in the Puget Sound Business Journal (Seattle)
, the Commissioner of Insurance in the state of Washington has determined that the growing practice of physicians charging patients a retainer for premium access (responses on nights and weekends, office appointments on short notice, etc.) violates the state's insurance laws. In two draft technical assistance advisories, the deputy commissioner of insurance ruled that such arrangements are, in effect, insurance, because "[t]he fee is paid by the patient regardless of the amount of services provided [and] even if no services are provided. These arrangements result in a transfer of risk and, in essence, are insurance agreements." Actually, the transfer-of-risk/insurance element of the analysis seems weird to me. In what sense do the doctors take on risk? The care isn't pre-paid with the retainer; only access is pre-paid. The patient's health insurer is going to be tapped for the care, and no part of the insurer's risk is being shifted downstream to the physician. Granted, there is some risk that the demand for services at any given time might outstrip the physician's ability to schedule, but that's not a financial risk, is it? The higher the utilization, the higher the fees for the physician. I'm not sure I see any insurance element in this arrangement at all. On the other hand, I think Troy Brennan's ethical analysis of these arrangements in the New England Journal of Medicine
(Volume 346:1165-1168 -- April 11, 2002
) (subscription required for full text) is spot on: "[T]he development of luxury primary care might be seen as a crystallizing event. The medical community must be prepared to step forward with ideas and programs that ensure an equitable distribution of health care services. No matter how innovative and attractive luxury primary care is to some patients and physicians, it poses questions about equity. We should identify ways in which luxury primary care can be regulated by the medical profession (perhaps by mandatory cross-subsidies and careful monitoring of the prevalence of such care), while also addressing other threats to access. The questions that luxury primary care poses should remind us that as physicians we have a commitment to the equitable distribution of health care and therefore a duty to address market innovations that could leave some patients without access to care." Thanks to health lawyer Jeff Sconyers for bringing this decision to my attention.