Recently, I had vigorous discussions about retainer medicine. In both discussions the “opposition” opined that every time an internist (or more recently family physician) leaves the CMS/private insurance grid patient access decreases. They imply that outpatient generalists have a moral responsibility to continue seeing too many patients and spending inadequate time with each patient.
The growth of retainer practices follows simple economic principles. Patients want to buy physician time; physicians are more fulfilled when they spend more time with patients.
Too many generalists express great frustration with their current outpatient practice. Many internists (and some family physicians) have left practice to do hospital medicine. Other generalists are leaving practice for a variety of options, including retirement, fellowship training or administrative opportunities.
Every time a student picks a specialty other than the generalist specialties, that student decreases patient access. Every time an internal medicine resident chooses a subspecialty, that resident decreases patient access.
We have an obligation to understand clearly the attraction of retainer medicine to patients and physicians. The reflex condemnation that I hear so often precludes solving the problems that have stimulated this practice option.
Since I chose internal medicine, I knew that insurance companies undervalued pure cognitive specialties (note the word pure, because interventionalists also use cognition). I chose internal medicine because I love the field and it fits me perfectly.
But the suits at CMS, the RUC, and the insurance companies do not understand the value of an excellent internist or an excellent family physician. Patients understand, and increasingly are willing to pay their generalist as much as they pay for cable service or cell phone service each month. Physicians understand the time is the key to practicing outpatient generalist medicine the proper way.
We often talk about the newer generations focusing on work life balance. I would argue that retainer physicians are regaining some work life balance, and providing excellent medical care.
So please do not denigrate this natural economic phenomenon. Its growth should send huge signals to health policy wonks, politicians, and medical societies. Only when we study this growth carefully can we truly have an increase in generalist access. Do not blame the physicians, blame the system that led them to their decision.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
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