The Omnimedix Institute’s JD Kleinke wrote in to comment on the thread triggered by last week’s news on the dossia project, a story that came out when Wal-Mart CEO Lee Scott revealed new details of the retail giant’s plans to work with major employers to help them cut healthcare costs in his annual January address to the company’s managers and other employees in Kansas City. Scott’s plan provoked the usual skeptical response from critics in the blogosphere and the media, but JD had this to say:    

"Omnimedix is currently in the process of resolving a legal dispute with Wal-Mart and the other Dossia corporations regarding the development and operation of the Dossia PHR system. And while this dispute has been an annoyance for us and no doubt for Wal-Mart, I’d like to make it clear that we support Wal-Mart’s overall health care ambitions, which involve not only PHRs for their own employees, but an expansion of health benefits for those employees, and the creation of a modern, affordable, accessible health care delivery system.  Think whatever you want about this oft-vilified mega-retailer; Wal-Mart has the singular ability to bring a low-cost, low-friction, high-value, high-access alternative to health care delivery in the U.S., one we have desperately needed for decades." 

In building out a “cash-and-carry” health care system across the
country, Wal-Mart clearly recognizes that our third-party payer driven,
fragmented health care system is overengineered, too costly,
inconvenient, and ridiculously inefficient.  Its plans to integrate
affordable and accessible primary care with low-cost prescriptions and
other in-store health services is exactly what a large percentage of
the American public – particularly the uninsured, underinsured and
working poor – so desperately need."

Meanwhile, THCB contributor David Donnersburger MD has an interesting response to "Concierge Medicine from a Physician’s Perspective," a post he wrote for THCB earlier in the month discussing his own theories on how the concierge practice model should be put into practice.    

"Indeed, this is really a FFS business model that allows for a
doctor-patient relationship that may be different from what other
business models allow.  We have no contractual relationships with any
insurance carriers.  We do however electronically submit to patients’
insurance companies, but that is where the relationship ends.
Uncovered or rejected fees are the patients’ responsibility, a
contingency that the patient knows in advance.  If a patient has a plan
that covers lab work drawn at a specific site, we gladly use that
option in order to contain costs.  Our practice has been operating in
this fashion since the 1970’s, so there was no alienation of patients. 

We do see patients every day who have received letters from their
doctors telling them that they are cutting their current practice down
from 2700 patients to 400.  In order to stay in the practice the
patient is told that that there will be a mandatory annual fee of $1500
and $2000 per couple, etc.  These letters commercialize the
doctor/patient relationship, alienate long-standing patients, and give
"concierge" medicine a bad name (understandably).  There are several
very slick companies that help practices morph into these models. 

Patients, in my experience, understand paying out of pocket for care as
they utilize it, rather than writing a check for an "entrance fee"
every year on Jan 1.  (Indeed, although we consider Europe a bastion of
universal health care, a significant percentage of Europeans pay
out-of-pocket to see specialists, avoid long waiting rooms, get the
MRI, move appointments sooner, or see a doctor who is perceived as
having better training or personality.)  Many of my patients live part
of the year in warmer climates.  Their doctors in AZ and FL require
annual fees of $1500 for a relationship that lasts from mid-Jan to
mid-April and includes no screening or health maintenance.  Such a
requirement engenders considerable ire in my patients, but allows for a
doc/pat relationship that hopefully redounds in better care than at a
walk-in clinic (I hope).

Although we work in a 5 million+ urban area, 60% of my practice
includes the siblings, spouses, grandparents, children, and grandkids
of other patients.  We practice generational, small-town medicine in a
metropolis.  My partners of different faiths and I attend the churches
and temples of our patients.  We work out, buy groceries, and use the
same dry cleaners that are frequented by our patients.  We try to know
the patients when they are well, so that we can take better care of
them when they are in the ICU.  (Pressure to use the hospitalist
serivice by our hospitals is making this more difficult.)  While
writing this I recognize how Pollyannaish it sounds; although it is
what happens.  I offer my thoughts not as a way to get rich practicing
primary care medicine.  Rather it is an alternative that allows for
financial survival while practicing medicine and building relationships
in a way that we think is best and without having to double-book or see
37 patients in a morning.  Obviously, the model is intensely
demographic-dependent."