Retainer Fees: If Lawyers Can Do It Why Can’t We?
Not too long ago I wrote about doctors, annoyed by too many visits from pharmaceutical company representatives, who found ways to charge for the right to spend time with them.
Now an article by Avram Goldstein in the Washington Post discussed another new program concocted by 19 doctors in an apparent attempt to get around Medicare and HMO fee restrictions. Goldstein’s title for his article pretty much tells it all: “Doctors on Call-for a Hefty Retainer. ‘Concierge Care’ Plans Tout Access but Also Stir Medicare Debate.” Think about it a moment. How would you like to be notified one day, by your internist, that you would no longer be welcome in the office unless you ante up $1,500 for an annual membership permitting you access? Incidentally, your doctor would also continue to collect all the usual fees from your health insurance plan. Before you pass judgment, let me present you with some of the more potent arguments concerning this new venture, both pro and con.
Members of Congress, as well as physicians, have criticized this membership program, originally based in Florida, and given the acronym MDVIP. As might be expected, some House Democrats who go so far as to propose that MDVIP doctors be banned from Medicare mainly opposed it. Medicare has been setting rules about how much a doctor can bill for 40 years, and these lawmakers consider this an attempt to circumvent these rules, labeling it denial of care and abandonment of poorer patients. One of them, Rep. Benjamin L. Cardin (D-Md.), plans to sponsor a bill, which would bar physicians accepting retainers from being paid by Medicare. This approach to the problem is nothing new since a similar bill was defeated in 2002. Cardin reasons, “basic health care protection for our seniors should be at an even par for everyone . . . I’m very much opposed to these boutique practices from the point of view of participating in the government insurance program. The federal taxpayers are subsidizing this type of practice.”
In spite of similar objections, many patients who can afford to pay for the privilege are rather pleased by its advantages. Commentary ranges from frustration by doctor defenders such as MDVIP general counsel Darin Engelhardt who calls the lawmaker’s objections an absurd “paternalistic approach” to advocates like Yet Mott who can’t afford it but would gladly join if able. Calling opposition on Capital Hill unreasonable Engelhardt expresses his opinion that their ideas stem from a “belief that if everyone can’t obtain care like this, no one should.” According to MDVIP advocates, the retainer fee pays for services not covered by Medicare including physical exams and preventive medicine.
The doctors had the Bush administration on their side with Health and Human Services Secretary Tommy G. Thompson permitting them to participate in Medicare. In any event, there is no doubt that doctors enrolled in the program are enthusiastic about it. This, to them, is a way of getting out from under a crush of patients, health plan bureaucracy, dwindling fees, and a threat to their health. They want more time to spend with their patients, an ability to see patients within minutes of scheduled time, and time to concentrate on their patient’s problems.
The plan allows them to drastically cut the number of patient visits yet earn an excellent income. This latter reason for approval does make one wonder when you realize that the MDVIP plan is geared to limiting practices to 600 patients instead of about 3000, collecting $600,000 per year, and, amazingly, requiring each physician to send $300,000 to MDVIP for its continuing oversight.
With doctors participating in protests by withholding services because of excessive malpractice premiums amounting to as much as $290,000 per year, retiring from practice, or switching to specialties such as cosmetic surgery, which are independent of Medicare or insurance coverage, the addition of retainer fees to the morass is rather depressing. In addition, new laws requiring drastic changes in practice management have become overwhelming burdens. The question that we all must ask ourselves is, “Are all these impositions on what has long been considered to be the finest medical care in the world a means of eliminating inherent evils in the system, or rather a destructive force fostered on the profession by well-meaning but misguided outsiders?”
The classical version of the Hippocratic Oath as it was sworn to by physicians throughout the ages prior to reading the revised version, which follows it. I created the latter for your amusement in order to reflect some disturbing current variations in medical ethics.
With tongue in cheek I am,
Marvin Ackerman, M.D.
Hippocratic Oath — Classical Version I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly, I will not give to a woman an abortive remedy. In purity and holiness, I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come. If I transgress it and swear falsely, may the opposite of all this be my lot.
The Hippocratic Oath as Viewed by Lawyers, Legislators, and Financial Advisors
I swear on a stack of Bibles, or whatever else might be handy, that I will fulfill according to my desires and financial judgment this oath and this covenant:
To hold him who has taught me this art as presently just a bit senile, and to live my life according to my own requirements, and if he is in need of money to chastise him for investing in tech stocks, and to regard his offspring as competition, therefore to discourage them in taking up the art, or if need be to increase medical school fees to exorbitant levels.
I would apply dietetic measures for the benefit of the sick if I had appropriate instruction. However, being totally ignorant of such measures I will avoid all mention of them.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect for fear of ending up in jail. Similarly, I will not give to a woman an abortive remedy without adequate police protection from Right-to-Lifers.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work for fear of a malpractice suit.
Whatever houses I may be asked to visit, I will avoid due to financial inefficiency. I shall remain free of all those with poor credit, and shall be particularly wary of sexual relations with both female and male persons who might be inclined to inform my spouse.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about unless forced to by an HMO, insurance company, or the government, or adequately compensated by the media.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come. If I transgress it and swear falsely, I shall be prepared with adequate malpractice insurance regardless of the horrific premiums.
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About Marvin Ackerman, MD
Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission. Copyright © 2009 by Marvin Ackerman, M.D.
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