Letters to the Editor - June 7, 2004

Concierge-model practices may deliver better care while cutting costs - Entrepreneurial imaging centers raise important issues about self-referral

Concierge-model practices may deliver better care while cutting costs

I have no interest in starting a concierge practice. However, I would like to point out that the concierge model might often save health care dollars, improve patient satisfaction, and improve the quality of care.

In my area if one calls their doctor, they often get an electronic answering machine that directs them to call 911 if there is an emergency. If the problem is not an emergency, they then get to push up to six more buttons, and are told to hang up and they may get called back later.

Take the case of the patient who does not understand the instructions for his new insulin therapy: Under the current model he would often become frustrated and end up in the emergency department.

Under the concierge model, he would get a real human, feel much better about his care, be more compliant, and save health care dollars presently and in the future.

If a patient calls late in the afternoon about a symptomatic UTI, under the current model, they are often directed to the emergency department in the area hospital. Under the concierge model, the patient would be treated in the physician's office or even over the phone!

I agree that patients are treated under either model but only a hospital administrator or a $30-million-a-year insurance company CEO could feel that the current model is better, cheaper, or more efficient than a concierge model.

After all, the concierge model is not much different than the way we used to treat patients. Maybe we, the members of the AMA, need to reconsider the benefits a concierge model of care would offer to society.

--Peter W. Rufleth, MD, Hyannis, Mass.

Entrepreneurial imaging centers raise important issues about self-referral

Regarding "Image conscious" (Article, May 17): Singularly lacking in your article was any analysis of the impact that self-referral of expensive imaging procedures has on the cost, and cost-effectiveness of health care.

Numerous studies have shown that nonradiologists who perform imaging studies order them at significantly higher rates than do those who refer to radiologists, without any evidence that care of those patients is improved. Your article not only failed to deal with this, but seemed to justify the ever-increasing number of CT and MR devices as an appropriate entrepreneurial adventure.

There are several reasons for the organized medical community to review such attitudes. With accelerating medical costs again occupying center stage in the public consciousness we need to be seen as advocates for efficient and high quality care delivery, not as advocates for every means to squeeze a few more dollars out of the system.

Self-referred imaging fails both counts. It encourages overutilization of expensive resources, and, by virtue of being a sideline rather than the center of a practice, is often of lower quality than the sort of work produced by imaging specialists.

Finally, the temptation to order a study of dubious necessity because it might just turn out to be helpful, creates an avoidable ethical question. No longer is the diagnostic utility of the examination the only factor that needs to be assessed; now the honest practitioner must wonder whether the potential for profit is influencing a clinical decision.

By requiring that any study that is not necessarily part of an office visit be performed by someone other than the referring doctor, or associate, we would go a long way toward saving wasteful imaging practices, radiation exposure, and our reputation as a profession.

--Michael Komarow, MD, Wappingers Falls, N.Y.

Editor's note: Dr. Komarow is a radiologist and chief medical officer for CareCore National LLC, a radiology benefit management company.