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Democrats fighting 'boutique medicine'
© St. Petersburg Times WASHINGTON -- If wealthy Medicare patients want to pay their doctor extra money out of their own pockets for special attention, what's wrong with that? Plenty, say liberal Democrats, who are up in arms over a trend toward "boutique medicine" they see as unjust. Conservatives and libertarians, on the other hand, argue it is the predictable result of free-market forces. The controversy began, predictably, in Florida. Medicare patients in Palm Beach County complained to Sen. Bill Nelson, D-Fla., last year when their doctors sent letters requiring a $1,500 "access fee." The doctors had joined MDVIP Inc., a Boca Raton-based group promising special services to patients who pay extra. The services include a free annual physical exam, programs to prevent illness, same day or next day appointments, access to the doctor by phone at all times, help filling prescriptions and unspecified waiting room "amenities." Collecting the access fees had allowed the doctors to keep 600 patients and send 2,400 others elsewhere. Disturbed by the complaints, Nelson authored a bill to end the practice. "I have a problem with it," Nelson said. "If a doctor wants to accept Medicare reimbursement, he must live within the rules of a program that's provided for all citizens. You can't say 'I'm only going to see patients who pay extra and not see others.' It would ultimately spell the doom of Medicare." Nelson's view is widely shared among Democrats in Congress. Last week, a group of House members including Reps. Pete Stark, D-Calif., Henry Waxman , D-Calif., Sherrod Brown, D-Ohio, Benjamin Cardin, D-Md., and Sen. Dick Durbin, D-Ill., wrote to Health and Human Services Secretary Tommy Thompson asking him to look into the matter. "In our view," their letter said, "physicians who participate in arrangements such as MDVIP and seek Medicare reimbursement appear to violate two laws. First, they charge patients more than Congress allows for covered services. Second, they routinely submit erroneous bills to the federal government." If the government allows doctors to charge extra, the letter said, "then patients have no financial protections against overcharges." The administration, however, does not agree that boutique doctors are violating the law. Nor does Nelson. When he consulted HHS before proposing his bill, he was told by department officials the boutique doctors were operating within the law. "If it were already illegal," Nelson said, "I would not be doing this." Tom Miller, a health care expert at the Cato Institute, a libertarian think tank, does not understand what all the fuss is about. "It seems to me like a simple case of a willing buyer finding a willing seller," Miller said. Miller said it is not illegal for a Medicare doctor to charge extra for services covered by Medicare. He noted that Medicare patients also pay for their prescription drugs and Medigap coverage. In addition, there are many medical procedures that Medicare does not cover. "If there is a medical procedure that the Medicare patient wants and the taxpayers don't want to pay for, why can't a person reach into his or her own pocket to pay for it?" he asked. As Miller sees it, Medicare is an outdated plan and not just because it fails to cover prescription drug purchases. He says Medicare is a one-size-fits-all program in an era when people want choices. In addition, Miller said, firms such as MDVIP are a direct result of a decline in Medicare reimbursements to doctors, a circumstance forcing them to take on too many patients to maintain their income. The boutique doctors have decided this is the best way to deal with that problem without adding more patients, he said. The government has cut Medicare payments to doctors by about 5 percent despite protests from some members of Congress. The economic pressure on doctors is reflected in legislation being considered in Congress. The measure, proposed by Reps. John Conyers, D-Mich., and Bob Barr, R-Ga., would exempt doctors from antitrust laws so they could band together to negotiate high fees from insurance companies. Health insurers are certain to oppose it. While boutique health care may be relatively new, Uwe E. Reinhardt, health care economist at Princeton University, said the argument between Nelson and Miller has been around for years in one form or another. Nelson reflects the egalitarian view, held by many older Americans, that health care is a social good that must be made available uniformly to all people. Miller represents a libertarian view gaining momentum with a younger generation, that health care is a commodity for private consumption that should be financed by the individual. Although Nelson may be pushing against the tide, he thinks his bill will pass. "I'm very optimistic," he said. Nelson noted that Sen. Edward M. Kennedy, D-Mass., recognized by Democrats as their leader on health care and other social issues, decided to co-sponsor his bill. But many members of Congress, such as Sen. Bob Graham, D-Fla., have not taken a position on boutique medicine. And the American Medical Association is trying to figure out where it stands.
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