Internal medicine is dead, will concierge physicians thrive?

by Steven Knope, MD

For the last several years, writers in the New England Journal of Medicine and the Journal of the American Medical Association have authored doomsday editorials about the prognosis of primary care medicine. There has been much discussion about the fact that internists and family practitioners cannot keep pace with rising overheads and falling reimbursement under the traditional third-party payment system.

Paraphrasing a recent story published in The New York Times, an internist in Massachusetts who practices under the new RomneyCare program said this: “Every time I see a Medicare patient, it is the equivalent of giving them a ten-dollar bill. I have a six month wait to see a new patient. I run from room-to-room. I can barely make my overhead. I’ve never felt so disrespected in my entire life.”

So is this all just whining and political hyperbole or is internal medicine really dying? The answer to this question was revealed to me by a colleague last weekend while I was at the hospital. I had been called to the ER for one of my patients who was hemorrhaging on the blood thinner, Coumadin. The ER doctor looked at me and said, “You are a dying breed.” I laughed and said, “Yes, I know…but why do you say this?” He responded, “See that list of 9 doctors’ names and phone numbers up there on the wall? You are one of the last of 9 doctors who still admits his own patients to this hospital when they get sick. All of the other internists and family practitioners have abandoned hospital medicine and limit their practice to the office.” I knew that this was a profound statement and it shocked me; but I did not fully digest its implications until I had stabilized my patient and started my drive home.

The hospital where I practice has over 700 doctors on staff. The fact that only 9 of us still take care of our own patients when they are hospitalized answered the question about internal medicine’s future. It is no longer an issue of whether traditional internal medicine can survive; the facts are – at least outside of the concierge model – internal medicine is already dead.

What are the consequences for patients? What happens to the average person in Tucson, Arizona when he or she gets chest pain, develops pneumonia or has a seizure? Can they reach their internist or family practitioner for a medical emergency? Most patients who call their primary care doctor for a medical emergency can’t even reach his staff during normal office hours. Instead, they will hear a recording on an answering machine, directing them to go to “call 911” for any medical emergency.

Once in the ER, the “doctorless” patient will be admitted to a hospital physician, who is unknown to them. This so-called “hospitalist”, who is a salaried shift-worker, will put in his 12 hours, and then go home. He is a doctor who knows nothing about the patient’s medical history. He has never met the patient. There will be no call from the hospital doctor to the primary care doctor in the office to get a thorough medical history. There will be no medical records transferred to the hospitalist. The hospitalist will attempt to get the best medical history he can from the patient, make some quick medical decisions, and then pass the patient off to one of his colleagues when his shift ends. And so it goes. No continuity of care, no understanding of the patient; the sick person now becomes a “case of pneumonia” or “the stroke in bed 3” to a group of unknown, rotating professionals.

As fewer and fewer young doctors go into internal medicine and family practice, and thousands of primary care doctors retire early due to financial pressures, the primary care shortage will only worsen. Not only will there be no primary internists to take care of their own patients in the hospital, there will be fewer internists available to see patients in the office setting. This inevitable vacuum of internists and family practitioners (traditional diagnosticians) will be filled by nurse practitioners and medical assistants; people with far less training and expertise than an M.D.. If you are fortunate enough to have a good nurse practitioner, you will eventually be referred to an appropriate specialist, who will treat one of your medical problems. If you are not so lucky, a nurse or medical assistant may miss an uncommon or rare diagnosis; he or she may misdiagnose the “headache” that is actually an aneurysm, the “flu symptoms” that turn out to be meningitis, or the “gallbladder problem” that turns out to be a heart attack. Bad things will inevitably happen when doctors are replaced by medical assistants. It is simply a matter of statistics. All doctors make mistakes, but those with less training make more.

As a concierge physician, people often ask me how this move toward a government-run healthcare system will affect me professionally. Speaking honestly, I tell them that it will help my practice, but I do not think this is good news for the country. As an independent concierge doctor, I am not subject to the rules or fees set by Medicare or Medicaid, nor do I deal with third-party insurance carriers or HMOs. I work for my patients, not a third-party with a conflicting financial agenda. As someone who practices full-service internal medicine, the demand for my services will continue to increase. However, this outlook about my own practice does not make me happy. I have small children. I am concerned about their future. I am concerned about what the changes in primary care will do the future of American medicine; what will happen if the art of internal medicine is completely lost. I am worried about what it will mean to the efficiency of medicine as a whole, to have no diagnosticians and clinicians to treat the majority of problems that do not need a specialist.

I have found a unique niche in medicine, which allows me to truly practice what I was trained to do. For most of my colleagues, however, this is no longer the case. They too were trained to care for patients from the office, to the hospital, to the ICU. Now, they no can longer afford to take care for their patients when they develop life-threatening illnesses. They are now “clinic doctors.” Their hospital skills have atrophied. They will never practice comprehensive medicine again. For them, the game is already over. For them, internal medicine is already dead. For their patients, and the society as a whole, this is a great loss.

Steven Knope is a concierge physician and author of Concierge Medicine: A New System To Get The Best Healthcare. This post was originally published in The Healthcare Entrepreneur Blog.

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  • NoVA doc

    For $6000/patient/year (with a couples discount) x 150 patients, I would provide a level of service far beyond what would be expected of the average primary care practitioner.

    An individual with those discretionary funds is, statistically speaking, not within 2 standard deviations. There are not enough of them to the rest to support PCP funding in such a manner..

  • Christie B

    I’m assuming the author means “physicians’ assistant” not “medical assistant”. I would agree that a physician with the training, time and inclination would in most cases be a preferably primary care contact than a nurse practitioner or other mid-level provider. However, as your article points out, I don’t think that’s a choice that most people have at this point. We can choose a mid-level provider or a frequently unavailable, disgruntled physician who is strapped for time when we do get into the office and probably wasn’t really trained for comprehensive care anymore anyway.
    I do think that the concierge model is intriguing, if currently not economically viable for most Americans. I would love to see if research would support a two-pronged insurance system with a subscription-based primary care portion and a hospital/catastropic portion that could be priced competitively based on saving from the enhanced primary care.

    • Doc99

      In the 1960′s, we had such a system. Blue Cross was hospitalization only, with either CASH or “Major Medical” paying doctors’ fees.

  • K Duchicela, MD

    I think most primary care docs are missing the fact that the health care bill will bring 30 million more patients into the insurance pool. For those lucky enough to be already insured, this means there will be longer waits, shorter visits and less availability of primary care docs and specialists. Obviously, this isn’t good for patients. But the exodus to retainer practices will increase. The patients of these practices will be happy with their care. The doctors will be happy with their jobs. With a reasonable income, and less paperwork and administrative hassles at the office, they will be able to practice inpatient medicine again. They will be able to mentor and teach, and we will attract more smart, compassionate, hardworking medical students to primary care.

  • ninguem

    I just don’t understand. If a doctor is that busy, then why, why, WHY does that doctor allow the practice to fill up with patients with poor-paying insurance?

    For Pity’s sake, stop handing out the ten-dollar bills. Close your practice to the poor-paying insurances. If the doctor has a six-month wait for a new patient, start closing to the poor insurances.

    Rank your insurances by payment and “hassle factor”. Payment is easily calculated, “hassle factor” you can put to a vote with yourself and your staff.

    Rank the insurances. Start closing to the insurances, one by one, starting with the worst combination of low pay and big hassle. No new patients with that insurance.

    The last thing you want is a patient that DOES pay, has to wait, get disgusted with waiting, and goes somewhere else, while your practice is choked with Medicaid and Medicare.

    • elizabeth

      I’ve often wondered this myself. Nobody’s forcing you to take Medicaid/Medicare. Charge reasonable rates. I would love to pay cash for primary care knowing upfront how much things are and that most of it is going to my doctor. All primary care should be like this with insurance for exceptional conditions. Most working people could afford this. They may have to rethink their priorities – maybe not spend quite so much on things they really don’t need. If they don’t find it important enough that’s their decision.

  • Anonymous

    Stop seeing medicare patients, save the 10 dollars.

  • Charissa Brown, RN, FNP, MPH, PhD

    As a nurse practitioner, I care for my patients just as well as any physician could. I take offense when physicians consider my colleagues and me to be incompetent, second-rate healthcare providers. If I have a concern, I always consult with one of my colleagues or will refer my patient to a specialist physician (or nurse practitioner). Physicians are leaving primary care in droves, as are many nurse practitioners and physician assistants who can make a better living doing inpatient or specialty work. Nurse practitioners are not “filling the gap” as many physicians believe they are. Bashing nurse practitioners for their supposedly “inferior” care will only make matters worse for the field. I am not a physician, and I don’t pretend to be one. That doesn’t mean, however, that the care I provide and the clinical knowledge I have acquired from my several years of primary care practice and extensive nursing education are inferior to a physician’s care.

    • Anonymous

      Not inferior care, but not equal either. No incompetance is assumed, but many of your colleagues feel that they are equal in education and experience to a physician and time and time again this has been proven not to be true.

    • Anonymous

      And right here is the problem with the mindset:

      “That doesn’t mean, however, that the care I provide and the clinical knowledge I have acquired from my several years of primary care practice and extensive nursing education are inferior to a physician’s care.”

      I also don’t care how many letters and acronyms you put after your name, you’re still not a doctor practicing medicine.

    • Primary Care Internist

      Actually, “the clinical knowledge I have acquired from my several years of primary care practice and extensive nursing education” ARE inferior, by definition. This is not bashing, just reality – NPs should be supervised by physicians, and not practicing independently. That is what their training is designed for.

      By your logic, why does one need an FNP at all? why not let RNs manage patients? or LPNs? or CNAs? I would say the scientific and clinical training is much closer between NP and RN, than between NP and MD.

      And i second the acronyms comment; I know plenty of doctors with other degrees, even very difficult to earn PhDs and MPHs from the nation’s top universities, that they don’t feel obligated to constantly advertise to the world.

    • Kathryn Reid, RN

      Nurse practitioners should not be supervised by physicians. Nurse practitioners are nurses with advanced clinical training who practice under the regulations set forth by a state’s nursing board, not the state’s medical board. Nurse practitioners and physicians have a large overlap in their skill sets. While some may argue that NPs have less education and less scientific background than physicians, they are very competent at providing primary and specialty care at costs that are lower than what many physicians charge. Physicians are generally hostile to nurse practitioners because they are now direct competitors to physicians (they can prescribe, order tests, diagnose, etc). Even with their “inferior” training, the public and health care organizations continue to choose nurse practitioners to be their healthcare providers. I guess their “inferior” care really isn’t that bad.

      • Anonymous

        Please tell me how two different “providers” can compete with each other ? Because they aren’t the same (as you correctly point out above), how can you also infer that they can compete ? Please don’t insult anyone’s intelligence with the practicing medicine vs practicing nursing argument. They are practicing medicine, period. They don’t have inferior training, but they do have less and with that a lesser scope of medical knowledge and training.

        Physicians aren’t hostile toward’s NPs. They are part of the health care team just like everyone else. That being said, all that is asked is that the minority that think as you, that they are “the same as a physician”, recognize their limitations and work as a team to provide better patient care.

        • AZ Nurse Practitioner

          Anytime another healthcare provider, whether it be a NP, PA, chiropractor or podiatrist, give the Almighty MD a run for his money, the medical community pulls out the “inferior” card.
          It is crazy to think some of these brand new MD’s have more clinical expertise than a NP who has been a practicing clinician for years.

      • Primary Care Internist

        So when you treat a UTI with cipro, it is practicing nursing; but when I do the same it’s practicing medicine???

        And how do charges matter at all? Medicare already pays NPs 85% of the physician rate, and are considering increasing that, while decreasing physician rates. Most NPs do not independently bill insurance or medicare, they are in fact working for a physician, and patients seen by them are probably being billed the physician rate, thus not saving the system any money at all. This idea of cost-savings with NPs is just a blatant lie, one that medicare & obamacare will find out the hard way after many years of waste and alienation of primary care doctors.

        • Not Savvy

          I am not going to look this up but I thought I read an article that stated that several states are promoting nurse practitioners to independent status to deal with the primary care shortage.

          In some states, this is already the case. Nurse practitioners practice independently, saving money for the patient…doing their own billing. Perhaps a study should be done on how these nurse practitioners are contributing to quality health care and lowering costs.

          If there is such anamosity toward nurse practitioners, why do MD’s trust them with their patients?

  • Zach

    Why would I stop seeing Medicare patients when the reimbursement for my locality is 2x that of BCBS, Cigna, Aetna, etc?

    • SmartDoc

      Where is Medicare the best payer: 2x that of BCBS, Cigna, Aetna, etc?

  • imdoc

    Regarding why a doctor fills up with “poor-paying” insurance – it is ALL poor paying…

  • ninguem

    If it pays better, then don’t stop. It’s poor in my area. It varies across the country. All I’m saying is rank your insurances, and lop off the ones that either pay poorly or make your life miserable with administrative hassles. If it really takes six months to get a new patient visit in a practice, then take advantage of it.

  • jim

    Dr. Brown:

    I don’t think you’re being called incompetent. I think it’s just being stated that NP’s and PA’s do not have the medical knowledge that a physician does (I don’t really understand who would dispute this, it is what it is). It’s also not that your care is vastly inferior, I would just guess that the majority of people would assume a physician would be best suited to spot a rare illness in a “simple” office visit. As a patient, I would ALWAYS want to see a physician regardless of my health status. That’s not a knock on NP’s care, it’s just I’d want the most educated and extensively trained professional treating me. Others, obviously, feel different. As I continue to age, my hope is that there will always be internists/Fam docs in my community for me to even make that choice (physician vs NP).

  • gerridoc

    Dr Knope is correct. General Internists are a dying breed. Many doctors take care of Medicare patients feel it is their duty to do so. Quite frankly, I enjoyed taking care of them, but if you accept assignment, you can’t make a living. It is a shame that primary care physicians find it impossible to care for their hospitalized patients. I refer to it as the “Balkanization” of medicine.
    As far as Nurse Practitioners go, they are well-qualified, but I don’t see how you can equate a rigorous premedical curriculum, plus 4 years of medical school, and 3 years of residency to a BSN and an MSN in Nursing.

  • CSmith

    The solution is really not that difficult. You need to adequately capitalize primary care and get away from the fee for service model. I like the idea of taxing health plans 10 % and setting aside 7-8% for vouchers for patients to purchase primary care and use the other 2-3% for preventive services. In a capitated model like this you would have on average $500-600/patient/year which is much more than you have now. Practices would avidly compete for patients and provide more services. The competition would spur more innovation. Niche primary care models would evolve. The creativity and enhanced income would attract young physicians. Evisits, Emails, phone calls and health IT would be embraced as cost-effective since the provider no longer has to have office visits to drive revenue. Most health plans currently only pay out about 78% of premiums for care. Primary care gets about 3%. An additional 7% would amount to 85% of premiums being paid for actual care.

    • Owen Linder MD FACP

      I think your idea has a lot of merit.

  • Marc S Frager

    The real problem is administered Medicare fees. No other business has their fees and charges set by an outside source. Until physicians are able to set their own fees, primary care is dead. Even if the administered Medicare charges are legal, they are certainly immoral and very poor business in the long run, in my estimation. Much as it would like to deny, professional businesses are still subject to the same laws of supply and demand as others. That is why concierge care is thriving, and third party care is sinking.

  • rezmed09

    So many blogs have appropriately complained about business problems of medicine, how the government has made it so much worse, how the insurance companies have ruined our practices and how all government reforms have failed. Concierge medicine is a logical outcome of this broken system. Although serving a much smaller pool of essentially wealthy patients, it restores docs’ independence from a morass of regulations and phone trees and billers and coders and office staff.

    Funny the Canadian PCP docs I know, seem to have a similar practice. A simple, single payer billing system, few office staff, better pay and essentially their own small business. Yet they are able to take care of more patients, no matter the patients’ incomes. Maybe I am missing something here, but in our complaints about the death of primary care, the terrible reimbursement system we have, and the resultant corporatization of medicine, we have not embraced the Canadian solution – a simple single payer system. Yes there are problems with single payer systems, but it seems that without a dramatic change we are all going to end up working for 1) a few wealthy people, 2) a big corporation (hospitals, practice groups, or insurance companies and their attorneys) or 3) a government practice. Right now, most of our reimbursement is tied into Medicare rates anyways.

  • NS

    Everytime I see a discussion about the inferiority of nurse practitioners, I wonder why no one ever puts value on the nursing curriculum. While one might think that calculus makes a better doctor, the nurse practitioner learns to care for patients in a way a doctor never does.

    If we use the argument that we want the most educated physician for the job, why not see an ENT for a sinus infection or a neurologist for a headache. No wonder prices are so high.

    • Anonymous

      Value is placed on nursing curriculum, but with the understanding that it involves much less instruction in disease and the disease process and more nursing theory. This may make a better nurse, but regardless of what opinions you have, nurse practitioners today are practicing medicing – not nursing.

      The argument isn’t to see the most educated physician – it’s the most educated provider. That would be a physician. That being said, a PCP or family practitioner is more capable of handling problems without referring where a midlevel provider may not have the knowledge or experience to manage a problem themselves.

  • Marc Gorayeb, MD

    Dr. Knope is right on the mark.
    Next time you see your recently discharged patient, ask him or her how many primary doctors were in charge of their care at varioius times throughout their hospitalization. Ask them whether they had access to one consistent unifying voice who could provide information, translation, emotional support, decision support and direction.

    • Lisa

      “Ask them whether they had access to one consistent unifying voice who could provide information, translation, emotional support, decision support and direction.”

      I don’t have that outside the hospital either. Over two years, I have seen 7 different providers at the clinic where my PCP is. He never has time to see me.

  • anonymous

    NPs don’t cost the patient any less than a physician. If you see an NP instead of a physician you have just been screwed in the current system. You received a “cheaper” level of care, but paid the same rate as you would for a physician with more training. The money saved by you the patient seeing an NP just went into someone else’s pocket other than you own, whether that be the physician who has hired them, the hospital, or the government is up in the air.

    In addition to this easily understood fact above, I have a theory that when push comes to shove NPs currently are no less expensive than doctors. Employees that have the ability to unionize to keep raising their benefits along with the attitude of no work over 40 hours without time and a half will be very expensive in the future.

    Add to this that NPs will be moving doctor NPs in the near future with 1 year additional residency training and it will get to the point to where NPs will not be able to afford to be paid less than physicians or they will not be able to pay back loans/recruit people.

  • jim

    Again, no one is bashing the NP’s “inferior” curriculum. It’s just been stated that they do not have the medical training a physician has. Why do NP’s take this so personal? I don’t see the paralegal association stating that their expertise on the law is on par with attorneys. Again, I am pro-NP’s and PA’s because it allows patients the right to choose their provider. Also, I understand what you’re saying with the training in care vs. calculus. Just keep in mind not all patients need to have their hand held throughout the process by their health care provider. Some (like me) care solely about outcomes. I want the job done right, even if my physician comes off as less compassionate as an NP would.

  • Barbara Hales

    Many interesting points have been touched upon here.
    Some need to be addressed as follows:
    1)Selection in premium insurance plans- many insurance companies base their reimbursement schedule on one that is established by Medicare. They carefully follow what Medicare fee plans enact and then adjust their rates accordingly.
    There will be few insurance plans to participate in that are attractive or enticing. This is why the 21% slashing of Medicare rates is especially worrisome.
    2) Fee for results instead of reimbursement for services rendered- this takes on some worrisome details. The most obvious one being that if you are only paid for good results, you will cull your patient list to those that are not “high risk” or more in jeopardy of a poor result. Will there be a separate tier of payments for high risk?

    We are at the crossroads of medical care and traveling down the wrong path will be deleterious for decades to come.

  • Shelley Myers

    I am fortunate to call several internists my friends and colleagues and, time and again, listen to their stories of day to day frustration about being on the ‘hamster wheel’ of medical practice. Some describe it as being on a treadmill that’s moving too fast…they are working as hard as they can but still they are flying backwards. They run and run, patient after patient, hours spent on non-reimbursed phone calls, emails, care coordination and can’t seem to move ahead. There is little job satisfaction and freedom to run their practice the way many small business owners or entrepreneurs do in a consumer-driven market where value is key. They are handcuffed by complex payer contracts which continually diminish the physician-patient relationship and dilute the physician’s time.
    It’s time for physicians to evolve and think like entrepreneurs or what we at Hello Health call the ‘doctorpreneur’. Doctors, now more than ever, need to think outside the box, be creative, find ways to investigate and measure what their patients find valuable and what they will pay above their insurance co-pays such as virtual consults for follow-up visits or 24/7 access via phone or email. These are the doctors who will be our future PCPs and happy PCPs at that.
    There is good news when it comes to being a primary care doctor but some need to take a step back, step off the hamster-wheel for a bit to reflect on how they are running their practice, how they are marketing themselves, their services, the value they are providing or would like to provide. Are they connecting with patients through social media? Are they educating their market on what differentiates them from Dr. Smith down the street through blogging or publishing a monthly newsletter on their website? Very few are but need to consider adding these tools to their current marketing efforts. It’s 2010 and times are changing quickly… doctors need to keep up.
    Patients and consumers are out there seeking out that special doctor who will give them the time, compassion, understand their lifestyle and behaviors, empower them to be a partner in their care. This is not for every physician, but for many there are other ways to practice medicine where they can be creative, entrepreneurial, and enjoy their profession. They just need the tools, the guidance, the support, the ideas, the motivation to get off the hamster wheel. Let’s keep primary care alive and well and our patients happy and healthy!

  • Anonymous

    The answer (or at least a part of it) is that the patient should pay for the service and then apply back to the insurance companies for reimbursement. Then the doc doesn’t have to have as much over head and/ or an accounts receivable collector.. I know this can’t be done with medicare patients – but it can with most PPO’s. I do it myself! It’s a pain but the relationship with the doc isn’t about the dollars it is about the care. He knows when he advises a test I will have it run, pay out of pocket and then I take care of the insurance paperwook and his hands are free to send me to the providers he feels will do the best job. Now my insurance company doesn’t like that I am doing this, sometimes I have to pay the higher %age as the care might be out of provider service but it’s worth it to me It’s my health!!! I don’t much like the high premiums or the fact that the insurance company’s first word is no but it is the only way that I can have a relationship with the doctor without someone looking over his shoulder. God helps him if nationalized medicine takes hold.

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