Posts from topic "ACPP"

South Carolina House Unanimously Passes Bill to Expand Healthcare Freedom

COLUMBIA, S.C. (Feb. 16, 2018) – On Wednesday, the South Carolina House unanimously approved a measure that would help facilitate healthcare freedom outside of government insurance regulatory schemes.

A bipartisan coalition of 12 representatives introduced House Bill 4643 (H4643) on Jan. 23. The legislation specifies that direct primary care agreements (sometimes called medical retainer agreements) do not constitute insurance, thereby freeing doctors and patients from the onerous requirements and regulations under the state insurance code.

The bill also includes provisions defining direct primary care agreements and establishing modest requirements.

On Tuesday, the House Labor, Commerce and Industry Committee passed H4643 with a favorable report. The very next day, the bill went to the House floor and passed 100-0.

According to Michigan Capitol Confidential, by removing a third party payer from the equation, medical retainer agreements help both physicians and patients minimize costs. Jack Spencer writes:

“Under medical retainer agreements, patients make monthly payments to a physician who in return agrees to provide a menu of routine services at no extra charge. Because no insurance company stands between patient and doctor, the hassles and expense of bureaucratic red tape are eliminated, which have resulted in dramatic cost reductions. Routine primary care services (and the bureaucracy required to reimburse them) are estimated to consume 40 cents out of every dollar spent on insurance policies, so lower premiums for a given amount of coverage are another potential benefit.”

This represents the kind of cost control Obamacare promised but failed to deliver. Last fall, Tom Woods interviewed a Kansas doctor who utilizes the direct primary care model. Dr. Josh Umbehr’s practice demonstrates the cost savings possible when doctors are unfettered from the bureaucratic health insurance system.

Under Obamacare, regulations define such programs as a primary care service and not a health insurance plan, and current IRS policy treats these monthly fee arrangements just like another health plan.


At this point, it doesn’t look like Republicans will repeal or even reform Obamacare, and the changes to the ACA proposed by the GOP would have arguably made things worse. Even with the penalty for not buying health insurance repealed by the Republican tax plan, all other Obamacare rules and regulations remain in place. Regardless, state actions can help completely bring down the Affordable Care Act, or any national healthcare plan the Congress comes up with in the future.

Oftentimes, supporters of Obamacare criticize opponents for not having any alternative. Direct primary care offers one.

These direct patient/doctor agreements allow a system uncontrolled by government regulations to develop. It makes doctors responsive to patients, not insurance company bureaucrats or government rule-makers. Allowing patients to contract directly with doctors via medical retainer agreements opens the market. Under such agreements, market forces will set price for services based on demand instead of relying on central planners with a political agenda. The end result will be better care delivered at a lower cost.

By incentivizing creative healthcare solutions, the market will naturally provide better options, such as the Surgery Center of Oklahoma, This facility operates completely outside of the insurance system, providing a low-cost alternative for many surgical procedures.

A more open healthcare marketplace within a state will help spur de facto nullification the federal program by providing an affordable alternative. As patients flock to these arrangements and others spurred by ingenuity and market forces, the old system will begin to crumble.

Passage of H4643 would take the first step toward healthcare freedom in South Carolina and would create a stepping stone to further action to nullify the onerous Affordable Care act. Once in place, South Carolinians could take further steps to fully extricate themselves from Obamacare for good.

For more information on a plan to nullify the PPACA, click HERE.


H4643 now moves to the Senate for further consideration. It was assigned to the Senate Committee on Banking and Finance where it must pass by a majority vote before moving forward in the legislative process.


How Amazon & Co. Could Fix Health Care

The first step would be to go completely outside the existing U.S. health care system.

by Leonid Bershidsky January 31, 2018, 7:02 PM GMT+5:30

Could this be the future of care for some U.S. employees? Photographer: Chris Ratcliffe/Bloomberg

Amazon, Berkshire Hathaway and JPMorgan haven't said much about what their new joint venture will do to "provide U.S. employees and their families with simplified, high quality and transparent healthcare at a reasonable cost." It's not hard to imagine, however, how the three companies could set up a large, closed system that could serve as a blueprint for the only disruptor with the ability to fix the entrenched, inefficient U.S. health care system -- the U.S. government.

The worst thing the joint venture could do is try to use its bargaining power to bring down costs within the existing system. It's not really big enough for that. The three partners have a combined 1 million employees; the health care industry is the biggest employer in the U.S., and even if you add in the family members of Amazon, Berkshire and JPMorgan employees, that won't be enough to go head to head with the medical juggernaut on doctors' and nurses' pay and the cost of pharmaceuticals. The partners need to start from scratch.

It's well-known that the U.S. leads the world in health care spending but not in life expectancy. But the U.S. health care system is inferior to those of other rich countries on a number of technical parameters, too: For example, it has more hospital admissions for preventable diseases and more medical and lab errors than comparable countries. It ranks 30th in the world on "basic physical and mental health, health infrastructure and preventative care" according to last year's Legatum Prosperity Index.

U.S. health care achieves similar or worse results compared with other Organization for Economic Cooperation and Development nations with a higher ratio of nurses per physician than any of them except Finland, Japan Ireland and Denmark -- 4.3. France does fine, and has a higher life expectancy than the U.S., with 2.8 nurses per doctor. Doctors in the U.S. are massively overpaid compared with most of their OECD peers. A primary care physician makes $217,000 a year, almost five times the U.S. average wage; according to OECD data, the average general practitioner's pay is higher than the average wage by a factor of four in Germany, three in France and two in Israel.

It's interesting to imagine how three large companies could build a better system for themselves. Start with the doctors and medical professionals. According to the OECD, 25 percent of doctors and some 6 percent of nurses working in the U.S. are foreign-trained. Other OECD countries -- especially Mexico, Canada and the U.K. -- are already the biggest source of foreign-trained doctors for the U.S.; India is close behind, followed by the Philippines and Pakistan. This implies there's already a functioning pipeline for getting the qualifications of doctors from these countries recognized. Amazon, Berkshire Hathaway and JPMorgan, with their combined administrative might, could turn this pipeline into a factory, bringing in enough foreign doctors exclusively to serve their combined workforce at more reasonable pay to average wage ratios.

Lower pay than in the rest of the U.S. health care economy would be justified by having to do zero insurance paperwork -- something that forces U.S. doctors to hire extra staff and waste precious time. The companies would merely set pay levels based on tasks performed -- something that, in much of Europe, falls to health care providers' unions to negotiate with the government or with payer pools. That's the system the joint venture would ultimately end up with. Amazon's tech could help track the tasks in real time.

Importing the entire workforce sounds like a mammoth task, but then the U.S., according to the OECD, only has 2.6 practicing doctors per 1,000 population. At this rate, some 7,800 doctors would be needed to serve 3 million employees and their kin. If the German level of 4.1 doctors per 1,000 residents were the goal, some 12,300 doctors would be needed. That's some 8 percent of the number of medical graduates OECD economies produce every year -- not an impossible number to bring in. Add in telemedicine opportunities -- whole clinics could be set up overseas on local budgets to do much of the necessary work -- and U.S.-resident doctors who'll accept a pay cut just to practice medicine and never deal with an insurance company again, and the task appears even more feasible.

Besides, the joint venture could consider offshoring some of the hospital care. The average cost of a hospital day in the U.S. was $5,220 in 2015, compared with $424 in Spain -- a country with a higher average life expectancy than the U.S. One could fly business class from New York to Madrid every day to spend a night at a local hospital and it would still cost less than comparable U.S. care. Even Swiss hospitals are, on average, cheaper than U.S. ones. In quite a few cases, it would make sense to relocate an employee or family member to save on the hospital costs. Of course, the new venture would need to help employees get passports, too.

Moreover, relocation could even work for people with chronic conditions requiring pricey pharmaceuticals. A recent IHS Markit study found that a basket of 30 innovative pharmaceuticals cost about a third as much in Germany, U.K., Spain and Italy as in the U.S. The U.S. protects its pharma market, making it difficult to import cheaper medicines than those produced by local companies -- but it can't ban companies with large overseas operations from exporting patients.

In other words, it's possible for a pool of big, multinational U.S. employers with a relatively sophisticated workforce to go almost entirely outside the existing U.S. system and shake off the layers of useless regulation and bad practice that make it up. The cost savings would probably be considerable.

Such a system, however, wouldn't be scalable beyond the biggest companies with mobile workforces: It would be hard to expand the doctor immigration pipeline or a massive medical relocation operation. It would still be worth building a separate health care system for big company employees, though, just to show the U.S. government how it could be done. Maybe someday there will be politicians courageous enough to start rebuilding U.S. health care from scratch, with less bureaucracy, fewer intermediaries, less protectionism, more efficiency and fairer prices.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

President’s Report - February

Warren Buffett of Berkshire Hathaway, Jeff Bezos of Amazon and J. P. Morgan the nation’s biggest bank just announced plans to bypass the American health insurance system and independently organize healthcare for 3 million employees and their families.

Anything that bypasses the health insurance industry and creates direct relationships between doctors and patients deserves our applause.

Throughout its history the health insurance industry has paid lip service to controlling costs while actually driving them higher. It profits from higher costs because it can charge higher premiums getting it’s ten percent profit regardless. This will continue as long as payers put up with it. Perhaps our tolerance has reached its limit.

Primary care practice disruptive innovations have been around for two decades in response to insurance industry failings. These innovations can help business leaders drain the insurance industry swamp, control cost and improve quality.

What Americans really need are a few hundred thousand independent, personal, private primary care physicians that work ONLY for their patients, not for the insurance industry. Berkshire Hathaway, Amazon and J.P.M. need only 6,000 such physicians to manage their three million patients and family member’s primary care. It would be a good start and a beacon for the rest of the nation.

Thirteen years ago I launched one of the early direct practices at a time when only a few hundred existed nationally. There are now tens of thousands of doctors, caring for millions of patients, who have made conscious decisions to get out from under the insurance system’s control and work directly for patients. The terms Direct Primary Care (DPC) and Concierge Medicine are both parts of this movement. Let me explain why private primary care physicians should be part of the package that these business leaders create.

First, we limit our practices to hundreds rather than thousands of patients, thus allowing us to spend much more time with each patient and still be fresh and rested when delivering care. Primary care doctors in conventional insurance-dependent practices are often failing to take good care of patient panels that number 2,000 to 3,000 patients per doctor. These huge panel sizes have been forced on them by the insurance industry’s relentless withdrawal of support for primary care over many decades. Great primary care is the backbone of any effective, affordable health care system, and the health insurance industry has all but destroyed it. Direct practice is recreating it.

Second, to allow our small patient panels, we finance our practices with membership fees directly from our patients. These fees vary with the practice and are usually age adjusted. Most practices charge fees between $50 and $300 per month, an affordable price for many, but a barrier for others.

Third, because we work directly for and are paid directly by our patients, we give incredible service. If we didn’t do so we would lose their loyalty, and they would move on. My partner Dr. Nicole Lawrence and I see and manage our patient’s care the same day they call, during and outside office hours. All our patients have our home and cell phone numbers and are encouraged to call for even minor issues. Our patients can reach us immediately 24/7/365 with one five second dial or text. We do home visits and manage their hospital care personally. In other words, we do what most doctors used to do before the health insurance industry took over and changed the rules.

We eliminate between 50 and 80% of costly emergency room visits and urgent hospitalizations. There are several published studies proving that. One of the best was published in 2012 in the American Journal of Managed Care: to-significant-reductions-in-hospital-utilization

Since ER and hospital care is such a huge part of the excess cost, we know placing employees in this kind of direct private primary care practice is key to solving the cost problems. However, direct practice saves money and improves care in dozens of other ways. Those who have carefully studied these practices understand why they work so well and why the insurance industry version of primary care works so badly.

Direct Primary Care and Concierge Medicine have not yet expanded to the general population, though attempts have been made, such as Qliance in Seattle. So far they have largely failed. Funding is the issue. It is hard to convince financially stressed employees to invest their own limited funds in a novel healthcare design they don’t fully understand while continuing to pay sky high insurance premiums. Enlightened employers could be part of the solution to that problem.

Like the cell phone and other disruptive innovations direct practice innovations are first adopted by astute consumers with disposable income. When it becomes clear that the benefits are huge for everyone, eventually such innovation are adopted by wider groups of people. Assistance can come from employers. Perhaps that will happen with Direct Private Primary Care. Employers could help to fund it with HSAs and vouchers for an aggregated list of vetted DPC/Concierge practices which would not handcuff the participating physicians as the insurance industry does. Physicians running such practices must remain in control of their practices, fees and decision making. The opposite path has already been tried and failed. Let’s try something that will work this time, since we’ve tried about everything else.

Urgent Message Regarding High Census

The hospitals are currently swamped with flu victims and have no beds or ER space. See below note from Torrance Memorial to Medical Staff.

You and I at least are not contributing to the problem. You and I have managed dozens of young and elderly flu victims recently without trips to the ER. I directly hospitalized only one, a 95 year old with flu A. He was in for just 48 hours for fluids and you had one also briefly too, both over a week ago. Both got Tamiflu within 24 hours of onset.

As is typical for us in this concierge practice, today, Saturday, I just met a patient at the office with 12 hours of mild symptoms, as yet still not too ill, and performed an office flu test which was 4+ positive for flu A. I found Tamiflu for her and her husband (who is not yet sick but would be soon otherwise) at a distant Walgreens after three phone calls and THEY won’t be at the ER.

Few people, even doctors, know as we do that Tamiflu (works on both A & B) and Amantadine (Only works on A) given within 24 hours of Sx onset actually stop the illness cold in many cases, but almost nobody gets it that fast, except our patients. If you wait past 48 hours it simply does not work. One has to attack during the viral replication phase, which is brief.

Almost ALL our patients had flu shots, 95% plus, which was quite effective agains B and blunting of A. The ones that refused the shots, and in fact all our patients, have had the lecture about calling quick when sick or hurt with ANYTHING. They can get us in seconds, and today we have NOBODY in the hospital for anything, let alone flu. And as you know we usually have a census of 3-4 patients.

Somehow in the midst of our two flu drugs becoming “Unobtanium”, we have found it somewhere for all of them, so far. Proof of concept I must say.

And of course this concept applies to hundreds of less dramatic illnesses and injuries too.

Joining a concierge practice is a no brainer, unless you want to sit surrounded by coughing masked flu victims in a packed ER unable to treat you with antivirals anyway. The hospitals are using Tamiflu only on patients so sick they are in the ICU. And in most of those cases they need not have bothered. They got their first dose long long long after the effectiveness window had closed. They should save it for the ones ill less than two days when it actually works!

A concierge physician's advice for battling burnout

Acquiring a horse may be inexpensive or even free—then the expenses mount: vet bills, boarding, training, new equipment, not to mention all time dedicated to your new pet. Similarly, your EHR may be cheap or free, then IT fees, hosting fees, hardware, update fees and user training all have to be paid for. Now, imagine the government telling us we all need to buy a horse and keep it for life—great for the horse industry, but perhaps not for you.

Read full story

Doctor’s Diary: October 27, 2017

(Snippets from the frontline)

In Denial

You suddenly become ill. The emergency room doctor feels admission is necessary. Your physician agrees, so you are hospitalized with IVs and testing done. Treatment is given, you survive and go home.

Your insurance company denies payment and claims you should not have been admitted. Now you are responsible for all medical bills.

Denial by insurance companies after hospitalization happens more frequently each day. Occasionally, your physician can have a “Peer-to-Peer” phone discussion with the insurance doctor to mitigate the issue.

Here’s the rub: They decide on an “approximate” call time (e.g. 8-12 noon), and expect your physician to be around a computer to reference the medical chart. If this contact is not made within a certain number of days from discharge (sometimes as little as three), their denial automatically becomes irreversible.

Trying to allot “Peer-to-Peer” time is like waiting for cable TV repair. Your doctor is under the gun and gets blamed. Worse, it is time infringement on medical care rendered to other patients.

It’s a new twist in their old game.

Another reason for eliminating insurance company middlemen.

Gene Uzawa Dorio, M.D.


Meet The 2017 and 2018 Top Doctor's In Concierge Medicine

A Biennial Recognition, Meet The Who’s Who In Concierge Medicine Throughout The U.S. In 2017-’18 by industry trade publication, Concierge Medicine Today.

OCTOBER 10, 2017

ATLANTA, GA USA – Twenty-five (25) Physicians have been named to Concierge Medicine Today’s biennial ‘Top Doctors In Concierge Medicine’ for 2017-2018. This national trade publication’s recognition is a distinction held by less than one percent of doctors across the country every two years.

“We look for physicians who have made a significant impact on patients, their peers, their community, their state, social media, clinical research and personalized treatment, use innovative technology and more,” said Michael Tetreault, Editor-in-Chief of the industry’s medical news and information agency, Concierge Medicine Today. “Concierge Medicine physicians don’t accept the status quo. Therefore, we believe it is important to acknowledge specific physicians and certain practices every two years within the Concierge Medicine space … they reflect, demonstrate and drive innovation, communicate with exceptional professionalism, provide value and uncover the unique benefits of this at-the-ready industry.”

Over the past several years, Concierge Medicine Today found distinguished doctors opening unique practices in markets like New York, Florida, Connecticut, California, Georgia, Texas and Illinois. This year, physicians are prominently working in various medical areas of healthcare which include: Integrative and Functional Medicine; Pediatric Care; Primary Care; Cardiology; Tropical Medicine; Family Medicine; Executive Healthcare settings; mobile medical facilities; and even Holistic Menopause and Anti-Aging practices. The result is Concierge Medicine Today’s ‘2017-2018 Top Doctors In Concierge Medicine’ across America list, which includes some of the nation’s most respected specialists and outstanding primary care physicians. These are the doctors that patients, peers and other healthcare professionals recognize as the best in their fields. They do not pay a fee and are not paid to be listed. Today, as in years past, it is a list which is respected by the medical profession and patients alike as a source of quality information.




“Patient Satisfaction in Concierge Care remains exceptionally high but inside traditional medical practice environments, patients expect to wait and they expect friction with staff,” notes Tetreault. “Nowhere else in our lives except inside a healthcare facility do we ready ourselves for this kind of tension. Attitudes toward Concierge Medicine have undergone significant and positive changes since the signature of the Affordable Care Act in 2010. Patients seeking Concierge Physicians tell us they expected insurance to cover their visit. When it is was not, they expected to fight. Consumers of healthcare today say, they expect a disengaged staff and an unpleasant visit when at their doctor’s office. We can do better. Concierge Medicine Patients are Invited rather than Expected. This counter-intuitive approach exceeds expectations, thereby creating a massively loyal and engaged audience which, in turn, is producing some amazing patient outcome data as released and seen by other organizations operating in this space.”

Congratulations to the following physicians named to Concierge Medicine Today’s 2017-2018 list of ‘Top Doctors in Concierge Medicine’ who made the list (in alphabetical order): 

“When healthcare is looking for innovation and ideas about care delivery, they are observing Concierge Medicine,” said Tetreault. “One of the most interesting observations inside of this years list of physicians is just how many are implementing genetic testing to help their patients understand more about their health.”

“Two notable observations we encountered throughout our entire review process was related to patient comments received prior to transition and staff issues— which seem to plague most medical offices, even those inside the four walls of a Concierge Medicine practice,” said Tetreault. “A physicians reputation in the public and online is dramatically different from the patient reviews they may receive prior to a physicians entry into Concierge Medicine vs. after the conversion. Many [physicians] go from zero to hero in the eyes of their patients in a matter of weeks or months. We have also noticed that the physicians staff and their individual attitudes towards patients still remains a sore spot among the doctor’s and patients concerns. Even post-transition, when physicians are well into managing their Concierge Medicine members … managing staff inappropriately can impact the clinic’s annual patient retention and ultimately, their bottom line. However, it is amazing what can be accomplished when Physicians walk this healthcare delivery process out and into their own communities. It is only now, that when we are able to look back and track these dramatic career moves of physicians that we see why so many patient experiences make so much sense.”


About Concierge Medicine Today

Concierge Medicine Today (CMT) is a news organization and the Concierge Medicine industry’s oldest national trade publication for the Concierge Medicine and Membership Medicine marketplaces. Its website is the online destination for businesses, consumers, physicians, legislators, researchers and other stakeholders to learn about the history of this industry, various business aspects of the marketplace, trends, breaking news and more that drives the conversation that Concierge Medicine and free market healthcare delivery is creating on a national and international level.

To read the latest headlines or register for the October 27-28, 2017 Concierge Medicine Forum, visit or, to register,

Ten Reasons

Ten Reasons Why Every State Should Welcome the Graham/Cassidy/Heller/Johnson Health Reform Bill

If a state is satisfied with Obamacare, it can keep Obamacare. But here are ten ways a state can improve on the current system if its citizens desire to do so. With the state’s approval, insurers will be able to offer coverage that is:

Affordable. Currently there are close to 30 million people who are uninsured and that number isn’t expected to change much under Obamacare. The reason: millions of people have decided that the products being offered are not worth the premiums being charged. This reform allows insurers to offer a more attractive package of benefits for a lower premium. Judicious use of risk pools and reinsurance will also help – especially with high cost enrollees migrating from group to individual insurance. If a state establishes a dedicated source of funding (outside of its block grant) for this purpose, it should be able to reduce premiums in the non-group market by as much as 50%.

Universal. At least one plan could be offered with a premium that is no more than the subsidy the state provides. Since these plans would require no out-of-pocket payment by the enrollee, people could be automatically enrolled through the Food Stamp program, by H & R Block, at the DMV and in other ways. Universal coverage could be a reality rather than an empty slogan.

Tailored. Currently, low- and moderate-income families are being forced to buy coverage that is completely inappropriate for their financial circumstances and health status. Instead of insurance that has unlimited annual and lifetime limits and a $13,000 deductible, would they rather have less upper bound coverage along with a low deductible and a Health Savings Account. The latter option would give the family easy entry into the system, but would leave some very expensive cases for a safety net (which is a more appropriate way of funding them).

Equitable. One of the worse features of Obamacare is the extremely inequitable treatment of people who are offered insurance at work versus people who purchase their own coverage. Employers of low-wage workers are offering Bronze plans with very high deductibles in return for a premium that is 9.5% of their wage. If employees turn down this offer (which almost all do), neither the employees nor their dependents are eligible for highly subsidized insurance in the exchanges. Under this reform, the employer and individual mandates go away and states can equalize the subsidy offered in the group and individual markets. This will be especially important in states where the non-group market has become completely dysfunctional and group insurance is cheaper and better.

Portable. Because states will have the power to equalize the government subsidy available at work and in the marketplace for low and moderate-income families, they will also be able to allow portable insurance for these same families. For example, a company might buy Blue Cross individual insurance for its employees, instead of Blue Cross group insurance, and the employees could take their insurance with them to the next job.

Private. Virtually every study of the matter has found that private insurance results in better health outcomes than Medicaid. Going forward, states will be able to subsidize private insurance instead of Medicaid enrollment for the poor and the near poor.

Fair. Currently, a large number of people are gaming the system by remaining uninsured while they are healthy and insuring only after they get sick. Because of a 90-day grace period, people are also dropping coverage to avoid paying premiums at year end. Of those who are enrolled in January, roughly 25% have dropped out by September and roughly half of those reenroll for the following year. Additionally, some people buy Bronze plans while they are healthy and then upgrade to Gold or Platinum after they get sick. This type of behavior unfairly shift costs onto other people. Under this reform, states will be able to require individuals to pay the full actuarial cost of any unfair gaming activity.

States will also be able to give their citizens access to:

Personalized care. At $50 per month for an adult and $10 for a child, the cost of direct pay (concierge) medicine has come down to a level that should make it accessible to almost everyone. This reform allows these fees to be paid from a Health Savings Account or by a third-party insurer.

Specialized care. Centers of excellence will be able to specialize in specific diseases – such as cancer care, heart disease and diabetes. They will be able to ask health questions and screen applicants to help get the right patient to the right plan.

A real health insurance marketplace. Obamacare’s risk adjustment is focused on plans, not patients, and there is no realistic way for a plan to know what compensation it will receive for enrolling a patient with a costly medical condition. This is one reason for the race to the bottom – as plans try to attract the healthy and avoid the sick. As an alternative, states will be able to set up a risk adjustment mechanism along the lines suggested by Cochrane, Goodman and Pauly. Risk adjustment will protect patients, not health plans, and centers of excellence will be rewarded for providing efficient, high-quality care to patients with the most serious medical problems.

The Folly of “Population Medicine”

“Take care of the patient,” directed my chief resident. “In the ER—he needs you.” My fifth admission for that 36 hour call cycle, and I was tired. Yet those words are as clear to me now as they were 3 decades ago in that post-call afternoon at Detroit Receiving Hospital. “Take care of the patient” is still my care-style and professional reputation, one patient at a time.

Vexingly, in this week’s version of our overseers’ mandates, they direct us, “Take care of the population.” What exactly does that mean? I think it means that once we all work for large employers, who aggregate our little-guy data, we might get paid if our data looks good enough? Big medicine pays little-guy PCPs in their little medical homes based upon “quality measures.” We should collect our “quality measures,” and are expected to change patients’ bad behaviors and habits, and become accountable for their actions and inactions. Is this what we want to do for a living?

Fortunately, in concierge medicine we work for patients (as opposed to third party payers) and can practice the right kind of medicine for each patient. From a business standpoint, insurance pocket change isn’t worth playing the population game. Realizing the folly of population-care, I sleep fine at night when a patient ignores my advice. He is responsible for his own life. My income does not derive from his decisions. If he makes bad choices and generates bad data I’ll do my best to help, but the real change needs to come from his side of the equation. At a recent EHR-sponsored happy hour, one population-incentivized PCP said it nicely, “Noncompliant patients—I just get rid of them. They (noncompliant patients) can eat what they want to eat and do what they want to do, but I want to get paid—so I get rid of them.” Concierge medicine is a better solution.

Payers have pushed physicians into the “you are responsible for your patients’ actions” trap. In today’s iteration of “best care,” doctors are expected to identify and allocate time and money to identify “at risk patients,” all to improve medical practice outcome data. Make no mistake, insurance work is a fixed-sum game, and individual doctors will ultimately pay to pay this game.

In Concierge Medicine we take care of the patient. In my practice, many of those were cast-off by population-treating doctors and their staff. Once in my practice, do the noncompliant suddenly comply? Usually not, but they appreciate the respect they receive, improve their life’s quality, while receiving much better, individualized care. Some smoke too much, drink too much, and-or eat too much. I don’t take on their life’s burdens and expect their numbers to improve. I do my best for them. In my concierge internal medicine practice, if the outliers’ numbers don’t improve, I will still be paid just as much, as I should. It is a lesson in futility for PCP’s to assume their patients’ risk. Collecting data, checking boxes, and groveling for a better performance bonus—who needs it?

Individual doctors cannot generate a generalizable data set. The n-size is simply too small. Bonus payments based upon doctors generating individual data that betters aggregated data will encourage doctors to lie about the data, cherry-pick patients (an insurance company favorite), and to throw out the outliers, AKA get rid of “bad patients.” As I learned in my research fellowship, “garbage in, garbage out.” Population data can only be as good as its weakest link—and there are plenty weak links! If population data looks valid, it won’t be.

The population health story is yet another Emperor’s New Clothes fable (1). The population idea has gained traction such that we all are expected to believe this idea; Like the emperor’s clothes, we should see how wonderful the nonexistent clothes/worthless ideas are—or we are fools! The concepts and PCP busy-work looks pretty to leadership, just as the emperor’s clothes looked pretty to his admirers and to him. In truth, there really isn’t anything to see. It will take decades for payers to realize individual patients generally cause their own poor outcomes, and that micromanaging doctors will not change patient behavior in the long run. PCP burnout and PCP shortages will be the collateral damage for our leaders’ misguidance.

In Concierge Medicine we take care of each patient, in times of sickness and health, and in times of good data and bad data. In Concierge, we guide our patients, and we let them make their own decisions. We respect our patients for who they are, along with their strengths and weaknesses. At days’ end, we take care of real people, not data sets. Keep up the good work!

1. Andersen, Hans Christian; Tatar, Maria (Ed. and transl.); Allen, Julie K. (Transl.) (2008). The Annotated Hans Christian Andersen. New York and London: W. W. Norton & Company, Inc. ISBN 978-0-393-06081-2.

John T. Kihm, MD, FACP

Director, ACPP

Physicians Convene in Atlanta (October 2017) to Learn About Precision Medicine, Genomics, Concierge Medicine, Direct Pay, Cash-Only and Other Innovative Healthcare Delivery Happenings

2017 Concierge Medicine Forum in Atlanta to Showcase “Precision Medicine” Use, Utility and Innovation Among Other Educational Topics

ATLANTA, GA — Concierge Medicine Today, in partnership with The Direct Primary Care Journal (The DPC Journal), are hosting a 2-day innovative healthcare delivery and precision medicine Forum in Atlanta, GA on Friday, October 27 and Saturday, October 28, 2017 entitled CMT’s 2017 Concierge Medicine Forum. (

Click here to sign up

Concierge Medicine Forum 2017: The Journey to Personalized, Precision Medicine | Concierge Medicine :: Direct Primary Care | ATLANTA, GA

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