Rationing Health Care: White Coats, Not White Gloves

By Dr. Paul Ehrlich

A certain eminent primary care physician affiliated with a prestigious hospital said to me once, “You have such a great reputation. Why do you put up with the headaches of insurance? Why not just take patients who can afford to pay in cash?” He used the dreaded “C word”—concierge. I said, “But what about all the people who need to see an allergist but can’t afford it?”

Recently this doctor asked me to see a patient. I was glad to do it. Referrals are the lifeblood of specialty practice. But then he added, “Please tell your staff to give preferential treatment. This is a concierge patient.” I said, “Have him call and make an appointment like everybody else.”

Over 30+ years we have had all kinds of patients sit in our waiting room, the rich and famous, teachers, transit workers, secretaries, students, and poor people. We take Medicaid, “Cadillac” insurance, and almost everything in between. We also take checks. I saw students from my volunteer work in the public schools through a program I co-founded called Project ERASE, at my office at my own expense. The concierge model may be a “rational” market response to health care disparities (it certainly doesn’t pretend to be a “solution”), but when you arrive at my office, class distinctions end. (Except for once when a rock star had an appointment and the staff dressed up—for naught, since he cancelled at the last minute.)

Will I do a favor for a friend or relative? Of course, and they sometimes don’t pay a dime, although if they are insured we take the money. Will I extend a professional courtesy? Of course. But there are limits, and the fact that a doctor has a lavish fee arrangement with a well-heeled patient isn’t enough to create an exception. There are only 168 hours in a week, and I have to eat and sleep, attend at hospitals, lecture, study, write for this website, love my family, and go to the occasional ballgame. That’s how we ration our care. You want concierge treatment? Go to a luxury hotel.

Photograph by dccondoloft.com

Dr. Ehrlich was chosen best pediatric allergist in New York City for 2012 by New York Magazine/Castle Connolly, along with Dr. Hugh Sampson and Dr. Scott Sicherer, both of the Jaffe Food Allergy Institute at Mount Sinai Medical Center. Dr. Ehrlich has now made the list for about 10 years.

How does Castle Connolly decide which doctors are the best?
The firm conducts a peer-review survey. The idea is that medical professionals are best qualified to judge other medical professionals, and if one recommendation is good (think of your doctor referring you to a specialist), multiple recommendations are better. Licensed physicians vote online (castleconnolly.com/nominations) for those doctors they view as exceptional. Participating physicians are asked to nominate those doctors who, in their judgment, are the best in their field and related fields, taking into account not only professional qualifications and reputation (education, residency, board certification, hospital appointment, and disciplinary record, for example) but also skills in dealing with patients (listening and communicating effectively, demonstrating empathy, instilling trust and confidence). Doctors cannot nominate themselves, and all nominations are confidential. The Castle Connolly physician-led research team then tabulates the results and vets the nominee pool, confirming the doctors’ board certification and licensing, and investigating their disciplinary histories.