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how should doctors be paid? part 1
By | May 16, 2010
i said about one of my patients, “i don’t know why she’s even paying me, actually,” and my daughter wisecracked, “don’t tell THAT to any of your patients!”
i often state that i never actually wanted to become a doctor. it’s true. i was not one of those kids who dreamed of someday wearing a white coat. i did not bandage the legs of neighborhood dogs. my earliest career aspirations were to be a roller-derby skater or a boarding-house proprietor; later, a poet.
my parents were graduate students, then college teachers, then professors (chemistry and english). my earliest understanding of adult work was that you went to your job every day, august through may, from 7 am until 8 pm – then you got summer off. as far as i could tell, the amount of money you got paid depended on how old you were. as you got older, you got paid more, until you were too old to work, and then you wrote books.
i was horrified to learn that most adult americans work all year round and never get a vacation. it just seemed uncivilized. (still does. in europe, the average worker gets 6 weeks paid vacation a year.) so, relative to most americans, i suppose i am at base a slacker.
as a young hippie mom, i was quite taken by famous midwife ina may gaskin’s vision, in Spiritual Midwifery, of how a community should support a midwife.
in her vision, members of a community should contribute resources appropriately, to provide their local midwife with an equitable standard of living, so that she would be able to counsel and care for clients without any financial conflicts of interest. the example ina may gave, as i recall, was that a midwife would not be constrained from advising clients to work on their attitudes, if she were not concerned about their payments.
a midwife supported by her community would also not be obliged to pack more clients onto her schedule to earn enough money, and would not be tempted to provide a lower standard of care to those who could pay her less. this economic model was removed from later editions of the book without elaboration, unfortunately. it was the “greed is good” reagan years; i suppose too many readers complained about such “unsustainable” high ideals, for the democratically-minded ina may to retain that part in the book.
but i agreed. i felt that, as we do with food co-ops, cooperative childcare, car pools, and community gardens, we should all chip in, with money and/or labor, each according to their means, to make a healthy standard of living – fresh vegetables, safe daycare, efficient transportation, neighborhood health care – affordable for everybody.
my intuition was that immediate hands-on care, by someone who knows you well, when you are sick or hurt, or when you need a midwife – just like fresh vegetables, safe daycare, and efficient transportation – are not commodities. they are not the same as fancy cars or high-end stereos, which are available only to those with plenty money. everybody needs them. everybody is entitled to them. and the people who provide them? they should not be given the opportunity (the temptation) to be motivated by profit.
even now as a doctor, it seems sensible.
this is the reasoning behind my “subscription” plan (i couldn’t think of a better name for it).
if each family of four that i see were on my subscription plan, it would cost them an average of $35 per month per person for unlimited access to primary care services (provided by me) – about $1680 per year for the four-person family.
if i saw a hundred families like that, it would pay for the costs of my office, the costs of keeping up with the medical research (fifty hours of coursework are required yearly), allow me to pay off my student loans ($200K, unfortunately), and sustain the current, reasonable, standard of living for my family (rented house, rabbit-ears-not-cable, ordinary car – maybe even basic catastrophic health insurance, which we currently can’t afford).
this “subscription plan” fee is based on current local primary-care fees, spread over an average of 5.5 visits per year per person (click here for services i offer).
i’d expect to see 100 four-person families for a total of about 1100-2200 hours a year, at least. (if you worked 40 hours a week all year, with no time off, you’d work 2080 hours.) so that seems fair, compared to what many family docs do (average 50 hours/week).
the subscription plan is most cost-effective (if that’s your main concern) for people who need more frequent visits. these are folks who often put off seeing a doctor, especially when they have insurance.
if you have high blood pressure or high cholesterol, have chronic stomach pain or headaches, need to lose weight or quit smoking (for example), you really should spend a transitional period of time “under treatment,” seeing your doctor on a very frequent basis. most people won’t do this, because they have to take time off work and pay out of pocket for it, and they don’t feel sick.
but by not, carefully, for once and for all, taking care of these conditions, they end up much sicker later – sometimes unable to go to work at all, hospitalized, with shortened lifespans.
although the plan is cost-effective for many of my patients, i am most interested in the effect it may have on the doctor-patient relationship, and on the place of “health care” in people’s lives (and on the place of “patient care” in my life). (let’s leave aside the question of how “health care” is to health as the “justice system” is to justice, and just presume that when i “do health care,” i am having an effect on your actual health.)
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