The crisis in American medicine runs DEEP

They system is breaking under the weight of its own costs and bureaucracy, Could a rush to concierge medicine by the healthy people who subsidize it provoke full-on collapse?

Some articles land hard.

Yesterday’s piece about my disappointing primary care visit was one. You have already offered hundreds of comments and emails with your own experiences. Many came from doctors — Unreported Truths has become a place (let’s not it call it a safe space) where physicians can vent to each other and engaged laypeople.

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(Writing articles that matter. With your help.)

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The comments are still flooding in. I’ll post a selection of the best ones soon.

A lot of you suggested concierge medicine. The more I think about going that route, the more sense it makes. But the fact so few of you think the current system can possibly work for an average healthy working-age person shows how unstable its underpinnings have become. And a broad move to concierge medicine — which essentially operates on a fee-for-service basis — will destabilize the system further.

It’s crucial to remember that the system as currently constructed benefits both its providers (at least at the corporate level) and its heaviest users.

The largely unrestrained prices inside the American healthcare system mean that taxpayers and employers spend trillions of dollars more than they should based on pricing in other advanced countries. That money goes to hospitals, insurance companies, drug and device companies, the executives and bureaucrats inside the system. Some of it even sloshes down to doctors and nurses.

But there are also hidden transfers happening within the system.

Men subsidize women, the healthy subsidize the sick, and the young subsidize the old, and, yes, the stoic subsidize the whiny. A lot of medical care, much more than most people realize, is of marginal utility and effectively optional.

Some people are heavy users of healthcare, others are light users. Insurance means that the cost of treatments plays no role in those decisions. But without a huge number of people who use essentially no care each year, the system’s pricing would be exposed for the insanity it has become and the patients inside it would have no chance of paying for it (whether they truly need it or not).

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(It’s a leech! And a metaphor.)

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What I need is what most healthy people under 60 need: a chance to see fee-for-service doctors once in a while combined with a catastrophic insurance backstop should my expenses reach, well, catastrophic levels due to cancer or some other rare nasty.

That catastrophic number will be different for different people.

But the actual cost of providing such insurance is fairly low, on the order of $1,000 to $2,000 a year for healthy people under 60, I’d guess. (That would put it in the range of $1 million to $2 million of life insurance, depending on when it kicks in.)

Combine that cost with a concierge service that costs $1,500 to $3,000 a year depending on the region and you get something close to the actual annual cost of medical treatment for a generally healthy person, in the range of $3,000 to $5,000 or so including catastrophic insurance.

Our health-care system as currently constructed does everything possible to ensure that healthy people cannot use it that way. When the additional cost was, say, $3,000 extra per year and employer-subsized and the care was reasonable, most people didn’t bother to opt out. The time and effort to do so wasn’t worth the trouble.

But paying $15,000 a year for care that feels worse than nothing simply seems wrong. At this point, I’m likely to opt out. And I am not alone.

The move to concierge will have its own momentum.

Many frontline physicians — internists, cardiologists, pediatricians — hate the current system (I know, I hear from them) and the way it restricts their autonomy. They would happily move to a solo or small group practice fee-for-service model if they thought they could survive without insurance.

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(Fee-for-service: the Unreported Truths way.)

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For decades, the federal government and the insurers and hospital companies have done everything they can to consolidate care and make it impossible for patients and doctors to opt out.

They have succeeded too well. They have created a system that is massively costly and unresponsive.

Fixing the system appears impossible. Breaking it will be incredibly painful. But how many more years can these trends continue?