Kenya provides free education for all children. The problem is that the quality of public education is poor. Classrooms overflow, many pupils sit outside, there is little or no equipment, books are scarce and teachers are grossly underpaid. To supplement their children’s learning those who can afford a little more pay an extra fee for additional drilling and exam preparation.
Since education is so prized in this East African country, there is a parallel system where parents believe their children will get the advantages they need in order to move on to secondary and college level schools. Private and self-help schools are everywhere. If at all possible, parents scrape together money for tuition for these private sector schools. Their efforts are often rewarded. A government sponsored national survey carried out in 2009 found that literacy levels are higher in private schools than public schools.
Nothing seems like a better investment than giving their children a good education. I agree. It is the key to their future. That’s why Lyn and I, through the Ethical Humanist Society of Long Island, have been sponsoring a private elementary school there for the last ten years (semaacademy.wordpress.com), even though we are committed to public education.
Many parents make similar choices here. Tutoring is common in middle-class families. The New York Times reported that one family paid six figures in private tutoring for their son before taking his SAT exams last year. Private schools, often with big price tags, are there for those who can afford them or, if they are lucky, can get a scholarship for their child. This creates a two-tier system of education but it is acceptable, even though it means that those with more money can buy a better education for their children.
Something like this now looms around medical care. Concierge doctors are on the rise. In this arrangement, doctors limit their practice to patients who pay a fee of about $1,500. Under this arrangement, doctors can limit the number of patients they see. As Rhode Island primary care physician Lewis Weiner says, “I don’t have to be looking at patient mix and how many are booked per hour. I get to know the individual. I see their color. I see their moods. I pick up changes in their lives, new stressors that I would not have found as easily before. It’s been a very positive shift.” Not to say financially rewarding. The math is this: if a doctor has 500 patients paying $1,500, that’s $750,000.
The problem is that while presently there are about 2,000 concierge doctors, the approach is so lucrative that it may cause further shortages amongst primary care physicians, especially for those receiving Medicare. MedPAC, a Congressional commission to advise lawmakers on Medicare, is concerned. Glen Hackbarth, MedPAC’s chairman, said, “My worst fear — and I don’t know how realistic it is — is that this is a harbinger of our approaching a tipping point.” He said that”there’s too much money” for doctors to pass up. “The nightmare I have — and, again, I don’t know how realistic it is — is that a couple of these things come together, and you could have a quite dramatic erosion in access in a very short time.”
More time spent with a concierge patient means less time with a poorer-paying Medicare beneficiary. And as more middle-class patients decide that $1,500 per year is a reasonable price to pay for personal attention and extended time with their physician, the greater the stress will be upon poor people. Robert Berenson, a MedPAC commissioner, called the concierge medicine the canary in the coal mine. “The fact that excellent doctors are doing this suggests we’ve got a problem.”
The fundamental problem is the shortage of primary care doctors. There are two ways to address this: train more doctors (Hofstra University’s medical school, which opened this summer, is meant to help address this shortage); pay primary care physicians more. One reason for the shortage is that specialists are better paid than primary physicians. Medicare and Medicaid reimbursements need a thorough overhaul.
Those with money will always seek better services for themselves and professionals will follow the money. Short of draconian measures that curtail personal choices, the system needs to be reconfigured so that reasonable medical care is available to all. This is no different from demanding decent public education without eliminating private schools. Finding a balance between freedom and justice is difficult and never perfect. In this instance, the adjustments need to be made on the institutional level, with society providing more opportunities to educate future physicians, then offering greater incentives to practice primary care.
Concierge medicine opens the discussion about how to best serve the community by offering better care for all while still offering choices for those who are willing to pay the extra premium.