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how should doctors be paid? part 2
By | May 16, 2010
i wonder how a person’s relationship to “health care” would change if insurance – and dependence on a faceless corporation that mainly acts to constrain one’s access to a mystifying set of hurdles – were out of the picture.
many of us, who don’t have insurance and/or don’t like or trust doctors, have a relationship to “health care” that entails a set of self-help books, websites, and a library of anecdotes from friends and family. i think participating in “the health care system” would be more like this, if insurance were out of the picture – except the home medical manual and anecdotes would be continually reality-checked with a thoroughly educated, constantly updated, and emotionally invested live physician who also lays their hands on your body and asks how you’re sleeping.
note: the health insurance industry hates “subscription”-type medical practices, and
wants them to be regulated as if they each were a large insurance corporation. so it is possible that the 5000 of us who practice this way, may turn out to be a flash in the pan one day – crushed, like national health, by the juggernaut of the massive american insurance industry.
unfortunately, the “subscription plan” still sticks a patient with a monthly bill.
if we had national health, that monthly bill would be paid by the government, and would be invisible to the patient, just like their contributions to their local fire and police departments. after all, we don’t make a cost-benefit analysis about how our relationship with the local firefighters and cops stand, before we buy a smoke alarm, lock our doors, or call 911. we presume that we’re covered, because we’re entitled to be covered, because covering our safety is a legitimate part of the public good. nobody really questions this, and in terms of responsibility for safety, we split the difference between public and private responsibility.
our relationship to safety is so different from our relationship to health.
this past week, i’ve had three different patients ask me how often they “need to be seen.” gosh, there are so many different ways to answer this! technically, if you take medicine, we should check every so often, one way or another, to make sure it works and isn’t having side effects.
“the guidelines” state you should have a yearly check-up, but i believe “the guidelines” are designed around a model of large group practice, where you are always a stranger “seen” by a stranger. (and i could literally go on 4EVER about the problems inherent in “stranger-based health care.”)
if you’re my patient and i’m your doctor, i can see you, and you can see me, by emailing me or phoning, any time. hopefully we’ll also “be seen” at the farmer’s market, the thai restaurant (mmm), and the park (howdy!), when your “health” is not a separate entity from your “life.”
if our relationship is based on fee-for-service, and either you or your insurance pay for each visit, but i never “see you,” i will, of course, go broke.
on the other hand, if you have to pay in full for every visit, and/or you’re penalized by your insurance company for visiting a doctor, you’re likely to avoid ever “seeing me,” to keep from going broke.
yet you know your blood pressure is too high, you should quit smoking, god only knows about your cholesterol, you’re just 5 pounds away from the dreaded “obesity,” and to top it all off, you’re going crazy from allergies… and, truth be told, you can’t sleep, back hurts, feel depressed…
right there, that’s eight health problems you’re trying not to think about – so add anxiety (with tension, restlessness, and irritability), to the problem list. “the guidelines” would say we coulda-shoulda covered all this in a 15-minute conversation, including a physical exam, for $112 (last year’s medicare rate).
for last year’s brief visit with your doctor, you paid $789.57 per month, on average, for your health insurance (in oregon; see here for your state’s monthly average health insurance premium).
maybe you saw your doctor three times last year. then your doctor got paid $336 or so, and you and/or your employer paid $2370. it’s at this point that americans often start to feel “lucky” if something went wrong and they had to go to the hospital; paying $3,000 instead of $30,000 starts to feel like winning the lottery.
do you agree with the guidelines – or indeed with this system? were your blood pressure, cholesterol, overweight, back pain, allergies, insomnia, depression, anxiety, and smoking “cured” by the 15-minute appointment you had with your primary doctor a year ago? will they be cured by this year’s visit?
do you feel like you saved $30,000, or even $3,000, by going for your yearly checkup? what if you could call your doctor’s cell phone whenever you had doubts – or your doctor emailed you to make sure you are, in fact, quitting smoking, or eating right?
what would your life be like if you were confident you’d live to a happier, healthier, old age, starting today (or last year) with less pain, better fitness, and a clearer mind? how would your plans change? what would you imagine as realistic possibilities for the future?
this is the ultimate potential, i think, of taking money out of the relationship between doctor and patient, and building a system where you can get comprehensive “health caring” whenever you and/or your doctor think you need it. let’s stop prioritizing problems, and people, according to monetary potential, and get down to living with care.
just like we do with the food co-op. the childcare collective. the car pool. the fire department. and so on.
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