Gordian Knot: 1: an intricate problem ; especially : a problem insoluble in its own terms —often used in the phrase cut the Gordian knot 2: a knot tied by Gordius, king of Phrygia, held to be capable of being untied only by the future ruler of Asia, and cut by Alexander the Great with his sword
Generations ago, the American Medical Association’s (AMA) Code of Ethics stipulated that allowing a third party to profit from a physician’s labor was unethical. This tenet resides in a time when house calls were common place; when trust and respect helped forge an immutable bond between doctor and patient; and when it would have been unthinkable to allow anyone other than the doctor, family, or patient to have a role within the doctor-patient relationship.
The landscape of today’s healthcare system and its delivery methods make the authors of the AMA’s forgotten code look prescient. Insurance companies, controlling the purse strings, have become an unwelcome partner within the doctor-patient relationship, frequently dictating what can and can’t be done, and are reaping a healthy profit from their oversight. Obscene salaries and large bonuses are awarded to the CEOs of these companies for keeping as much money as they can from those providing health services, with the CEO United Healthcare being reported as receiving a $324 million paycheck during a five year period. Thus, short-term business strategies are given priority, often at the expense of patients’ long-term medical goals, creating a Gordian knot so entwined that no one – patients, doctors, insurance providers, or government regulators – can see a way to unravel it.
A result of so much money being skimmed off the top is that no one seems to be getting what they need, let alone want. Patients long for more time to discuss problems with their doctor and wish it were easier to get an appointment. Yet physicians are unable to receive adequate reimbursement from insurance companies for their services, and if they do get reimbursement, it’s after months of waiting and often at the high expense of having a posse of back office staff needed to negotiate these payments. These physicians therefore are forced to overload their schedule and rapidly move patients through their office if they are to earn their typical $150,000 per year, pay off medical school debt, and afford the salaries of their office employees. Finally, government agencies, looking for the elusive loop to tug on, ultimately burden physicians further with a myriad of onerous rules and regulations.
Numerous discussions have occurred regarding the declining state of primary care and with a very real shortage of primary care doctors rapidly approaching, the time for honest answers is now. Skyrocketing costs coupled with no discernible improvement in our overall health have driven some physicians to find the courage to simply cut this knot. Charter Internal Medicine, a large medical practice in Maryland, provides one example by recently announcing their plans to adopt a concierge model of medical practice.
Charter Internal Medicine’s announcement prompted the Maryland Insurance Commission to hold a hearing on December 19 to determine if concierge care is a type of health insurance. Ralph Tyler, the commissioner, said, “Our concern is whether the practices are structured in a way to constitute insurance.” Tyler later stated that they would use this hearing to issue a report for the Maryland legislature before convening in January. This autocratic threat to impose government oversight seems designed to intimidate any physician with dreams of cutting themselves and their patients free, and led Charter Internal Medicine to mail a letter of retraction to their patients as they wait for the Commission’s report. I believe this Commission is acting beyond their authority and by failing to look at the insurance companies is directing their attention and effort in the wrong direction.
During these hearings, Baltimore’s Health Commissioner testified, “that each new concierge practice can mean that thousands of patients will be searching for new doctors.” Is he saying that a concierge doctor’s decision to care for fewer patients will leave some searching for a doctor or is he implying that the membership fee will be unaffordable by many patients leaving them without a doctor? Both are valid points, but these points do not address the fact that leaving the current system alone will guarantee a crippling shortage of primary care doctors in the very near future. If the insurance commission would explore what is driving doctors away from primary care, they would stay within their mandate and help all patients by aiding physicians in creating an environment conducive to the practice of primary care medicine, instead of further tightening our Gordian Knot.
The courage the Charter doctors showed in trying to continue practicing primary care medicine in a way they felt they could best deliver patient care, as opposed to leaving primary care altogether, should earn accolades. In our practice , we have cut the knot binding us to a failed and broken system and we applaud any of our peers creative enough to find their own way to free themselves and their patients whether we agree with the specifics of their plan or not. By doing so, we have been able to return to the AMA’s Code of Ethics set forth so many years ago.
Until next time, I remain yours in primary care,
Steve Simmons, M.D.