclusion

Payment models need to be changed. Primary care must be paid for the unique services they perform. However, the creating of a direct, financial relationship between provider and patient, which relationship is dependent upon the patient’s ability to pay an additional fee, is not the solution to primary care providers being underpaid or to patients having access to the care they need.

Related Letters

	Medical Home News July 2013 Response to Alex Tolbert’s Top Three Obstacles to Better Primary Care Medical Home News July, 2013 Alex Tolbert’s Top Three Obstacles to Better Primary Care

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