| Imagine trying to do your job with one hand tied behind your back. For a lawyer or a banker this wouldn’t be nearly as much of a disadvantage as it would for, say, a doctor. Yikes! When it comes to the practice of medicine most of us want our physicians unencumbered and fully functioning. No one-armed heart surgeons for me, thanks. It’s hard for most of us lay people to imagine the pressures doctors face in the practice of medicine—the actual doctoring they do. The health and well-being, and frequently the very lives, of their patients are quite literally in their hands. However, in order to succeed in the practice of medicine, doctors must be more than good doctors. Doctors must be scientists, biomechanics, counselors, accountants, attorneys, and entrepreneurs. And they must excel at each. Talk about pressure. But many doctors, locally and nationally, feel strongly that their doctoring—the caring for the patient part of their practices—is undermined by relationships with health insurers that are grossly one-sided, in favor of the insurers, putting them at significant risk. Testifying before the U.S. Senate Judiciary Committee in September last year, Edward L. Langston, MD, a member of the Leawood, Kansas-based American Academy of Family Physicians and chairman of the American Medical Association’s board of trustees, stated “Many health insurer contracts are essentially ‘contracts of adhesion’ submitted to the weaker party on a take-it-or-leave-it basis and do not provide for negotiation. Physicians typically have no choice but to accept them. Choosing to leave the network often means destroying patient relationships and drastically reducing or losing one’s practice. Physicians simply cannot walk away from contracts that constitute a high percentage of their patient base because they cannot readily replace that lost business.” Langston’s colleague on the AMA board, Cecil Wilson, MD echoed those sentiments in a statement this summer to the House Subcommittee on Regulations, Health care, and Trade Small Business Committee. Wilson’s testimony specifically addressed concerns about health insurers delaying payment to physicians. “A common problem confronted by many physicians is insurers paying claims late,” said Dr. Wilson. “Even if a claim includes all the appropriate information, insurance companies often find reasons to delay or deny payment. This is tantamount to small physician practices extending interest free loans to large insurance companies.” Businesses—especially small businesses—live or die by their cash flow. When the flow of cash into a business is impeded, bills can’t be paid, payrolls can’t be met, supplies can’t be purchased. You get the picture. It’s slow suffocation. Now, imagine this: You’re the proprietor of a nice family restaurant; well-known in your part of town for the quality of your food and service. You’ve spent years developing relationships with your regular diners. It’s one of those “where everybody knows your name” kind of places. Then, just down the block, a slick new joint pops up, selling some of the same food you sell, for a fraction of the price, and five times as fast, with an advertising budget that’s many times more than your whole operation makes in an entire year. Plus they give toys to kids with each meal, and they have a clown for a mascot. Sound familiar? Fifty years after fast-food chains revolutionized the restaurant industry and fundamentally changed the way Americans think about eating, similar changes are taking place in the practice of medicine. It’s called retail medicine. And it’s available at the pharmacy down the block, or the neighborhood supermarket, or the big box mega-mart just off the Interstate. They’re “walk-in” clinics, staffed by nurses, nurse practitioners, physicians’ assistants, or, sometimes physicians themselves. They’re fast, efficient, clean, convenient, and cheap. Chances are, if you haven’t visited one yet, you will soon. And though they don’t promote themselves as substitutes for primary care physicians, they tend, in many cases, to function that way. For sniffles, sore throats, and minor rashes, aches, and pains, these clinics can be a quick and easy way to get the treatment and attention you need. And if you also need a prescription, well, you just happen to be right there in a pharmacy. Imagine that. And, as if the relationships between doctors and insurers aren’t already contentious enough, many insurers are beginning to include visits to such clinics in their health plans, which will divert many patient visits away from primary care practices. Members of the Leawood-based American Academy of Family Physicians recently debated issues relating to the proliferation of retail clinics at their recent annual national convention. Many resent and resist sharing their patients’ medical records with these clinics. Yet others feel duty-bound to do so, on principle. Many are suspicious of the quality of care provided by these clinics, especially if they are not closely supervised by a physician. Yet all seem resigned to the inevitability of these clinics. They cannot choose to ignore them, only how to manage the impact they will have on the practice of primary care medicine. Finally, imagine that you’re an employee at a Fortune 500 company. You go to work everyday at a beautiful, state-of-the-art, corporate campus. But today you’re not feeling all that well. So you tell your supervisor you’re going to the company clinic to get checked out. There at the clinic your comprehensive medical records are instantaneously accessed with the swipe of your employee ID badge. You wait a few minutes, for a company-employed doctor, who spends as much time with you as you need to describe your symptoms and to discuss an appropriate treatment. While you’re there, you also talk about your overall health and fitness goals, including exercise, nutrition, weight management, and stress reduction. When you leave, your prescription is waiting for you at the door. The co-pay for this elegant service is negligible, compared to a traditional doctor’s office visit. And there’s no need to worry about health insurance covering the cost of the visit, because you don’t have conventional health insurance anymore. Your employer is now your health in-surer, and your primary care provider. Here in Kansas City, and in other cities across the nation, this is not some futuristic dream. It’s a present reality. What role is there for the traditional family physician in this equation? Hmmm. It’s hard to imagine one. Talk about pressure.
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