By Laura Turner
SDN Staff Writer
“Boutique” or “retainer” medical practices have been steadily growing since 2005. In this practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. (1)
While it is growing in popularity, some physicians, ethicists, and policy makers are concerned about the trend. (2)
“Concierge care…is like a new country club for the rich,” Representative Pete Stark, Democrat of California, said at an economic committee hearing to Congress in April 2004. “The wealthy will pay for exclusive access to quality care, and everyone else will continue to have inferior access to primary care physicians, specialists, and basic medical advice.” (3)
Proponents of concierge medicine, on the other hand, say that it enables doctors to provide the best possible care and remain in a clinical setting. Dr. Bernard Kaminetsky, an internal medicine physician in Florida, told the New York Times he would be working for a pharmaceutical company if he hadn’t been able to move to a concierge model. “I’m really helping a lot of people. I feel good about what I do,” he stated. (2)
To learn more about this growing trend, the Student Doctor Network spoke with Arney Benson of SignatureMD located in Santa Monica, California. SignatureMD helps primary care physicians transition their practice to a retainer medicine model. He is a graduate of the Massachusetts College of Pharmacy & Allied Health, and has over 25 years of healthcare consulting experience. He currently serves as President of AB Consulting and Senior Vice-President for Physician Development for SignatureMD.
How do you define “concierge” or “retainer medicine”?
Retainer medicine, sometimes referred to as “concierge” or “boutique” medicine, is a different type of care delivery experience in which physicians limit the size of their patient panel in order to provide more proactive health care services and greater convenience and access to their patients. Patients pay a defined fee to experience this type of care, the specifics of which vary among physician practices.
How do retainer practices fit into the current health care structure (i.e., Medicare, insurance companies, etc.)?
A retainer practice focuses on patients in a proactive continuum of care. You get to know your patients well and help them to coordinate their healthcare. Instead of building your practice up to a panel with thousands of patients, you will have a panel between 300-500 patients. While you can still accept insurance, you will also assess a yearly membership fee from your patients.
This retainer model typically requires fewer supporting personnel because of the lower patient load. Therefore, you will have fewer patients and fewer staff to manage.
The retainer practice also offers a different service level that might include cell phone and/or e-mail access, same day appointments, longer physicals and routine appointments, coordination with fitness and nutrition providers and 24/7 access.
However, any practice continuing to participate in insurance plans must take into consideration the view of retainer fees by those insurance providers. When the legality of retainer medicine comes into question, it’s typically because an insurance provider has a provision that does not allow the patient to be billed a fee for such management. It is wise to work with a team of legal advisors, or a company like SignatureMD, to mitigate your risk.
One needs to always remember that a retainer fee is for non-covered services. If you stick to that, there should be no added issues for the current carriers.
Arney Benson
What do you see as the benefits of the retainer medicine model for patients?
Many patients complain today that by the time they get in to see their primary care physician, they have 10 to 15 minutes to explain their concerns before the physician is exiting the exam room. Your patients need a relationship and a physician that knows them and thinks about the bigger picture. A retainer practice allows for more time and more questioning. A retainer practices focuses on prevention and the overall continuum of care. Many physicians who practice in this manner also include their patient in the process in a more educational manner so they work on wellness plans together and discuss options in an informed (and un-rushed) manner. If you were the patient, wouldn’t this type of care be what you prefer?
What do you see as the benefits of the retainer medicine model for physicians?
Here are the benefits we find:
- Increased income
- More time to spend with patients: This increased time available to spend with each patient will allow you to address all of their problems, rather than just one or two. It also gives you the luxury of having the time to truly explain their diagnosis and treatment, which will enhance the patient’s trust, education, compliance, and satisfaction.
- More compliant patients
- Patients who value and respect their physician
- Less time at the office
Our company, and others like it, also provide help with practice management, such as:
- Secure online electronic medical records (EMR)
- Ongoing patient marketing
- Help with business operations
- Help with regulatory and legal issues
What types of personalities enjoy a retainer practice versus a more traditional structure – do your doctors tend to be more entrepreneurial, for example?
Not necessarily more entrepreneurial … but what that physician is: a forward thinking healthcare service provider that wants to deliver a quality of care model, and not the run of the mill reimbursement model (which is) stealing the only commodity necessary to function well in medicine, and that is the time factor.
The typical physician, if there is such a thing, that would do well has to have a driving force to change the status quo and deliver the kind of medicine and diagnostics as he or she sees fit and not be buried under the bureaucracy of the reimbursement model of short time diagnostics and paperwork equal to the time, and sometime more, than the treatments the physician delivers.
Is this a model that a physician could enter immediately out of residency?
Typically no. However, one could start a retainer practice, advertise the concept and build it from there. Realistically, that would take the better part of 24 months to 36 months to get to a reasonable patient enrollment to support the overhead of an office and earn a living. However, a better suggestion would be to seek out a retainer medical clinic for employment to build a relationship with patients so in 3-5 years, once your “affinity” relationship is such to support a retainer model, you can consider a boutique or concierge model. By the affinity relationship I mean, would the patient be willing to pay a retainer to keep you as their primary care physician. We find that a good professional relationship takes between 3 to 5 years to establish.
How would you anticipate retainer medicine changing if universal healthcare is implemented?
I think that’s it’s not a matter of if universal healthcare were to be implemented but a matter of when.
That being said, the retainer practice model will continue to gain popularity, as it has, as an example, in Massachusetts where healthcare for all has been implemented for the last two years. The reasons are many, but the driving force for many patients is that they are already frustrated with the existing system, including the wait times and care they receive from a 5 to 10 minute appointment.
The system will be a tiered system where everyone will have healthcare and those that wish a different service offering will seek out an alternatives, i.e. retainer model or a different delivery option for their primary healthcare needs.
Footnotes:
1) Jeff Levine, “Boutique Medicine: For Your Well-Being? Or the Doctor’s?”, AARP Bulletin Today, April 18, 2008 (http://bulletin.aarp.org/yourhealth/policy/articles/boutique_medicine.html)
2) Abigail Zuger, “For a Retainer, Lavish Care by ‘Boutique Doctors’”, New York Times, October 30, 2005 (http://www.nytimes.com/2005/10/30/health/30patient.html)
3) Congress of the United States – Joint Economic Committee Hearing, Opening Statement, Representative Pete Stark, April 28, 2004 (http://www.jec.senate.gov/archive/Documents/Releases/starkopenstate28april2004.pdf)
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I didn’t even know this kind of healthcare option existed until reading this article. Is this a service that aims to gain patients that are wealthy (about how much more will this cost) ?
this just seems like a new “trend” for the wealthy, but since +40% of the salary is going out the window for today’s physicians, i surely cannot blame them for trying to earn a bit more by targeting the “rich”.
i also did not know that such practice existed in real life. (since that new tv series about a blacklisted doctor making house calls for the wealthy community aired recently, i thought such thing existed only in the tv world)
What people including Pete Stark do not understand is that the yearly retainer fee in many cases is not too high. Yes it can cater to the rich, but it can be quite affordable for the middle class and there are many instances of retainer practices with mostly middle class patients. To simply dismiss it as a scheme for better care for the rich would not do it justice.
Great article. People need to realize that this is a win-win for the doctor and the patient; even the insurance company wins. You can go to a center of excellence like the Mayo or Cleveland clinics or UCLA… and get an executive physical for $3,500 or you can get a concierge doctor and get a comprehensive physical and 24×7x365 personalized care for half that price. The statistics indicate that 5% of all executive physicals surface a life-threatening condition! Statistics have also indicated that patients under concierge care programs have 75% fewer hospitalizations than do like-age counterparts (granted there is some selection bias). I think that demand for personalized healthcare will skyrocket with the perfect storm of the aging baby boomer population, shortage of primary care, and the move to more federal involvement in healthcare.
I’m curious to know what happens when one of the retainer patients becomes seriously ill and requires a lot of coordinating of care. I’m betting the patient is dropped faster than – insert cliché here -
No question that primary care reimbursements need to be increased and we need more primary care physicians – but this is a very troubling trend – it smacks of entitlement – for the docs not the patients – Entitlement to an easy life and easy cash. 300 patients X $1,000 each per patient = $300,000 + the added fees for patient visits. Nice work if you can get it – but you shouldn’t have been given that spot in medical school – it should have gone to someone who actually wants to practice medicine. You should have gone to b-school.
Why would someone be dropped because they’re ill? Seems like they’ll probably get better care coordination than a patient that has a 10 minute doctor.
Missy, doctors are not priests. Why would someone that has spent at least 11 years in college, medical school and residency going into 180K of debt want to work for the same amount they could make with a 2 year PA degree?
Haven’t you been paying attention — NOBODY wants to go into primary care because insurance companies and Medicare have squeezed them to death. Primary care is a great field and possibly the most complex, but NO STUDENT wants to go into it because they can’t afford to. Until something better comes along, this may be one of the few models that encourages the best students to go into primary care where they belong.
Further, if you’re a patient with money, why shouldn’t you expect better care than the average Medicaid patient gets?
Missy, perhaps you’re misdirecting your concern? If we had universal health care and everyone was guaranteed a base level of quality, would you still have a problem with this model?
Let’s not beat around the bush or lie to ourselves people. This is health care for the rich, plain and simple. Doctors want a better, more flexible lifestyle with better compensation, so they pursue concierge medicine. They don’t want to waste 3 hours in surgery on an injured construction worker, worrying whether workers comp is going to pay their bill.
The poor get screwed, the rich win–just as things always have been.
A lot of people don’t become doctors purely (as in 100%) out of some innate, endless source of altruism. This is the sad truth.
Dear Tony, what exactly is “base level”? You mean, low, crap level, right? You do know there’s a doctor shortage?
First, I have to agree with Spencer…it is a great article!
Using Spencer’s estimate of a $1750 retainer for the year (let’s round up to $1800), that’s $150/month. Considering the fact that many insurance premiums are much, much greater if you have pay on your own or are on COBRA, that is a much better deal for the patient.
Since most places are putting more and more costs of health care to their employees, it is seeming more and more attractive.
I would actually prefer to just have plan like this and a catastrophic medical plan that covers hospital coverage, that fighting with an insurance company about an office bill.
I think that most patients that are able to see a doctor when needed, will probably seek out care only when needed, and not wait until too much has to be done due to poor health.
A few years ago, a friend of mine was paying over $600 a month for coverage for his family – wife and 3 kids…and that was to insurance companies…he still had co-pays, and any other crap that insurance companies wouldn’t pay…
So Missy, think about my friend here…he is paying over $7200, plus co-pays, plus whatever the insurance companies won’t cover…and you are quibbling about $1000 a year?
I’ve a long way to go, but this is something I will definitely look into, and it won’t be for the rich…it would be more geared towards family medicine and the middle class. Also, I would not just drop my patients like a hot potato if they require more specialized care.
Who says that doctor isn’t practicing medicine? I’m guessing you aren’t even in medical school yet, and I doubt that you are even in practice…I’m sure that your demeanor will change when you are.
I believe that a seriously ill patient could be dropped at the conclusion of the yearly contract – because a seriously ill patient would require more care from the concierge than the concierge wants to spend – the whole reason for becoming a concierge in the first place. Concierge practice is cherry-picking at its most refined. It seems the whole point of concierge practice is to practice as little medicine as possible while still making a pile of cash. I guess they didn’t have the scores, personalities or connections for a ROAD or plastics route and found another way to Easy Street.
It’s also what insurance companies do – drop subscribers when they prove to be a heavy user.
And of course physicians need to be compensated for the level of education they must achieve and the stress and time it takes to practice – but with so few primary care physicians and so many of those choosing a concierge practice – the level of care overall will decline and it will affect society in profound ways. Do we really want to go the way of third world countries – too bad you don’t have the money – suffer – or beg for charity care – and oh, we’ll only provide charity care to those who meet our criteria of worthiness for such care.
Andy, I understand the statements. However, I am not following the statement about there being a doctor shortage. Is the implied statement that because there is a shortage, primary care doctors should work more and for less?
Literally, working for less is not possible — for instance, when the CDC says that patients should have a vaccine (say Gardisil), but then insurance companies don’t even pay the wholesale price of the vaccine, you can start to get an idea of the money losing situation primary care doctors are in right now.
This is the real free market in medicine, not the hodgepodge we have right now. The lower end of medicine is underserved by this practice, but that is because of ubitquitous medicare and medicaid, which are “free” and therefore crowd out the private competition. Lift those restrictions, and the implications are stunning.
For one, a surgical abortion (not covered by insurance) costs only $468, as opposed to $9-17,000 for the simplest delivery. Government care is hurting the poor by restricting the development of free markets in medicine at the lower end, keeping it an exclusive domain of the rich.
Kris,
Your model of paying only the retainer fee to the concierge does not take into account the cost of the individual visits to the physician. The retainer is just to be a patient – one comprehensive yearly exam and the privilege of having a doctor to see without a long wait for an appointment. You still pay for office visits and any treatment required. In many of these practices no insurance is accepted, so you will pay the full price of an office visit (not the insurance company-negotiated reduced price) and apply for reimbursement as out-of-network which will reimburse 60% of the “usual and customary.” So, you pay the concierge his $300 fee for a routine office visit. The insurance company’s “usual & customary” rate is $120 for that same appointment. It reimburses $72 less the co-pay of $35 for a total of $37. That means the appointment cost out of pocket $263. Let’s assume some minor ailments that require quarterly follow-up – so 4 routine visits per year in addition to the comprehensive exam included in the concierge fee. $263 X 4 = $1,052.
It’s going to cost more out-of-pocket than premiums + co-pays + catastrophic care insurance than concierge + cost of office visits + routine treatment + catastrophic care insurance. Some people will be able to afford this. Many will not. In many circles today (perhaps not any you visit) that extra $2,800+ per year is absolutely impossible. Even if they give up cable TV, all entertainment of any kind and eat only beans and rice, all clothing bought second hand or through the charity of some religious organization (if you meet their criteria of worthiness). Do you really want a world that provides a lush living style to all physicians and leaves their patients a subsistence life. That’s what the extreme of this model asks.
My grandparents paid $25 for a routine appointment with their doctors – there was catastrophic care insurance for everything else – but the routine care was affordable. This model is not affordable routine care for most Americans. It asks that the middle class give up some part of their modest middle class lifestyle in order to provide a physician an even greater lifestyle. And, yes I know the years and expense it takes to be a physician and I do believe that WE are entitled to an income appropriate with that endeavor. Fix PCP reimbursements. Pay for the “thinking” not just “doing” of medicine. Concierge medicine is not the answer.
$25 back in the day or $25 today?
I guess I don’t see it that way. I think it can also be physician-dependant. I can only talk for myself…but I would personally prefer to not to deal with insurance at all if I am able to build up a practice like this. I would also definitely not be charging my patients $300 an office visit if I am charging a retaining fee.
$25 back in the day – sometimes a bit more for longer visits – that was like 30 years ago.
Missy,
I really admire your passion and commitment to humanity and primary care. This discussion is really great, and I agree totally with what you are saying. Are you a practicing physician, resident, or student? I will hopefully be starting medical school in 2010 and would love to get to speak with you and learn about your track so far and what you currently do.
I don’t see much harm in such a practice, and it doesn’t necessarily need to be solely for the wealthy. If a physician wants to be slightly more altruistic or wants to expand the swath of their practice, the concierge fee would go onto a sliding scale. As a veteran who has dealt with being a patient at the VA, knowing that is what universal care will most likely look like, I wouldn’t mind paying an outside fee for better access. Take the private health care system as a whole and you see a stifled system. Now take the government health care system and you see a system stretched beyond its limits, beyond stifling. Now take that system and expand the skeleton out to overarch an already stifled private system and you’re dealing with serious implications. I can definitely see the concierge trend expanding as the public gets sick of the many limitations that will without doubt come with universal health care – which is still sorely overdue. I would have no problem paying that fee, so long as it logically fit my economic abilities. Of course I don’t believe the scale should only favor the wealthy, but even if it does (and it really always has), that’s slightly less volume for the remaining majority of providers to deal with.
I think Lobo et al have it right. For starters, the rich already have better healthcare and better access to it anyway. Secondly, there are only so many “rich” people to support the boutique doctors. Thirdly, there is already a population (albeit small) of doctors that do not take insurance and have a fee schedule listed out front. That’s what I call transparency. If a doctor wants to shirk the annoyances of insurance, then so be it. If they want to substitute an always-on cell phone for an office, then fine. It will either become wildly popular if it is indeed the superior method of delivering care, OR it will go back to being a niche thing for those who can make it work for them. Not sure what the big deal is…
I am watching CNN and right now, and while speaking of Michael Jackson’s death, they were exploring boutique doctors. One doctor they interviewed charges $150,000 a year for this service but is on call 24/7. She said the strangest visit ever was when some actor was afraid he had contracted a STD; she had walked into a “very strange party”
In contrast to concierge practices for the affluent only, there is a growing movement of what are called “direct primary care practices” or “direct medical homes.” These practices provide concierge-level care but at everyday prices in lieu of insurance, not on top of insurance. They are premised on the fact that using insurance as a payment system for routine primary care almost doubles the cost of that care and creates the need to see so many patients that much of the care is simply shifted to expensive specialists and hospitals due to lack of time and access at the primary care level.
For instance, Qliance, the direct primary care practice I’m affiliated with in Seattle, charges a flat $39 to $79/month depending on age (slightly higher if on-site hospital rounds are included) for unrestricted primary care, preventive care, chronic disease management, and coordination of any necessary outside specialist or hospital care. X-rays and many lab tests are included. Prescription meds, as with any other ancillary supplies, are sold at our wholesale cost to patients if patients want to buy it from us for their convenience. The practice is open seven days/week (12 hours a day on weekdays) for same day, unhurried (at least 30 minutes allocated) office visits plus email and 24×7 phone access to a physician. There are no co-pays, deductibles, co-insurance, pre-screening or long term contracts. If we don’t add value, our patients will quit. So our incentive is to keep patients healthy and provide great access and service.
Most patients combine this kind of direct primary care practice with a low-premium, wrap-around insurance plan of some sort – often a high deductible health plan. By eliminating the insurance middleman for inherently inexpensive routine primary and preventive care (90% of what people have to see physicians for) and using insurance only where it adds the most value–for covering unpredictable, expensive or catastrophic care–individuals are actually saving 40-50% in out-of-pocket cost for comprehensive health care while employers are typically saving 20-35%. This is what true health reform should be about, not simply expanding expensive “soup-to-nuts” insurance coverage and trying to find a way to pay for it.
We often meet with med students from UW and they tell us that this direct primary care model gives them renewed hope in choosing primary care as a career. Experienced physicians, tired of seeing the 25-35 patients a day necessited by having high insurance-reimbursement overhead and low insurance reimbursement rates–but whom don’t want to become a concierge doc catering to the rich–are converting to this model. They can make market-competive compensation even at these low fees, but more importantly, then can spend the necessary amount of time with patients to really take care of them rather than having to refer them off to expensive specialists and hospitals because they don’t have the time to do what they are trained to do. It’s really back to the old Marcus Welby days of care, but with 21st century technology support.
I wonder if concierge medicine might influence the patient-doctor dynamic in a negative way. Currently, ideally, the physician provides the care and prescribes the medicine that he or she feels is appropriate for the patient. If the patient does not like this care, they can try to find another physician. With a large patient base and no money on the line until service is rendered, physicians can be free act in an ethical and legal way (for example, not prescribing pain medication to a patient who does not need it). If, however, the patient belongs to a concierge service (which for all intents and purposes is a club to which patients belong), the patient might feel that he or she has the right to DEMAND a certain type of care, or certain prescriptions, from his or her physician. Additionally, the physician may feel pressured to comply as he or she has already accepted a fee from the patient without yet providing a service, and stands to lose one of only a few patients in his practice (or club) plus the future retainer. I realize that there are laws and ethics that all physicians should follow when providing care, but this has to put the physician in a difficult position. No longer are physicians their own boss, now they may feel that they must cater to the patient in both accessibility and choice of treatment provided. I’m referring specifically to the concern that MJ’s doctors may have prescribed him pain killers in order to keep his business, which may have ultimately led to his death. Whether this is true or not, it is certainly a believable scenario and the business model may be to blame.
ramengi – as a practicing doc I can tell you that it is not likely to change habits for these reasons:
1. you must prescribe what is medically appropriate no matter what your relationship is financially, otherwise you put your license in jeopardy.
2. doctors already feel pressure to do what a patient wants because when you don’t the patient complains and can even rate you lowly on sites like yelp even if you’re doing the right thing (which is an entirely different story)
3. bad doctors will prescribe whatever for whomever. they’ve existed for as long as there have been doctors, no matter the model
missy – your argument fell apart with $25 “back in the day”
Here’s why:
$25 inflation adjusted from say 1970 (”back in the day”) to 2008 is $137.15. ( used the calculator at http://www.westegg.com/inflation/ )
average family physician office visit payment today … wait for it … somewhere between $50-$70 depending on your source. So (inflation adjusted) doctors are paid 1/2 of what they got in 1970, but their overhead has increased significantly.
Back in 1970 a doctor had at most 1 front office employee and 1 back office employee. now you need at least 3 employees: 1 in front, 1 in back and 1 for billing. that increase aside, then you’ve also got increases in rent, employee wages and benefits, all the materials needed to keep the practice running, etc. etc.
don’t bag on doctors that are trying to make ends meet while also improving quality of care. you’re tilting the wrong windmills … go after the for-profit insurance companies that take ever increasing amounts of your healthcare $ for ‘administrative overhead’ and shareholder payouts
It’s interesting to compare the AMA Principles of Medical Ethics and the principles of concierge medicine.
The critics of this practice are driven solely by the political belief that people who are successful need to be punished. Doctors who have found a niche that is beneficial to them and their patients are of course going to get criticized by those who believe we need a “communal” health system. Communism never works. Communal retirement, aka social security, is the biggest burden on american workers nowadays. Why isn’t anyone trying to go after that? It is because many people want a communist-like system here in America. I ask them, why don’t they go to China? To argue that retainer medicine is evil or harmful because doctors are compensated more is asinine. Any argument which ignores valid contrary evidence is null. The only arguments against retainer medicine is that 1) doctors are paid more so some can’t afford it 2) Some people will be ‘dropped’ by their docs when the docs switch. Seems pretty narrow minded to count something out for those two minimally relevant reasons. The heart of the issue is improvement in quality of health care delivery and access. As physicians we need to ensure our opinions about politics do not jade our understanding of factual evidence in our professions. Evidence shows retainer medicine results in far better health care for the patience as well as improved lifestyle and working conditions for doctors. Further, we critically need to allow our minds and attitudes to remain independent of the political forces which surround us, that is if we want to remain free and independent of their powers.
Joseph, Would you like to reference those principles, or a comparison for the rest of us?
Concierge medicine is one of the most innovative ideas of medicine for this upcoming economy. If socialized medicine pursues as it looks, it will take weeks, maybe even months, to see a physician for an illness. And if a CT/MRI is needed, you’ll be lucky to have an appointment within a few months. Countries in Europe and Canada are experiencing these problems with the same health care that Obama is trying to introduce with socialized medicine. So with an extra cost, I think this program will be dramatically appreciated in the future.
Also, this will help physicians earn a living. People fail to understand the years it takes to earn a medical license. With 8 years of college/med school loans and a 3-5 year residency program making only $35,000/yr, physicians are left with an average $300,000 debt.
This sounds like a great idea. I live in North Dakota where medicare reimbursement rates are much lower than the rest of the nation. The current public policy option that will reimburse at medicare rates will bankrupt our hospitals and do nothing about cost controls or litigation limits.
Sounds like a good idea to make up for lost income by charging an access fee so that student loans can be paid off.
Basically this guy is trying to anticipate universal healthcare in the US and bring to the US what has already existed in other countries with universal healthcare: an elite care service for an additional price.
Physicians are the ONLY group of professionals as a whole that have allowed others to tell them what their services are worth since the advent of Medicare. Shame on us. Let the naysayers graduate medical school, go through residency, and then try to start a practice. Let them accept Medicare or any other type of insurance coverage that they would like. They will find out how difficult it can be to earn a living and still be able to spend time with their family.
Prior to Medicare, physicians set their own prices for their services. Prior to Medicare, the American public as a whole, paid for their primary care. There is nothing wrong with asking someone to pay for their primary care. I’ve found that those who pay nothing for their care are less likely to be an active participant in keeping themselves healthy. If you give someone something, they are less likely to appreciate it than if they contribute something themselves. That is what is wrong with the logic that some in healthcare espouse today. They have the “let’s just give everyone healthcare for free attitude.” Some do need help in attaining healthcare, but out of those 50 or so million who don’t have coverage, over half don’t have it because they choose not to and could afford it if they wanted.
I am in Primary care, and I am practicing in a model not too different that these concierge practices. I do not accept any insurance. My patients pay my fee at the time of service, and I provide them the documentation that they need to file a claim with their insurance company. I spend more than 10 minutes with my patients, and am actually able to build a relationship with each one because I’m not as rushed as the doc who runs a medicare factory and has to see 50 people/day.
And for the little ninny who has been on her high horse, bashing concierge medicine as yet another tool to deny the poor care, I would tell her that I actually provide more indigent care now than before I went to this type of practice. Before I converted my practice to one that doesn’t accept insurance, I provided minimal indigent care (maybe 2-3 patients per week) because I did not have time. Now I see at least 10 patients/week that have NO way to pay me, and I do not ask for payment. So, grow up, and practice a little before you start pretending like you know what goes on in the real world.
Dear Missy,
I feel quite compelled to ask you, as others already have, what your relationship is to the medical field. After reading your comments, it is crystal clear that you are not on the inside but perhaps a starry-eyed pre-med lacking the understanding and info needed to contribute relevant commentary. If you had ever spent a single day practicing medicine (not to mention endured the years of training that allowed you to arrive at that day) you would have a erspective. Your arguments are so flawed in so many ways. This was most evident by your statement implying that retainer medicine is “doing” and not “thinking”. It’s actually the exact opposite. Take a busy PCP office practice. Doc sees 20 patients before lunch -yeah, it happens. Spends 3-7 minutes with each patient. Some cases are simple: drug adjustments, follow ups, poison ivy that you’d recognize with your eyes closed. Others are not so simple but maybe would be if you had time to go back to the basics that you learned in med school – complete review of systems, complete review of meds, complete physical, complete converstation even. Then time to…think. Our current system doesn’t afford this luxury. Instead, we listen to the problems, scratch our heads, and order a million tests. That is “doing”. I won’t bother to restate what others have about your flawed cost analysis either but I will go ahead and assume that you do not a.) pay for an individual private health insurance plan, or b.) personally have any experience with retainer medicine or the physicians who choose to practice it.
Medicine is a business that the Uncle Sam wants to concierge. Oh, and guess what, the more money you earn the more you’ll pay for the service anyway. Tax the rich right into the middle class that is already over taxed and in debt. Wake up, don’t look at patients for money. They owe 200k each and every one to their uncle the concierge. You lose, game over.
I haven’t made a conclusive personal judgment on whether concierge medicine is “good” or “bad”, but I’m surprised that the naysayers of concierge medicine are bagging this idea primarily through the argument, “Concierge docs are in for the money” but are excluding in their realm of biting criticism all the CEO’s of America such as Sanjay Jha and Robert Iger ($104KK and $30.6KK respectively) who have constantly been failing their career roles. Let’s restate this: Concierge docs who get paid more to do better care v.s. CEO’s who get paid more to do more damage to the economy –> concierge docs are the victims of criticism? Perhaps for all of the premedical students out there like me, we should escape a bubble of negative attitude towards doctors (pass that attitude towards the true suspects of our debilitating and money-hungry actors in the health care industry known as “Big Pharma” and “Insurance Companies”) and work our way towards brainstorming ideas on making collective, cooperative efforts (doctor with patient) to a better health delivery system. It seems to me that naysayers and those who only bash on doctors cannot lift their feet from 1970s medical care and set it on modern medicine grounds, aka “reality”; without recognizing and accepting reality, we cannot drive further towards making “change”. Passionate critics are failing to accept reality and therefore lie in their gum of “I hate today’s medical doctors” and pout, to be blunt. How do you think complaining without thought will improve medicine delivery? You say it’s wrong for medical doctors to live in fear, but it is entirely legitimate for patients to live in fear. Tell you what—- everyone, doctor or patient, has been a patient at least several times in their lifetime. How could doctors not know what it is like to deal with the health care industry? Would you like doctors to hand you all their paperwork so that you can “happily” fill them out, yourselves? Would you like to speak with insurance company representatives about patient needs, only to be rejected the claim? Primary care physicians have willingly completed two-digit worth years of grueling schooling in order to attempt to improve your health for the less the income than plumbers receive. Did you know that? If you care about health and medicine so much, why don’t you dumb down your cynical attitude towards modern medicine and find ways to actively advocate for your patients through organizations such as NGO’s, lobby the policy-makers?
I am not a medical professional, but am very interested in concierge medicine.
I have the belief that the only people who should profit from healthcare are those who spent years of study, testing and internship, i.e. the healthcare professionals. I don’t believe that the CEO of Cigna should earn more than a neuro-surgeon or a PA for that matter.
My husband has been recently diagnosed with MS and I have had radical surgery for cervical cancer. We are both uninsurable if we lose his group insurance.
I would welcome paying a concierge fee to our fabulous primary care physician because he deserves it. Unfortunately he does not have that type of practice.
Why does anyone feel is out of line for a Physician to earn in excess of $300K
per year? I don’t.
As a middle class (very), self-employed business owner, and unfortunately, now, a patient caught in the middle (very) of a complex medical business system, I am attempting to understand what I should be “fighting” for regarding the future of healthcare.
In reading the above exchange, I am not sure I have any better ideas. I CAN relate to the concept that when I raise my fees for service that my customers expect better service. That’s kind of a no-brainer. The higher the fee, the greater their expectation for the quality of my service and ability. They actually don’t care how long it took for me to acquire the ability to do what I do, they only care that I can do what I claim to be able to do.
I suppose it is all about expectation, and whether what the customer is asking for is reasonable for the price they are willing or able to pay.
I also have clients that want a discount on every service I offer, and even some that refuse to pay (they are one-time customers, obviously). I can’t bill my clients before service is rendered and sign off on the project (expectations, expectations delivered). In good times, I can usually ask for a deposit on the work, but that is also no guarantee that I will get 100% paid of the total bill in the end.
I have a few “types” of clients: those that keep coming back because of the quality and return on investment of my work; some that want that quality, could afford it, but try to get it for nothing; and finally, some that need it, but can’t afford it at all.
Now, lives are not being saved by what I do, although, if what I do results in more income for them, especially if the return is greater than their investment on my services, I am affecting them differently, than if I were a simple vending machine, $1.00 in for a candy bar, candy bar out.
So, when it comes to looking at this problem of delivering medicine, I can only scratch my head.Dang. I do think that the price to see a doctor is too high for a few minutes of a physician’s time, when he/she is more likely trying to do the paperwork/notes of the patient who just walked out ahead of me. But isn’t that the outcome of insurance being in the picture?
I also think it costs too much to have health insurance, and that is where my cash flow goes first for health care now ($1100. monthly for health insurance for a family of 4, PPO). Why do I do this? Out of fear. Fear that something completely catastrophic will come along and wipe us out financially. Since we have an utter fear of insurance companies, and the tactics that they use to decline coverage, we maintain MORE coverage, not less. Now, you can argue that is stupid, but when you are middle class, you are not that far away from the bottom, quite frankly.
With the cost of procedures, hospitalizations, etc… one needed surgery could wipe us out on copays alone.
Now, that wasn’t always a fear and we didn’t always spend more on health insurance. What happened that we would have one spouse take a lower wage/position (despite years of education/cost/actual experience) just to keep portable health insurance? Health problems.
Both myself and my spouse are not insurable. Not because we led un-healthy lifestyles, didn’t floss, didn’t care. We put more cash into upfront preventive care, just because it made sense, we didn’t need someone telling us to do it…just common sense.
So, what happened? We are human? We both ended up with chronic “states” that doctors don’t want to deal with, didn’t care about when we first sought medical opinion/care, were, sadly, mis-guided about cause (time?), and the end result? Health problems that, while not terminal, not life-threatening, have completely depleted us financially, from getting expert opinion, to affecting our efficiency to generate an income…
Why did this happen? If I had to point fingers…our health problems developed at that point in time when Insurance companies began denying claims big time, claiming that doctors (and their patients) were over-utilizing expensive testing/diagnostics, etc. and that, in order to remain profitable, doctors began altering their diagnoses, whether they realized it or not, depending on a patients’ health coverage.
What to do now? We are plain out of cash. In order to fully understand what was wrong, we paid cash to specialists in the hope that if they weren’t “worried” about the bottom line that we could remove that poor reimbursement element. Then we found that when doctors had us by our credit cards, seriously, the outcome still wasn’t that much better, for the amount we were spending.
We thought, money would solve our problems, and it didn’t. Now, we don’t have that option of throwing more cash at the problem. We are down to maintaining status quo, and having a simple vote when it comes to legislation.
Even after paying into the overall system, over 30 years (x2), paying our way (taxes, insurance, all our copays and remaining fees), and playing by the rules, we not only don’t have access to “incredible medical”, we are the “type” of patients, none of you guys would “want” on your waiting list.
What is my gut telling me? Doctors are not the problem, this “need” to carry insurance, at any cost, even if the return isn’t there, IS. The insurance companies are for-profit, but expect doctors to work in the red, and the patients to be able to fill in the rest.
There are plenty of patients who could pay (higher than middle class) who work the system, and find a way weazel out of their medical debts. I know of many that don’t carry health insurance, have the means to do so, and when big medical expenses come up, lay claim to being indigent (magically).
The problem is just too complex. I do appreciate that you guys are at least talking about it without making the patient the absolute problem. Good luck!
Concierge medicine was not created by doctors. It was created by patients.
Just quit my primary care practice of 15 years, after several major crises in my practice with me actually PAYING $10 per patient I saw (a net loss of about $250,000 last year) taking a mix of HMO/PPO/Medicare/Cash & indigent care.
The insurance industry’s increasing intrusion into my practice so I could provide them with data to “prove” that I am providing quality care continued to decrease patient face time and increase my paperwork time. (Actually, this “report card” was developed so insurers & IPA’s could benefit from additional payments they received for higher acuity that was never passed on to me – nor in the form of reduced rates for their clients – my patients).
I’ve been in office based medicine since completing residency, teach clinical medicine at a major medical school, work for a MLB team and cover sports & entertainment events. I provide basically “free” healthcare at those venues for the countless ushers & security who don’t have insurance. Over the past 4 years, the “extracurricular” work I’ve done has financially carried my practice, which I kept because I felt it was important to provide continuity of care to all of the patients in my office.
Unfortunately, what it lead to was alienation from family and friends because of the long hours spent in the office, spending LESS time with patients so I could do their paperwork, and seeing patient care actually suffer because I had to work “other jobs” to keep the practice afloat.
In the end, it was cut the practice loose, alienate the hundred upon hundreds of patients I had in my practice, but be able to cut back on the “extracurricular” work, so I can devote the proper amount of time to the patients I do have.
Providing better quality of care is “elite-ist”? Providing medicine for the masses at 40-60 patients a day & giving myself an MI stressing over how to make payroll is not what we trained to do.
One of the “there-is-no-answer” questions I ask med school applicants is “if health care is a right & everyone should have free access to it, how do you justify charging the $250,000 per year it will cost you to maintain your practice, pay your loans & feed your staff – before you make cent one so YOU can eat?”