Traditional primary care needs concierge care to survive

Concierge care is often discussed as a way for primary care to survive in the United States.

Pauline Chen talks about the concept in her recent New York Times column, discussing the well-known issues involving “two-tiered” care that boutique practices inevitably bring.

But what I found fascinating was how Tufts University utilized the concept.

Here’s how it works:

Since 2004, the primary care physicians at Tufts Medical Center have offered patients the option of being part of either a traditional general medical practice or a retainer practice. Patients in the retainer practice have longer visits, around-the-clock access to one of five physicians, comprehensive wellness and prevention screenings and on-time office appointments within 24 hours of a request. But unlike other boutique practices, the retainer fee of $1,800 per year that these patients pay does not go directly to the doctors’ coffers. Instead, it is used to support the traditional general medical practice, the teaching of medical students and trainees and free care to impoverished patients.

Interesting.  A couple of things to note here.

First, I’d be curious to know if both the concierge doctors and the traditional physicians were under a similar salary structure.  On one hand, the boutique physicians would see less patients during the day, but would have to be available 24-hours a day to provide “VIP” services, while the traditional doctors may have to see more patients in the clinic, but would be off-pager during the evening.

And second, it’s starkly implicit that the traditional primary care needs the revenue generated from the concierge arm to function at all — it’s a depressing sign that it’s impossible for a traditional primary care practice to fiscally self-sustain.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • jsmith

    So this is what we have come to in this country. We are unwilling or unable to finance properly the single most important component of our health care system, so we doctors will now kowtow to the rich and throw crumbs to the others. Kind of a metaphor for modern America, eh?
    I suspect it will get even worse. Soon physicians will abandon primary care altogether. It is what America, by the incentives it presents to us, wants us to do.

  • http://drpullen.com Ed Pullen

    It would be good to see more details of the financial arrangements. Using the concierge retainer for support of the general medical practice which also does free care and trains students is vague. What is the payer mix of the general clinic? I suspect high in government payers. Maybe a retainer practice could allow others to accept more Medicare & Medicaid patients in a private practice model.

  • http://www.twitter.com/alicearobertson Alice

    Did this study show the outcomes of similar diseases treated on both sets of this class distinction model of medicine? I ask because it would be interesting to see which set will get better results (if any). I ask because I once asked a doctor I know about Roger Ebert (the movie critic, who lost his ability to speak and will probably die from thyroid cancer. He was in the news because a new computer program was developed in the UK that takes recordings of a person’s voice and uses that to speak for the patient). Since my daughter has thyroid cancer I was curious and asked if the doctor was informed about this case. The answer was spellbinding and shocking……..the doctor said that some believe Roger Ebert’s wealth may have caused this. Huh? Yes, this doctor to the elite felt that rich people often get lesser care. Why? Because some are arrogant (and demanding) and privately doctors don’t like it. I could only utter to my daughter, “I guess we don’t have to worry about that!” Lesson learned……no matter what is in your bank account be kind to the doctor who is treating you.

  • http://www.drdialogue.com Juliet K. Mavromatis, MD

    Kevin,
    Glad you posted this. I found Pauline Chen’s column thought provoking–particularly the reader responses. Patients should be able to purchase a higher level of personal service from their primary care physician than insurance guarantees if they want to. Whether or not this translates to improved outcomes I suspect is as variable between two concierge doctors as it is between two non-concierge physicians, and I think that this is irrelevant to the discussion. However, smart concierge primary care physicians should be accountable for demonstrating their outcomes in a similar manner to traditional primary care physicians. People spend money on all kinds of crazy things that are of no appreciable benefit to them. Why not let a chronicaly ill patient purchase a more intensive relationship with a physician if he or she feels that relationship will provide meaningful support? Physicians are not only like air traffic controller or pilots of a plane, they are also like ministers or priests, providing connectivity and support to their patients. The benefit of this type of relationship may be harder to measure. Not all patients will choose to hire a concierge-model doctor–they may be quite comfortable and able to receive high quality care with the shorter doctor-patient interaction and team approach that current insurance reiumbursement allows for. However, I do see that there are advantages to letting this model continue to exist. The Tufts example is interesting. In my model I will be able to take a higer percentage of Medicaid patients than my colleagues around town. In effect my retainer-fee patients are subsidizing the care of these patients who often are medically complex and can also benefit from my hybrid model with time for longer office visits and more direct access to me.

  • gzuckier

    Interesting. I have proposed a concierge patient system, whereby in exchange for a payment of $1800 per year, the patient agrees to not waste the doctor’s time during the appointment discussing the latest miracle cure shown on Oprah, not to show up for an appointment half an hour late and expect to get ushered right in, not to call the doctor at 5 AM on Sunday because they’ve had the sniffles for two weeks now, not to demand an MRI every time they bruise their shin, and not to badger the doctor for free medical advice at cocktail parties.

    • http://www.twitter.com/alicearobertson Alice

      You want to charge then limited the discussion? Does that make you completely in charge? A Svengali type of doctor for the rich? Interesting!

  • http://www.twitter.com/alicearobertson Alice

    Whether or not this translates to improved outcomes I suspect is as variable between two concierge doctors as it is between two non-concierge physicians, and I think that this is irrelevant to the discussion.. [end quote]

    What? You are obviously speaking from a defensive doctor’s position, instead of a vision for good patient care. Outcomes don’t matter (?) just the right to the service……hmmm……..the discussion should absolutely compare outcomes so the paying patients can make better choices (realizing this is the darker side of medicine. Time magazine covered this and at this point I think only Cleveland Clinic will share the true clinical outcomes of their patients with prospective patients. Other doctors running hospitals prefer to keep patients in the dark about the nitty-gritty performances. My daughter is being treated for cancer there, so these were important figures).

    The service being discussed gives patients more choices, and patients should absolutely know what they are paying for. If it’s more time, faster service, or indeed, the possibility of better care …….not just convenience. If it is just convenience then put that in the brochure that the outcomes aren’t on the table…..at least the patients won’t be deluded.

    You cannot separate a patient’s choice of service with the outcomes. It’s like saying people would pay for first-class tickets on a less save plane. It just doesn’t jive.

  • http://www.drdialogue.com Juliet K. Mavromatis, MD

    Alice, I agree, outcomes are very important. However, my point is that there is likely just as much variability in quality amongst different concierge practices, as there is amongst non-concierge practices. Concierge practices should be prepared to report on their outcomes, just as traditional primary care practice are beginning to do. There has been criticism about the financial model implying that retainer fee practices have not been proven to provide better care than traditional practices. I find this criticism artificial because it lumps all of these practices into one category or practice model, when in fact, they are highly variable.

  • http://www.twitter.com/alicearobertson Alice

    I love when there is true communication and dialogue…and lsitening. Thanks!