Dear PoPville – Alarming medical practice trend in DC

Photo by PoPville flickr user KJinDC

“Dear PoPville,

I am a DC resident living Logan Circle. Yesterday, I received a letter from the office of my primary care physician asking me to join a Privia Health membership in order to receive “VIP” treatment when going in for services at his office. It asked for $25 per month in membership dues ($40 per month if over the age of 40) and indicated that if I do not join, there is a chance that I will be relegated to being treated by a physicians assistant or nurse practitioner. The letter stated that this is a new business model many physicians are soon to follow, and that others have gone “cash only” in lieu of accepting health insurance. I am shocked and thought many of your readers would be too. I fear this may be a growing trend in the DC area and I’m not sure what role, if any, health care reform is playing. It seems like a way for doctors to make more money rather than book more patients.”j

Anyone else ever heard of a “VIP” treatment option?

88 Comment

  • With the current state of healthcare in this mess of a country, I can’t say I’m surprised.

    It’s only gonna get worse.

    • In my humble opinion as long as the GOP has any power in Govt. health care for us “little people” will get worse.

  • Mob-run health care. “Nice healthy body you got there. Sure would be a shame if something happened to it.”

  • That sounds ridiculous/extortionate. If I were the OP, I’d consider switching doctors.

    • I think it sounds like a bargain. When I was on COBRA I was paying something like $400 a month for a typically crappy health plan. My plan now is much cheaper (and heavily subsidized) but even crappier, in that it’s virtually impossible to find a doctor who is both part of the plan, and accepting new patients, and does not have any pending legal actions against them. So I end up out of plan, and paying for basically half of the actual cost anyway. How awesome!

      So $25 a month for premium service? I’d pay that just to be able to see someone in less than two weeks.

      • I’ve been going to these DRs for years and now have to pay $45-75 for the SAME level of service? Glad you have extra money but I haven’t had a raise in 2 years and all my health insurance costs keep going up.

  • ah

    I recall a NY Times article on practices like this from several years back. It’s not new, just new to you.

    It just responds to the basic challenge of healthcare, which is how to allocate scarce resources. You can wait (see Britain) or you can pay (see US) or you can accept reduced quality (US if you don’t pay).

    • +1. My parents in Colorado have been paying for “VIP” service for a few years. Their plan includes the cell phone number of the doctor, so that they can reach him when the office is closed.

  • I would gladly pay $25 if it meant that I did not have to sit in the waiting room for an hour every time I go to the doctor.

    To me, this is no different than any other premium service.

    • Except that this isn’t like shelling out for the Premium Car Wash at Mr Wash. This is health care. And the other side of coin is that people who can’t afford the $25 fee (sure to rise, by the way) get stuck perpetually at the back of the line, getting sub-par care or end up having to delay or not receive care at all (because that 1 hour in the waiting room now becomes half a day for them).

      Once again, poor people get the shaft.

      I don’t know what the answer is, but this just doesn’t sit right with me.

      • Some doctors are charging $2000 annually for this service. And the older you are, the higher the monthly fee, on top of your monthly insurance premiums.

        • My parents pay around this for their doc. He makes house calls if you pay so I guess it is worth it?
          Give me the single payer system any day of the week. My getting sick shouldn’t be a profit making venture.
          PBS had a good documentary – “Sick Around the World.” For every $1.00 spent on health care in the U.S. $0.20 goes to administration (including excessive CEO salaries). In Europe and with Medicare its closer to $0.08. These fees will only skew that ratio.

      • “Once again, poor people get the shaft.”

        Well, yeah, that’s the crux of the debate – are all people equally entitled to a certain level of healthcare? If yes, what’s that level, who pays for it, and how do we guarantee it?

        Until that question has a solid answer, poor people will continue to see services erode and disappear altogether.

    • i would totally pay for this.

    • $45-75 if you are over 40.

  • We got the letter, too. Rip off. Not signing up for it, would rather change doctors.

    However, I can’t say I’m surprised. Doctors (especially internists and GPs) get screwed by Medicare and are taking every opportunity to take in a little extra cash. Not that I agree with their taking action like this, but if it can keep them from dumping all their Medicare patients, then I can’t totally condemn them.

  • good luck finding a primary care physician accepting new patients…I called nearly 20 just a couple of months ago before I found one.

    this trend is not new, btw. And $25 a month is actually pretty cheap for this service. Not saying it is a good thing, but its hard to blame the doctors when insurance companies are such a nightmare to deal with…

  • You’ll have to get used to it; this is just the beginning. Health insurance companies have hung general practitioners out to dry for years now, and this is the response.

    Local practices are banking on the area’s high salaries to take advantage of these types of programs. Patients who do not want to pay $25 extra per month will seek out other practices that will take on extra patients, taxing them further.

    The upside is that if you pay for the “VIP” plan, you’ll likely get better service, since the practice will now be able to focus more time on fewer patients.

    There is a great article on this from a services and business revenue perspective:

  • me

    While doctors may be making more than the average person around here, they’re not necessarily rolling in it. They are getting screwed by the system quite often and find it hard to treat patients the way that they feel that they need to. That being said, I can see how it might be off-putting to see this in your mailbox. But many across the country are doing this- one, it allows for the patients to really try to stick with one doctor so the doctor can have a longer history of the patient and also be more familiar with them. Two, yes, it does help with a lot of the costs of running a practice and the malpractice insurance that has skyrocketed within the past few years. And three, if you are a person that would see a doctor more often than other patients (like I am), then I would tend to try it out so that I waste less of my time in the office.

    Unfortunately, it’s a growing trend across the country and it will start to pop up in most practices. It’s like this everywhere- remember when airlines started charging for food, drinks and baggage because the price of gas went up? The price went back down… but the airlines continued to charge for those things.

    I guess it depends on how valuable your time is to you.

    And no, I’m not a doctor, but I have friends that are struggling to pay off med school loans with their “hefty” checks that everyone thinks that they get.

  • Some of my best “doctors” have been Nurse Practitioners and Physician’s Assistant. But, I’m sure they will be in the same situation as MDs if they become swamped with everyone who cannot or isn’t willing to pay for “premium” service.

    • Emmaleigh504

      Some of my favorite “doctors” have also been PA’s. What kills me is that my current Dr’s office charges the same for seeing a PA as for seeing a specialist. There is no doubt in my mind that they do this because my insurance company under pays.

  • I’m sorry, but how does this work out with medical ethics?

  • This is a relatively new trend called “concierge medicine.” It’s a way to keep revenues up and patient volume down. To me, this is an alarming new development in health care.

    I disagree with the comment that this is no different from any other premium service. This is a general practitioner, not a specialist. Further, this is HEALTH CARE we are talking about, not a gym membership or a country club. If people cannot afford to pay the monthy membership premiums on top of their monthly insurance premiums, they may be denied access to a doctor. So, only the wealthy will have access to doctors while everyone else is relegated to seeing a nurse practitioner or physicians assistant? Come on.

    • So you want Doctors to get less money and more patients? Do you understand how little Medicare pays? They’re not denying care in an emergency. Plus, PAs and NPs can do practically the same job an MD can do.

      • Yes, I do want doctors to get less money and more patients. They get paid much more than doctors in other countries, and don’t deliver much better results.

        I also think there should be more medical schools, with lower tuition. Guess who caps the number of med schools? The AMA, aka doctors.

        • i am so glad you said that!

          to me, that is the solution right there. double med school output and give great student loans.

        • The problem is is that you have many Medicare patients who have a program that pays literally next to nothing. Therefore, the doctor has to start seeing more patients and passes on the cost to the insured. To see enough patients to keep the lights on, he has less time with each patient. The concierge service ensures people can have more time OR, if they can’t afford it, they can see a perfectly acceptable and competent PA or Nurse Practioner. Really, if you want someone to blame, blame the broken Medicare system.

          Sure, it’s their fault for having a god complex, but MDs also went through more schooling than just about anyone. Their debt is high (especially if they’re young doctors), and it’s not fair to say that they went into a “compassionate” field, so therefore they should not want money enough to pay to live. The same could be said about lawyers, because people have a right to lawyers. And nobody blames lawyers for being filthy rich. And sure, med school should be subsidized, but that would also come out of that tax payer’s wallet.

          And I’m willing to bet one of the reasons why AMA caps the number of med schools is for quality control, not some evil domination plot over peasants.

          • Teachers went into a compassionate field. 4 or 5 years of undergrad, plus masters, plus continuing education classes, plus the bonus of dealing with children 7 hours a day. They get less pay.

            Comapring doctors to lawyers is silly. Doctors are asshats with big egos, lawyers are scum with big egos.

            Surprised you forgot to toss in the medical insurance issue. My friends who are doctors pay almost a 1/3 of their annual sal. to insurance.

          • Emmaleigh504

            Health insurance also pays next to nothing; it’s not just Medicare. The only group that wins in the health care debate is insurance companies.

          • I agree that Medicare is fairly broken, but not because it has set reimbursement rates too low. Rather, private insurers’ reimbursement rates are too high. If Medicare does too god a job controlling costs, then docs drop it to make more money from private insurance.

            At any rate, Medicare reimbursement rates are effectively set by the AMA. The fact that specialists within the AMA have chosen to screw GPs within the AMA is unfortunate, but even so it’s not like GPs are starving, even if they accept Medicare. The mean pre-tax income of family physicians after expenses is $189K. If they received all of their compensation under the medical fee schedule it would be $169K. I would think that’s enough money to live on.

            We have a truly screwed up health care system, and physician pay is hardly the most pressing problem, but claims that docs can’t get by if they accept Medicare, or can’t get by without these “concierge services” are just not true. I don’t necessarily blame them for trying to maximize their income, but they ought to be honest in their reasons. “I want to make more money while working less” is completely understandable to me. It’s just not terribly noble.

          • Oops. I screwed up the link to the study. Here it is. Also, the sentence with the link shoud read “If they received all of their compensation under the Medicare fee schedule…”

            POP needs a preview button.

          • Wait, now… are the doctors struggling to “keep the lights on”, or are they entitled to a high upper-middle class income as a reward for schooling? And why on Earth should the AMA have anything to say about the number of medical schools? You might as well argue that the AFT has the right to cap the number of education schools for quality control. Or the ABA the number of law schools.

        • Also, no graduating med students want to become general practitioners. The pay is crap and the liability is high. Everyone wants to be a specialist, since they can often charge patients out of pocket and avoid the nightmare of insurance companies. We need policies that will encourage med students to become general practitioners. And we need to expand the use of NPs and PAs as they can deal with about 95% of the issues that people see a GP for. Doctors are not the evil ones here, just trying to find creative solutions to the mess we call our health care industry.

  • We must have the same Dr since I got the same letter recently (actually the Premium service is $75 per month.) Very disapointing since I have gone to this doctor for almost 20 years

  • There’s a serious shortage of doctors in DC, so they need to do something.

    PA’s and NP’s are pretty much doctors, usually better at listening to real patient concerns, and don’t have God complexes. For typical primary care concerns and checkups, I would have no qualms with seeing one instead of an MD.

    A key part of health care reform in this country is going to be filling the gap between nurses and doctors– PAs and NPs are here to stay, and you’re going to be seeing them more frequently. There’s just too much incentive for doctors to specialize rather than go into general practice.

  • We must have the same doctor since I got the same letter recently (actually the Premium service is $75 per month.) Very disapointing since I have gone to this practice for almost 20 years

  • Single payer FTW

    • + one thousand hundred million trillion hundred zillion (as my 4yo daughter would say)

    • How does that help? Explain. Doesn’t nationalizing health care mean longer lines and worse service?

      • Not neccessarily.
        Look at Germany or Scandanavia or even little old Canada.
        We pay a larger percentage of our GDP for health care and are less healthy – seems like the current situation is a lot worse than waiting an extra week to see a doctor.

        • You’re joking right? Do you actually know anyone who uses the health care system in those countries? I do, and anyone who can afford it comes to the US.

          Just for starters:

          Median wait time to see a specialist: 30 days.

          That’s median. That means half the time it’s longer.

          • pablo .raw

            I just waited 3 months to see my dentist here

          • Also, I don’t know if it’s a DC thing or what, but it’s impossible to find a doctor in this area that is taking new patients. After living here 5 years I finally got a hold of one, but he’s out in Alexandria and frankly not very good.

          • A lot of people like to scare the general population with horror stories about Canada, but it’s not that much worse than the U.S.. The only difference is that it’s harder to pay for extra-premium care and you get less choice in who your doctor is.

            I have migraines and go see a neurologist. When I go in for my appointment I book the next year’s checkup — that’s right, one year in advance, here in America. A routine checkup is 30-60 days, as is a specialist.

          • I have to make my annual lady-doctor appointment SIX MONTHS in advance, here in the good old USA.

            When I lived in France, you could usually see your own GP same day, or next day at the latest, and two weeks at most to see a fancy-pants specialist. I really believe the media has picked up a couple of outlier cases from single-payer systems. If the Americans who have lived overseas, and have friends and family overseas, combat this mistaken perception perhaps we can get closer to a saner system.

          • Are you the same Jamie who wrote this:

            I think it sounds like a bargain. When I was on COBRA I was paying something like $400 a month for a typically crappy health plan. My plan now is much cheaper (and heavily subsidized) but even crappier, in that it’s virtually impossible to find a doctor who is both part of the plan, and accepting new patients, and does not have any pending legal actions against them. So I end up out of plan, and paying for basically half of the actual cost anyway.

            And this:
            But that makes me all the more irritated when I do need to see someone and I realize how incredibly time-consuming and frustrating it is to just get an appointment in the first place, then wait, then wait, then wait, then hassle with my insurance company because they don’t want to pay, then file an MSA claim, blah blah blah.

            It’s amazing to me that Americans with shit healthcare think it’s still better than Canada or Europe. It’s really not. You and your employer are paying more for worse care.

      • I’m glad you asked that question, Timmy. Here…watch this short informational film…

    • Emmaleigh504


  • I got the letter too… from a certain pair of doctors in West End (my primary care provider). It does indicate, however, that they will not discriminate against me for not signing up for the Privia membership… We’ll see how that goes.

    • Yup, I got that letter too, and sent them a letter of my own telling them how disgusted I was that they are moving to this model and informing them that I would be seeking another practice. I’ve never been treated particularly well by them either (billing code errors that they refused to change, etc.), so I’m not exactly confident that paying the Privia tithe will make things better.

      Honestly? If I’m in need of a doctor after hours or feel that I need to be seen immediately, I go to an urgent care center and follow up with my GP if necessary. There’s a serious lack of these centers in DC; I schlep all the way out to the Virginia Hospital Center’s Urgent Care center in Arlington. These places are efficient and can handle most non-serious health issues quickly and easily.

      Granted, I’m a healthy 28 year old with no chronic conditions, so a yearly physical is about all I got out of them… but even if I was a frequent flier there, I am still loathe to embrace any model that gives “VIP” healthcare treatment to those willing to pay more. That’s like showing up at the ER with a fist full of $50 bills and bribing the nurse to cut the line.

  • What’s Elvis have to do with this? Does VIP service get you a shady doctor who prescribes all kinds of good pills for you?

  • It’s not new. My doctor joined the VIP program because it lessened his patient load and he could spend more time with his patients. He charges a flat fee per year but still accepts insurance. The fee pays for a complete physical. I have noticed that he does spend a lot more time talking to me without seeming to rush off to the next patient, I get appointments immediately, I never wait to see him and if I call him he’ll return the call quickly. He said he lost patients but gained new ones. I did it because I had my doctor for years and didn’t want to change. He gave a huge presentation about the change to all of his patients. Some people were upset because they said he gave excellent service anyway so why should they pay more for the same thing. Do I like having to pay more, no, but with insurance companies rejecting you if you fart too much now its an option.

  • Health care is a service. Doctors are not indebted to sick people. If they are offering this, it is because they are so stretched that they must do it.

    • Captain Obvious of the Non Sequiturs!

    • It isn’t a must…it is GREED.

    • That’s pretty naive. How about this — one day, a doctor discovered that using a premium to ferret out price insensitive patients (read: customers) led to higher profits for his business.

      The $45 or $75 generates profits, but it’s perhaps more valuable as a tool to attract patients willing to pay for procedures or additional check-ups that price sensitive patients aren’t. The result for the price sensitive is that care is downgraded to some degree.

      It’s reallocation of limited resources (a doctor’s time) to the “haves” of society. Obviously, you should be able to buy better care with your own damn money, but given the fact (as others have mentioned) that the number of doctors is kept artificially low by the medical profession, it reeks/acts as a racket.

      I’d be completely for boutique health services if they didn’t detract from services for the “have nots” of society. Increase the number of doctors. Let the free market supply the needed number of docs, which would allow for a broad spectrum of niche treatment options. As it is, less affluent folks are being put in a situation where they have to choose between average care (relative to what they’ve been receiving) and less-than-average care.

  • NPs and PAs offer fantastic health care. I’d take the cheaper route and see one of them. Often times their knowledge of basic primary care is on par with MDs in the same fields and their bed side manner and social skills are often far superior.

  • Concierge medical practices are the wave of the future. yes it creates another caste system of healthcare but it may help doctors improve the care they provide. I wish my doctor offered that, I am sick of waiting two months for an apt and then waiting 1.5 hours and then still having to call back 3 times to get any follow up information. yes, I know most people can’t afford this so I feel lucky. I believe in Obama healthcare reform but did anyone stop to think about what an influx of 30-40,000 more insured people is going to be like into drs offices in five or ten years? As it is now I am waiting THREE months to see a dermatologist in August in DC. I think DC will be especially hit hard as insurance rates in the District are higher than surrounding areas so drs may become even more scarce. The minute an OB/gyn practice goes concierge in DC I am going to be all over it. I would like more than 7 minutes for my annual exam (and yeah I timed it last year, its just so ridiculous). Not sure what the overall solution is…maybe the govt needs to subsidize med school so more people will attend and not have crazy loans?

    • Yeah, or just maybe the government could subsidize people’s health care and pay the doctors their salaries. Like every other developed country in the world.

      Yeah, works so horribly there. You don’t have to even give the doctor any money. They don’t even know what to do with it if you do.

      Really, is this THAT hard a concept?

  • I got the same notice from my last 2 doctors, so this seems to be happening a lot. The first was a meat market with a million too many patients waiting in front of me each time, so no way was I going to pay. The 2nd is much better, but I still resisted the fee. My health insurance is ~$500/month (though I only pay part of this – my employer pays the rest), and I go to the Dr. once a year for a checkup. I haven’t been sick enough for a Dr. visit in years (knock on wood), so paying an additional $25/month on top of the insurance seems crazy. At my last checkup, which was after I got the notice, the Dr. never mentioned the fee, so he seems to understand that it’s a rip for me, but I bet if I started needing more of his attention, it would be brought up. I hate thinking that he’s going to wait until I really need his services to drop the fee issue on me, but I think that’s the way it’s going to be.

    • I look at it differently. $25 a month is a drop in the bucket compared the ridiculous amount that the insurance already costs. I’m like you, I am healthy and rarely need to see a doctor.

      But that makes me all the more irritated when I do need to see someone and I realize how incredibly time-consuming and frustrating it is to just get an appointment in the first place, then wait, then wait, then wait, then hassle with my insurance company because they don’t want to pay, then file an MSA claim, blah blah blah.

      I’d gladly pay $300 a year to make some of that lunacy go away, and if you can use an MSA for that too which seems likely, it’s even less.

      • Yeah. Did it not occur to you that a government single-payer system would eliminate almost ALL of the headaches to which you refer?

        Would you be ok paying $300 more in taxes for health care?

      • again $25 if you are under 40. Otherwise $45/75.

  • My primary care doc switched to a concierge practice a few years ago. It sucks to have to find a new doctor, but it’s an economic and patient quality of care decision on their part – I imagine that I might do the same if it were me. If I were older or had significant health problems, I would be willing to pay the retainer (or whatever they call the monthly fee), but since I’m relatively healthy I go to the CVS Minute Clinic when I need something now. In any event, everyone knows that the more money you have in the U.S., the better the medical care that you can access.

  • My doctor is a well-known, in-the-know type doctor in Dupont Circle, who treats a mostly gay clientele (many of whom have HIV) and he provides superior service, accepts certain insurances such as the federal Carefirst PPO and my current plan, United Healthcare, spends plenty of time with each patient, I saw him last week for about 10 minutes and I really had no complaints, and doesn’t charge this “Lexus healthcare” fee.

  • My doctor does this but it’s only $25 per year. I paid it.

  • I lived in a city further north of DC for many years, and it was pretty typical of doctors there to not accept any insurance at all; it was up to you to submit claims directly, meaning I usually got reimbursed $60-80 for a $100-120 visit.

    I don’t really see a problem with that . It saves the doctor time and money in filing the insane amount of paperwork for claims, and you get better and faster service as a patient.

    If I couldn’t afford it, I would have gone elsewhere. I know that seems unfair to those who cannot pay, but this is America: home of “unfair”.

    • That is unfair.

      • It may suck for some patients, but there is nothing “unfair” about a doctor refusing to accept what an insurance company will pay. It’s called capitalism. If these doctors could not find patients willing to pay out of pocket, they wouldn’t be doing it. I know a number of people who go to doctors – and dentists – who don’t accept insurance.

    • Would love to see you sick with out your checkbook. Selfish douche.

  • I thought Obama was supposed to provide free health care for all Americans (and illegal immigrants.)

  • claire

    I’ve heard of a system some other countries use where you pay your primary care physician a monthly fee like this for every month where you *don’t* have a health issue. Don’t quote me on the specifics because this was just something that I seem to recall coming up in conversation, but the idea is that it incentivizes doctors to provide good enough yearly check-ups that you rarely, if ever, need to go in otherwise – and if you do, the doctor has a vested interest in fixing your problem so that you don’t come back in.

  • The “discounted” rate schedule for “existing patient pricing “ is $25 (under 40) and $45 monthly for the Gold plan and $75 for the Platinum plan. The letter indicates that when the initial memberships sell out the price of a new membership will “significantly increase.”

  • I would just go to Minute Clinic at the CVS. I have insurance, but go there if I need a Z-pac or some other script. They also do immunizations. Put a few stitches in, etc. No wait and it’s very reasonably priced.

  • Another reason to invest in healthcare and education — with accountable systems and rewarded professionals. Our economy is to military-industrial.

    Money is running like water to defense contractors though. More criticism and focus on the contractors and less on health and education please.

  • pablo .raw

    I believe society works better if most of the people is healthy; if most of the people is going to get deficient healthcare because they can’t pay the extra cost, lots of diseases are going to be floating around, remember we all use the metro and go to the mall and that is why government should be involved…

  • I love the random Elvis photo that has nothing to do with the topic.

  • The concierge care is one thing but the pay up front is another. Doctors have negotiated fees with insurance so your overall care is less, and can charge much more on the open market. so why am I paying for insurance as well if the doctor is just going to charge me the cash-only fee then let me fight for the reimbursement with my insurance company which is only going to cover a fraction of my cost (i.e. their allowable cost per the negotiated rate). I would find another doctor.

  • Interesting that these DRs now have the same rate schedule as Washington Sports club.

  • This is becoming a common practice, and is nothing people should really get upset about. Private medical and dental providers are facing a big problem currently. While their costs continue to go up quite a bit (remember they are paying for health insurance too for all their employees which can be astronomical)their revenue has not been rising. So they are getting squeezed on both ends, higher costs, less money coming in. So they need to raise extra money some how. This will also help thin out their patient load which will help a bit. Because even though they will lose some patients, it is generally not high revenue producing patients.

    • “While their costs continue to go up quite a bit (remember they are paying for health insurance too for all their employees which can be astronomical)their revenue has not been rising. So they are getting squeezed on both ends, higher costs, less money coming in…”

      That is the situation ALL businesses are in.

      Thank you DR. RT!

  • I got the same letter, with the $45 charge.

    Interestingly, my partner, who is also a patient at the practice, did NOT get the letter.

  • It would help if half of you had any clue what you were talking about. There is a reason you get better care, attention, service, etc. for your dog when you go the vet than when you see your doctor. I’m not rich. I’m not even close. But I know my doc has to see way too many patients to make ends meet and that the current healthcare system forces him to run patients through like a fast food chain.

    The service in question here is for a bunch of stuff your doc currently doesn’t do. It’s additional services and resources to help you live better. God forbid your doc sells you something highly valuable at a reasonable price to help you lead a better life and help him stay in business. This is why healthcare is so screwed up in this country. A bunch of people whining and being entitled. When asked to crack your checkbook and actually pay for something, it is evil out of the gate. No one is rationing care or discriminating here.

    Just wait and see what happens if docs don’t find ways to supplement income and adjust their practice patterns. There is already a shortage of primary care physicians. Why? Because they get paid terribly and are forced to work endless hours just to keep the practice afloat. Meanwhile, not actually helping their patients. Don’t know about you, but charge me a premium. Give me some extra support. A better product. I will take that over the alternatives.

    • ‘This is why healthcare is so screwed up in this country’

      No, healthcare is screwed up because it is not able to be run like a capitalist business, yet we cannot figure out a way to run it well as a socialized system.

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