Letters from Maine

One Size Should Fit All


One of the things that I enjoy most about practicing in semirural, subsuburban Maine is that it allows me the privilege of caring for children representing the entire socioeconomic spectrum. I may begin the morning peering into the sore throat of the daughter of a former governor and finish the day by putting a cast on the son of an underemployed bloodworm digger.

There are four pediatric groups here in Brunswick and, although my partners and I may quietly feel we provide the best care in town, the truth is that no practice is considered the office to visit by the economically blessed elite. Nor is any group thought to be on the wrong side of the tracks.

This diversity is intellectually stimulating and keeps us on our diagnostic toes. It also gives us the warm fuzzy feeling of being community servants. That fuzziness comes with a price, though, because it is no secret that state-funded reimbursement often falls short of our costs. The unfortunate families who have slipped into the cracks between private and public funding present an even more troubling challenge.

As you can imagine, this situation has not gone unnoticed by our CEO, who sends us regular e-mail reminders that our patient mix is getting too heavy on the Medicaid side. We tend to ignore his warnings because we all enjoy seeing infants and the bulk of the new babies seem to be coming from underfunded families.

When pressed to close my practice to Medicaid families, I have been able to negotiate a temporary compromise that limits new patients to those residing in Brunswick and any town that abuts us.

I imagine myself to be a new-millennium Robin Hood, venturing deep into the Sherwood Forest of community pediatrics bent on robbing Peter to pay Paul. By trying to provide the same high-quality care to every patient in the most cost-effective manner, I hope that the occasional overpayment by some third parties will offset the underfunding by the rest.

Those of you who still remember enough high school math to do your own taxes may fault my economic logic, but so far it works for me and allows me to continue seeing the exciting mix of patients that I enjoy.

What doesn't work for me is the concept of concierge care that was the focus of a recent PEDIATRIC NEWS article (“Concierge Care Gives Time for Kids,” September 2005, p. 1). This is a free country, and any of us can carve out a high-end economic niche if we choose to, but the notion of skimming off the rich cream of economically advantaged families troubles me.

The standard of care for outpatient pediatrics demands availability—availability that cuts across socioeconomic strata. Regardless of who funds their care, at 10 o'clock at night all patients registered in our practice will have the same access to me or my fellow pediatricians in the community. As I interpret concierge care, it ducks this challenge of providing quality pediatric care to all children of the community.

It smacks of elitism, and I suspect that, because of its narrow scope, concierge care actually fails to provide the quality and availability that it promises and that my partners and I offer without surcharge. We don't ask our patients' parents to sign a contract that includes coverage gaps for our vacations.

We encourage families to develop a close working relationship with one physician, but my partners and I work very hard to create as seamless a coverage arrangement as possible. This means maintaining close communication with each other and trying to standardize our care without shackling our unique clinical personalities.

I'm confident that the majority of families here in Brunswick will say that our system works. Concierge care, on the other hand, serves neither the community nor the subgroup it has isolated. In my view, it robs both Peter and Paul.

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