First Skirmish of the PHCA Wars

Almost four years ago, DrRich boldly predicted the rise of a new medical profession - the Personal Health Care Advocate (PHCA).  This profession, DrRich asserted, would surely arise as the most obvious response, by frustrated patients and frustrated doctors, to the systematic destruction of the doctor-patient relationship.

DrRich now must take note that, despite the passage of a fair amount of time, PHCAs are nowhere to be found.  Yet, while DrRich now freely admits that his timetable was a bit off, he does not back down on his fundamental assertion - that PHCAs are inevitable.

So where are all these PHCAs?  The "evolution" of PHCAs, it is now clear, is less direct than DrRich originally thought.  The hang-up?  Doctors are understandably reluctant to give up on the practice of medicine altogether.  So before they give up the profession of medicine to become PHCAs, doctors are trying to fix the broken doctor-patient relationship in other ways.

Nonetheless, doctors are increasingly cognizant of the fact that under our current health care system they are unable to place the interests of their patients over the interests of the people who actually cut their checks - the insurance companies, the hospitals and health care systems that employ them, and the Feds.  And more and more of them are acting to fix the broken doctor-patient relationship, not by abandoning the practice of medicine altogether (admittedly a radical "solution,") but instead by forging new economic relationships with their patients.  Under these new relationships - variably called "boutique practices" or "concierge medicine" - patients pay an annual fee directly to their doctors, and for this fee they receive some form of a restored doctor-patient relationship.  The doctors promise, essentially, to place the patient's interest first.  The most obvious manifestations of this promise usually include 24-hour access to the doctor, fax and e-mail contact, and same-day appointments, but in fact the greatest benefit received by the patient is the knowledge that the doctor now is obligated to place their needs on a higher level - at least on the same level as for other payers.

It is now estimated that around 150 practices around the US have adopted this "boutique" model.

Predictably, the "boutique practice movement," as small and as under-the-radar as it is, has already engendered a forceful and violent response from both Gekkonian insurance regulators and by Clintonian legislators - neither of whom are happy with anything that might restore the doctor-patient relationship they have spent so much energy trying to destroy.  Insurance regulators and legislators are also constitutionally hateful of any movement that threatens to take the flow of health care dollars out of their hands.  For instance, the Washington State Office of Insurance Commissioner is issuing "advisories" that would require many boutique practices to register as insurers - a virtual impossibility, given the financial criteria necessary to become an insurer.  And members of Congress - including presidential candidates John Edwards and Bob Graham - are sponsoring legislation that would forbid doctors from enrolling Medicare beneficiaries in such programs.

As DrRich predicted, at the first sign of a plan to restore the doctor-patient relationship, both Gekkonians and Clintonians are pulling out the stops to nip it all in the bud.  Only when they do, apparently, will doctors be forced to consider the more radical solution of becoming PHCAs.

DrRich, for one, thinks patients should seek out good boutique practices and enroll, both for their own self-preservation and to demonstrate that restoring the doctor-patient relationship is something they value and something they demand.  These practices, if managed honestly and ethically, could offer most of the benefits to patients that PHCAs would offer.

October, 2003

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