Two Tiers? America Has Multi-tiered Healthcare Now

One of the questions I hear often from reporters and others about hybrid and concierge programs is this: “Don’t they create a two-tiered system healthcare?”

Consider the reality of medicine today

Debate about two-tiered medicine creates a lot of lively discussion; but it’s a red herring. The reality of medicine today is that no matter what your income, your age, or where you live, we already have a multi-tiered system of care. Here are important points to consider:

1. Despite standards of training, education, and accreditation, there are differences in who provides care to patients. There are terrific doctors working at free clinics; average ones working at upscale private offices; and doctors who may not have gone to an Ivy League school, but who provide outstanding care.

2. Physician relationship and interaction with patients varies. In some large groups, patients never see the same physician twice. In others, patients may frequently see physician extenders. Not everyone who wants to gets to see a physician today. As more people enter the healthcare system, even fewer will be able to schedule routine visits with physicians of their choice.

3. Access to care is directly related to what insurance covers. Patients typically don’t request a service if it won’t be covered by insurance. What’s more, I rarely hear of a doctor sending a patient for a diagnostic test to a provider with newer and perhaps better equipment if it’s not part of the “plan.” Referring doctors follow a similar path. Often, they know the doctors who participate and those who do not in certain plans. Referrals are often guided not by medical concerns, but by economic and health plan coverage limitations.

4. Variations in plan participation are yet another reality that leads to tiered systems of care. One of the frustrations many patients have is that a doctor they want to see may not participate in their insurance program. Many practices choose not to accept certain plans because of low reimbursement, or because they simply don’t have the capacity to see every patient who wants to join the practice. If a physician doesn’t take Medicare, Medicaid, or some other plan, a patient’s options are limited.

5. Some days are different than others. Some days the car didn’t start, you got stuck in traffic, had a disagreement with your significant other, some not. Factors such as seasonality, weather, changes of personnel, differences in facilities and equipment, etc., all impact - to some degree - care provided. Do most physicians always strive to provide ideal care no matter what their personal circumstances? Sure, but physicians are also human beings. Even world class athletes have good days and bad ones.

Is care slipping?

I’m a big believer in offering a range of options to fit the needs of patients, payers, and physicians. However, my concern as I observe the healthcare landscape is that the overall level of care offered by the healthcare industry is slipping. What’s more, there is a potential for quality of care to degrade further as the shortage of primary-care physicians continues and growth of non-physician primary-care increases.

Therefore I’d like to see us move the debate away from tiers of care. By the very nature of our healthcare industry there always have been - and always will be - differences in care.

However, let’s make sure quality is not one of those differences. Let’s move the conversation away from debates over tiers to one focused on finding real solutions to ensuring that all Americans have access to a high standard of care at a cost we as a nation can afford.

To do so, let’s ensure that we offer options to encourage good physicians to stay in practice - caring for all their patients. Let’s make sure practice options encourage those good physicians to accept a wide range of plans - including Medicaid and Medicare.

Finally, I’m the first to admit there’s a lot to debate in healthcare today. Here’s to hoping discussions in the future are focused on what really matters: keeping good doctors in the system, attracting bright committed young people , and making sure all patients get the care they need.

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