Wednesday, September 1, 2010

Medical care and airlines - should there be a difference?

A recent article by Pauline Chen features a group of primary care physicians at Tufts Medical Center in Boston, who have created a concierge practice that funnels income into the traditional general medical practice that sees less-advantaged patients. Surveys (performed by the medical center itself) found that patients rated the quality of interactions with their doctors similarly regardless of their affiliation. The only significant differences in responses had to do with the services offered — care coordination, physician access and interactions with office staff. According to the medical director, analogous to airline services providing both first class and coach services, the parallel practice gets patients to the same destination - some eating peanuts, others eating caviar.

I believe this is an intelligent hybrid that may have successfully reacted to our broken medical system, but the ends does not justify the means. Differing services based on the ability to pay is discrimination - it is demoralizing for coach flyers, but morally wrong for economically-disadvantaged patients. This is because medical care is not the same type of services as airlines - people will not die if they cannot fly to places, but they will die without medical care.

In a civilized society, its members should have equal access to life-saving services regardless of the ability to pay. Just like the fire department, medical care should be provided as a societal safety net so that, instead of worrying whether our house will burn down while we're off at work or whether a catastrophic illness will take away everything we've worked hard to earn, we can focus on higher pursuits like being a productive member of society.

Differences in health outcomes between two groups remain unclear. If they are unequal, then there is discrimination based on the ability to pay. If they are equal, then first-class patients pay more money without justifiable returns other than convenience and a more pleasant office staff, which I argue should not be different in any circumstances - I'd like to believe that medical professionals treat fellow human beings in sickness with utmost compassion at all times, regardless of payment scheme.

Either way, segregating patient care leaves a bad taste in my mouth. As a doctor, we ask patients to trust us with personal life stories that they may never share with their parents or their significant others. Such level of trust can hardly be established in the settings of discrimination.


  1. Personally, I fly coach all the time, domestically and internationally, and I have a good laugh at the suckers who paid (or more likely, had their employers pay) 10x more than me just to get to the same place. If some weak-minded people feel demoralized because they have to fly coach, well, I just don't know what to say to them.

    YOu sound like you believe people have a right to more than just life, liberty, and the pursuit of happiness. Yet if I were to come up 25 cents short at the grocery store, the cashier wouldn't let me walk out with my groceries, and in fact, would call the cops on me if I did. Most rational people would probably also suggest food is a more basic biological need than health care. Therefore, why should I, as a future physician, be *expected* to discount my services or offer them for free? I might lower them voluntarily to a patient I felt needed a break, or because I wanted to price out other physicians in my catchment area and thus offer patients or their insurers a better deal (as an aside, liberals have a conception of health care w/o markets that precludes this), but not because government or some hippie tells me to.

    Sure, these Tufts physicians have a setup that may smell bad to you, but if there is no functional difference in care, there is no problem. I'm not going to quibble with you over how outcomes would be compared, but obviously any economics major would know from 2nd year econometrics that an independent variable may be correlated with others not accounted for in a measurement. You can't compare outcome without factoring in the additional risk factors associated with low-income, that are outside the control and intervention of any physician.

  2. Dear Stockandscalpels,

    Thank you for continuing to read my blog. I would ask that you refrain from using condescending language to label other people (like suckers) so that we can continue to have a constructive discussion.

    To me, health care is part of the right to life, just like food. We all eventually die, but without health care, people die sooner than they would otherwise, just like going on without food.

    As for your grocery store example, the government provides food stamps, among other kinds of subsidies, to help those who are starving. I think the same could be done for healthcare, and when universal coverage kicks in, no one will force you to discount your services or offer them for free - as far as the legislation goes, you are free to run a private practice and charge as much as you want. So far, the reform only extends coverage but controlling cost will take much longer and happen much further down the line, once the CMS figures out the payment scheme and insurance companies follow suit.

    If you read the second to last paragraph, you will see why there IS a problem even if there is no functional difference in care.

    I respect your differing opinion and life values - I think it all comes down to how important money is to us. As you can see in my other post on KevinMD (Why do we use carrots and sticks if humans are not horses?), I believe that in the end, life is about autonomy, mastery and purpose - not money. And I think helping those who are a bit more unlucky than me brings a lot more to my day that ruminating over how big my paycheck is.

  3. You make it seem like *I'm* the bad guy. I'd actually say I'm more concerned with a fundamentally sound design and structure of a health care system, than the perspective you come from.

    First of all, food stamps are sustainable, because its actually a very small amt of money. The gov't imposes a cap on how much stamps you get. This makes it sustainable. It won't bankrupt the system. But medical costs, for a SINGLE patient, can easily run into the millions.

    Now, I'm all for setting up a gov't program that gives everyone 5k/yr to spend on health insurance premiums, or HSAs, etc. This is sustainable, it keeps the free market, and it's equal - everyone gets the same amount.

    If you want a public option, fine, but you can't subsidize it ad infinitum, and I hardly can believe you trust the government to control costs.

    As I said before, we need private sector oversight of health care spending, with a strong profit motive to do so efficiently, because gov't bureaucrats don't have an incentive to control costs. Just look at Medicare now, and compare it to the great job private HMOs did in the early 90s.

    Now, if you want to take a lifelong paycut so that people in the ghetto who eat themselves to the point of needing a quadruple bypass can get one at will, then please, do so. Personally, my threshold for a satisfactory income to take care of myself and my family is pretty high, so I won't be doing that. But asking others to do it for you is a different story. You're free to donate your services as you please, but when it comes to designing a system, you're not going to get universal coverage that's simultaneously fast, cheap, or effective.

  4. Please join the discussion for this same post on KevinMD at I think you will benefit from discussing with others and carefully re-reading my post/reply.

  5. i'm sorry, but i'm not going to bother because i frankly don't understand how you can claim an understanding of economics given your demonstrated naivete thus far. you seem to think resources are unlimited, gov't is great at cost-cutting, and primary care docs can't respond to pricing pressures and incentives just like any other businesspeople.