Health care’s fundamental problem: Your doctor doesn’t work for you

Health care’s fundamental problem: Your doctor doesn’t work for you
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You seek us out when you’re sick, share with us the most intimate details of your life, and trust that our treatments will make you better.

There’s just one problem: Your doctor may not actually be working for you, the patient. 

Over the last three decades, as patients have seen their medical costs increase dramatically, the number of self-employed doctors has plummeted. Today, just a third of doctors are self-employed, as more doctors find independent practice difficult and seek the sense of security offered by large hospitals.

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Once the backbone of America’s health care system, primary care physicians have been overtaken by medical middlemen that drive up costs and get between doctors and our patients. Every step of the way, the patient’s interests are subordinated to another customer. Doctors answer to their hospital employers. The hospitals are eager to please the insurance companies that decide whether to pay medical claims.


Throughout its history, the health insurance industry has paid lip service to controlling costs while actually driving them higher. At any time, your doctor’s years of training and knowledge of your unique condition can be vetoed by your insurance company. By overriding a doctor’s recommendation, a patient’s condition can deteriorate and lead to more costly procedures. 

Patients have little recourse to hold insurance companies accountable. In 2018, more half of all counties in the United States have just a single health insurance plan offered through the Affordable Care Act marketplace. More than 157 million Americans receive health care coverage through their employment, and these plans cater to employers’ wishes. Patients are left with fewer plan benefits and increased out-of-pocket costs. In fact, the most recent analysis of health care spending shows patients’ out-of-pocket spending increasing at the fastest rate in a decade.

Thankfully, Amazon’s recent announcement that it is partnering with Berkshire Hathaway and J.P. Morgan to bypass the health insurance industry could usher in a new era of consumer choice. Although few details have been announced, patients should be excited by Amazon’s notorious customer obsession and track record of market disruption. What would an Amazon customer-obsessed, disruptive health care system look like?

“Leaders start with the customer and work backwards,” Amazon explains of its core philosophy. “They work vigorously to earn and keep customer trust.”

Direct primary care — where your doctor works for you, not an insurance company — is the most logical option. Think back to the days of the town doctor making house calls.  

Direct practices offer home visits, answer calls 24-7, and personally manage patient’s hospital care. These physicians work directly for and are paid directly by their patients, which forces doctors to provide the best service. Under the conventional health insurance system, primary care physicians can be responsible for 2,000 to 3,000 patients per doctor. Concierge practices, in contrast, limit the number of patients to a few hundred in order to spend more time with each patient.

Direct primary care can help reduce health costs by addressing minor issues early on. Emergency room visits and urgent hospitalizations represent one of the greatest financial burdens in health care, both of which are reduced with direct practice. A 2012 study published in the American Journal of Managed Care found that personalized preventive care substantially lowered hospital utilization rates and reduced overall health care spending by an average of $2,551 per patient while reducing emergency room visits and urgent hospitalizations by 50-80 percent.

There are now tens of thousands of doctors caring for millions of patients, who have made the conscious decisions to get out from under the insurance system’s control. Most practices charge between $50 and $300 per month, an affordable price for many, but a barrier for others.

Until now, concierge medicine has struggled to gain widespread appeal. It’s understandably a tough sell for financially-strapped patients who can barely afford their sky-high insurance premiums. Enlightened employers, such as Amazon and Co., could disrupt the health care framework by adopting a system based on independent primary care physicians that work only for their patients. To serve their 3 million employees, Amazon, Berkshire Hathaway, and J.P. Morgan would need as few as 6,000 physicians, thereby showing a proof of concept for broader reform.  

When doctors work directly for patients, patients become empowered consumers in charge of their medical care. In other words, it returns to what most doctors used to do before the health insurance industry took over and changed the rules.

Dr. Thomas W. LaGrelius serves as president and chairman of The American College of Private PhysiciansLaGrelius owns a concierge practice and is paid directly by and works directly for his patients.