0
Editorials: Point and Counterpoint |

Rebuttal From Dr Freedman FREE TO VIEW

Neil Freedman, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Department of Medicine, Northshore University Health System, Evanston, IL

CORRESPONDENCE TO: Neil Freedman, MD, FCCP, Department of Medicine, Northshore University Health System, 2650 Ridge Ave, Evanston, IL 60201


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(2):259-260. doi:10.1016/j.chest.2016.09.043
Text Size: A A A
Published online

Although I agree with many of the arguments by Foreman et al on why we should consider limiting the expansion of concierge pulmonary medicine, current and near-future changes in reimbursement and delivery care models will force physicians to make difficult choices on how they practice.

Foreman et al argue that “pairing of the words boutique and medicine or membership and medicine is disheartening and classist” and that linking the ability to pay with the quality of care and ability to obtain care demeans the covenant between physician and patient and risks increasing health-care disparities. Although I agree with these arguments in principle, current changes in reimbursement are already limiting access to care for many patients regardless of their geography. Whether we like it or not, patients are currently making difficult choices on who provides their care, mainly based on out-of-pocket expenses and not preexisting relationships or perceived quality. In addition, current projections for higher patient deductibles and continued growth of narrow network plans will likely expand this trend in the near future.,

Furthermore, future changes in payment will likely make practice decisions for physicians more difficult regardless of their employment model. Assuming that the Medicare Access and CHIP Reauthorization Act of 2015 goes forward as planned in 2019, the majority of physicians in groups < 25 are expected to take a 4% penalty from Medicare, with penalties increasing to 9% per year by 2022., Unfortunately, the economic risks for physicians in even smaller groups are predicted to be greater. Thus, health-care economic forces will continue to drive physicians to limit the number of Medicare patients that they care for based solely on reimbursement.

Because the costs of maintaining a practice will continue to increase, the only ways for practices to remain financially viable going forward will be for physicians to increase the volume of patients they see per week. This approach will have the unfortunate consequences of lower job satisfaction and higher levels of burnout. Patients will likely be less satisfied with their patient-physician relationship as their physicians spend less time with them during routine office and hospital visits. Finally, this trend may also negatively impact the quality of care that will be delivered because we all know that quality care (however it is defined) cannot be maintained when we are seeing too many patients per day. Thus, transitioning to a concierge type of practice model could improve patient and physician satisfaction and potentially improve quality by allowing more time for patients and physicians to interact.

In conclusion, I agree that the ultimate goal for pulmonary medicine and the entire medical field should be focused on “no patient being left behind.” At the same time, the realities of practicing medicine in this era of revolutionary health-care economic transition will likely result in a multi-tiered system based on geography and income regardless of whether we morally agree with it. Although concierge pulmonary medicine will not be for everyone, it is a practice alternative that physicians and patients should consider in the future.

References

Foreman M.G. .Lopez V. .Flenaugh E.L. . Counterpoint: is it time for pulmonary concierge practices? Not yet. Chest. 2017;151:257-259 [PubMed]journal
 
Reed A. . Cost, not choice, is top concern of health insurance customers. The New York Times. August 12, 2016;:A1- [PubMed]journal
 
Mathews A.W. . Insurers move to limit options in health-care exchange plans. The Wall Street Journal. August 31, 2016;:- [PubMed]journal
 
McKinsey Center for US Health System Reform. 2017 Exchange market:emerging plan type trends.http://www.healthcare.mckinsey.com/reform. August 24, 2016.
 
Nelson M. . A MACRA primer. CHEST Physician. 2016;11:8- [PubMed]journal
 
Centers for Medicare and Medicaid Services. Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.Services DoHaH.  :1-962 [PubMed]journal
 

Figures

Tables

References

Foreman M.G. .Lopez V. .Flenaugh E.L. . Counterpoint: is it time for pulmonary concierge practices? Not yet. Chest. 2017;151:257-259 [PubMed]journal
 
Reed A. . Cost, not choice, is top concern of health insurance customers. The New York Times. August 12, 2016;:A1- [PubMed]journal
 
Mathews A.W. . Insurers move to limit options in health-care exchange plans. The Wall Street Journal. August 31, 2016;:- [PubMed]journal
 
McKinsey Center for US Health System Reform. 2017 Exchange market:emerging plan type trends.http://www.healthcare.mckinsey.com/reform. August 24, 2016.
 
Nelson M. . A MACRA primer. CHEST Physician. 2016;11:8- [PubMed]journal
 
Centers for Medicare and Medicaid Services. Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.Services DoHaH.  :1-962 [PubMed]journal
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
Guidelines
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543