All Commentary
Wednesday, September 23, 2009

Health Care: A Future Free-Market Alternative

I visit a new doctor because of complaints I’ve been having. The primary-care doctor begins his first visit with me by explaining his payment system. I need to put down a retainer based on his assessment of the time it will take him to deal with my problem, which he’ll inform me of at the end of this, his first, evaluation, for which I’ll be charged a flat fee. If I find this acceptable, I sign a form stating my understanding.

The doctor indicates that labs, imaging studies, and other services will be paid by me and I can go anywhere I choose. However, he has made arrangements for reasonable fees with quality providers he can recommend if I wish.

The doctor then takes a history and physical, spending about 30 minutes with me, for which the flat fee is $50. He explains his hourly billing is $100–much less than a typical lawyer charges, I’m happy to note. He tells me at the end of the evaluation that my problem can likely be evaluated in under five hours of his time, and that the retainer will be $500. I will be billed monthly and asked to replenish the retainer if it drops below $150. I can pay cash, write a check, or use a credit card, but I have money saved in a health savings account (HSA), so I just pay using my HSA debit card.

I do not have to wait to see my physician. He makes himself or his physician assistant (PA, who bills at only $50 an hour) readily available to me. He phones and e-mails to answer any questions I have or to convey health information to me in a timely fashion.

The doctor successfully manages my health problem in only three hours over the course of two months and four visits (not all of this is face time, of course; he bills me for his research time, time to consult with other physicians, time to review my test results, time talking with me over the phone or e-mailing me, and so on), and with the final month’s bill comes a check for $150, retainer minus charges.

Since I’m generally healthy, I find my costs each year are under $1,000. I recognize that at some point I’ll likely have a significant illness, so I have an insurance policy that pays for all charges over $10,000. It’s a very inexpensive policy that, like my fire insurance, I’ve never had to make claims on.

My mother, who has a chronic problem, diabetes, tells me she has a specialist who offers a flat fee per year to his patients. It’s more expensive than what I pay, of course, but she uses the service much more than I use mine. Fortunately, she bought insurance coverage years ago, before the diabetes developed, and paid a little extra for guaranteed renewability at a stable price (inflation charges only). She tells me her specialist places his patients in one of three tiers, with graduated prices, based on the severity of their problem and associated complications. In an effort to minimize her charges, she works diligently to keep her blood sugar in the appropriate range and has consequently had few complications so far.

Sadly, some people develop chronic diseases without having obtained insurance. Many of them, who can afford it, simply accept that they will pay more for their health care, just as very litigious people pay more for their legal care. Some can’t afford it on their own, and family or church is often there to support them, as was the case before third-party payers took over that role. In addition, such people often receive pro bono care from a wide variety of physicians who feel offering such free care for a percentage of their practice is both good business and the professional thing to do. It’s also true that once you have a working relationship with a doctor, he can’t just drop you because you’re falling behind in payments (which is why doctors demand retainers in the first place).

Many healthcare items–from CTs to cholecystectomies–are clearly priced, and people compare prices and shop for quality as well. You can look up surgeons and radiologists on the Internet, for example, and see what prior customers thought of the quality of their services. Other people choose to use a qualified middleman to recommend a local physician of high quality and reasonable price. Such middlemen advertise their services and list many reasons to use them, including the opportunity to take advantage of volume discounts and to have someone knowledgeable to guide you through the various medical options. Yet others make their own decisions, using the Internet and new software programs, just as they use software to help them make the right tax-paying decisions.

Mayo and Kaiser, among others, take strong advantage of their brand name, which signifies quality, but the competition from many other physicians makes it difficult for them to charge too much additional for “value-added.”

Of course, I am not forced to see a licensed physician. If I am willing to assume the risk (usually associated with a lower price) of seeing an unlicensed physician, it is my own choice. The law says only that those offering the services of a physician must truthfully and prominently display whatever certificates they have. Often there is little actual risk: It turns out that many “unlicensed” physicians are simply physicians who are properly licensed elsewhere (another state, another country) but who didn’t want to jump through all the regulatory hoops to get one more license. Given that this is allowed, the cost and hassle of additional licenses is, I hear, coming down. (Before these licensing regulations were changed–back in the 1990s, for example–you had bizarre situations where top-flight general surgeons from Britain or Canada became anesthesiologists or even PAs here, because those licenses could be obtained more quickly than that of a general surgeon. What an economically inefficient use of scarce resources, economists pointed out.)

I need not even see a doctor for all my medical complaints. For example, nurse practitioners and PAs both offer deep discounts on monospot swabbing and rapid strep test if I have a sore throat. And pharmacists are happy to make recommendations for medications, which no longer require a physician’s prescription. Granted, many people are not comfortable taking what had been prescription meds without some input by a physician and are willing to pay extra for that privilege, but in some instances and with some people, the pharmacist seems sufficient. (Most pharmacists feel comfortable not getting the advice of a physician as to what drugs are best for their diagnosis.) Some upper-scale pharmacies require you to compensate the pharmacists for their time and advice, as you do other professionals, though some large-scale businesses like Walgreens and Wal-Mart offer the pharmacist consultation as part of the price package.

People make mistakes, of course, as with any institution involving human beings, though the mistakes associated with overly burdensome regulation are no longer a problem. When they do make mistakes, they can be sued, as before. But the introduction of a “loser pays” principle in malpractice suits has reduced spurious lawsuits. Some physicians offer discount fees to those who agree to waive their right to sue, and courts have recently modified past precedent to allow people this option. (Reputation is sufficient to prevent abuse.)

Hospitals are run competitively. Some are small boutique hospitals, catering to those with specific problems–cardiac, musculoskeletal, and others. Others are megaplexes that offer a total package with every imaginable specialist coordinating all aspects of your care. For many problems there are clear prices that cover all aspects (labs, imaging, post-op care), and long-term payment plans are commonplace. Many hospitals have a sliding scale for the less fortunate, but the idea of offering “free care” is considered laughable, since most recognize that people overutilize scarce resources that are underpriced. Some have a local reputation, while others are branches of well-respected national chains. Mayo hospitals are often located near major highways and can be recognized from afar by their bright yellow arches. The price of a major operation is typically more than an inexpensive car, less than an inexpensive house (though transparent pricing and market competition lower these prices each year), and is financed as people finance cars and houses: long-term. Hospital companies, like car companies, have associated financing wings (such as “MAYOAC”) that offer long-term financing options.

Some people choose to go without insurance, as is their right. For young, healthy people it is often a reasonable risk to take. When people without insurance have an acute medical problem or trauma requiring immediate care, they are usually treated in a basic fashion and compensation is handled at a later, more appropriate time. Hospitals often try to attract physicians to help with things like trauma by offering to compensate them immediately and up front, adding these costs onto the bill to be financed.

Most people, though, have health insurance. Because there are no state or federal mandates, health insurance is inexpensive, especially for high-deductible packages. You only insure against those things you want to insure against. Cancer and diabetes: yes. In vitro fertilization and hair transplant (to name two of several hundred mandates previously required in one or more of the 50 states): no.

Even a majority of the poor can afford health care now, just as they can, according to government studies, afford flat-screen TVs, air conditioning, computers, cell phones, two cars per family, and many other goods and services not available to the rich of 50 years ago. There is a society-wide discussion about how to help the poorest of the poor–some urge reliance on family, charity, and the resurgent friendly societies; others seek some form of government involvement–but all agree that concern for the poor in no way justifies government take over of nearly 17 percent of the national economy.

Health care is not perfect. But we have saved a lot of money by no longer pretending it could be made perfect if we handed it over to the political class. If only we could as easily solve the continuing problem of first-class mail delivery.