Concierge and primary care medical home hybrid model of care

As a consultant, I spend a lot of time on airplanes and subsequently get to meet a new “person in the next seat” almost every week. Once the small talk is over, the conversation is nearly the same every time. “Oh, you work in healthcare! What do you think about all of this reform stuff anyway? Is there an answer?” I’m always very cautious how I frame my answer. As those of us who work in this world know, there is not an answer so I am very careful not to endorse one model or the other, keeping the conversation turned toward the general nature of reform and the complexities it entails.

Well today I am breaking my own rule. I want to talk about a model that just might work. I’m not sure if my inspiration was generated by the storms this weekend, making me feel a bit like the good Dr. Frankenstein, but I began to consider what a new model of care might look like if we took the best parts of some good models and built an entirely new “beast.” My thoughts are not entirely complete and your feedback is welcomed, but here goes….

The model is based on the following premises:

  • Some of the best and brightest physicians have become frustrated with the complexities of billing, the noise of paperwork, and the inability to care for an unmanageable number of patients to make ends meet. As these complexities worsen, more and more physicians will either leave practice, seek out a partner (read “hospital”) to accept the growing economic risk, or move to a model of “cash for care.”
  • A small number of the sickest patients consume a large share of available medical resources. In many of the new models proposed, safeguards are built in so that physicians don’t select these patients out of the care model as the risk for caring for them poses too great of a financial penalty.
  • Carrots work better than sticks.

So here is the plan. Why not pay the best and brightest physicians to care for the sickest patients as simply and effectively as humanly possible? Let’s take the best parts of a concierge model of care, throw in a bit of primary care medical home and a touch of Dr. Gawande’s hotspotting model and see what we get.

The model would work like this. Take a population of no more than 300-400 patients with at least one chronic disease as their primary diagnosis and assign them to one physician. This physician would be responsible for the care of those patients and those patients only. But rather than pay the physician through any type of complex, CPT driven payment mechanism, pay them cash. No billing, no coding, simply cash up front.

Sound too much like capitation? Here would be the key difference. In a capitated model, it is assumed that too much care is given and the payments are designed to reflect the risk of managing care down to a certain level of payment and reimbursement. Physicians are motivated by avoidance of an undesired negative financial outcome. In this model, the assumption up front would be one of excellent care. Remember, only those physicians who have demonstrated that they are already the best of the best in caring for complex patients would be invited. Physicians would receive payments based on their continued provision of the highest quality care to patients – not just to avoid negative outcomes, but assure positive ones. Payments would be based on the assumption that at least one hospital admission for at least half of the patients would be avoided on an annual basis.

Although current payment structures for hospital care are based primarily on the volume of admissions, this model will set the stage for a value based model of reimbursement that is likely represents the next iteration of hospital payments. If you assume that a hospital admission for a chronically ill patient can quickly add up to $10,000 or more, you would very easily have enough cash flow to run a practice.   In order to assure that excellent care was given, outcome based quality and cost metrics would be measured on all patients. There would be no “quality bonuses.” Quality care is assumed and paid for on the front end. As long as the highest quality is continually demonstrated, physicians would be allowed to continue practicing in this model.

So in the end here is what we get:

  • Patients who need the most care get focused attention from the best physicians leading to better outcomes of care than they can achieve in our current fragmented system.
  • Unnecessary care, in particular expensive hospital based care, is reduced, thus decreasing total costs to the system.
  • Physicians are rewarded (instead of penalized) for caring for complex patients with financial recognition, and by minimizing the administrative burdens inherent in practices currently.

As always, the devil on any idea like this is in the details, but if we are to come up with meaningful solutions we may need to develop a tolerance for living out here closer to the edge of creativity, avoiding the gravitational pull of current thought and the status quo.

Mark W. Browne is Principal, Pershing Yoakley & Associates and can be found on Twitter @consultdoc.

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  • Donald Tex Bryant

    It might be that this type of arrangement could be set up in an accountable care organization. Since the ACO is assuming the risk of managing patient care, it would make sense for the physicians who excel in the care of patients with chronic diseases to provide the needed care.

  • soloFP

    The easiest fix would be to simply not accept insurance or Medicare. Let the patients file their own claims. For 2011, it is idiotic to file a claim with the HMOs with a $30 primary care copayment and a massive $20-$$30 check from the insurance company for outpatient visits. It is a lot of wasted time and overhead to deal with insurance companies and Medicare. You would not need concierge but would charge the patient for the care they receive, which would include phone calls, paper work, email, and other routine care. If the patient needed help with prior auth for a CT/MRI or specific drug, there would be charge for this. It would cut costs, as the under the current system, the patient gets all this for the $30 copay and no additional charges. There would be no monthly fee, as patients would only pay for the care they receive. Patients would think twice what really needs to be done with their care with more financial responsibility.

  • Juliet K. Mavromatis, MD

    My medical practice is in the very model that you describe, I call it a Patient-Sponsored Medical Home. I describe my thoughts in the following blog:
    It seems to me that doctors that believe that this model is viable should be working with legislators to make the annual membership fee going toward medical home services clearly reimbursable with FSA and HSA funds. Patients should be able to choose primary care physicians who are able to offer better direct access and a lower patient to full time physician ratio, and offset the cost by using HSA-FSA money. We should make this model workable with health insurance for those who want it.

  • Dr. Matthew Mintz

    Excellent post and interesting concept. I think one of the flaws in your financial model is that it assumes an large savings with concierge care from outstanding physicians. Though it would make sense that better access by excellent physicians with virtually unlimited time to assist patients with their chronic disease would reduce hospitalizations, this is not always the case. If you are really looking a small number of the sickest patients, this model may make little difference in these patients’ outcomes which are usually affected by other factors including socioeconomic and psychosocial. The best doctor in the world with unlimited time can not convince every patients to take their meds as prescribed. Even with 24/7 access, a patient may not be able to make it to the physicians office because they can’t take off from work or can’t get transportation.

    • jsmith

      Bingo. The assumption that excellent outpatient medical care saves money is sometimes unwarranted. Whether society would save money with this approach to, say, heart failure patients, is not a sure thing. Or maybe it would work for heart failure but not for angina, let’s say. I suspect it would vary by diagnosis. So if the goal is excellent medical care, this idea has merit. If the goal is to save money, which is, after all, what policy makers care about, this model might or might not be an answer. But this idea is worth a try, if docs can be paid reasonably to do it.

      • Matthew Mintz

        there are actually two questions/issues here:
        1. If we used retainer model for chronically ill patients, would the cost of paying primary care docs more be offset by savings. If all patients with diabetes, asthma, CHF, cardiovascular disease, COPD, etc. had concierge access to the “best and brightest” would that improve outcomes (decreased ER visits, hospitalizations, utilization, etc.) and therefore save money? This MIGHT be possible. Assuming you can achieve retainer model care for $500/patient, and the number of patients needed in this model (NNT) to prevent one expensive outcome is 100 (not an unreasonable number and a conservative guess), then it would cost $50K to prevent one likely equally expensive event. However, the up front costs it would take to pay for this would likely be too much for folks on either side of the aisle to stomach. (20 million diabetics would be an upfront cost of $10 billion, and that’s just for diabetes)
        2. Dr. Browne’s proposal is not to do concierge for all patients with chronic disease, but just the “small number of the sickest patients (who) consume a large share of available medical resources.” This is clearly a much lower up front cause then the scenario above. The problem with this premise is that for some of the sickest of sick, in my experience, you can throw all the free medical care and access at them, and they will still be sick. Poverty is a huge factor. If patients can’t afford fruits and vegetables, and they keep eating fast food, their diabetes will not be under control no matter how much time I spend with them counselling them on diabetes control or send the email reminders. In other words, for the outlier patients that consume a disproportionate amount of resources, “best medical care” is often only a small part of the solution.

  • David Yanga, M.D.

    Thanks for your article. Certainly a subscription model of payment is appropriate for the type and level of services that chronic disease patients require. If primary care physicians were paid on a subscription model then emails, phone visits, online visits, home visits and other unique care delivery formats would be adopted much more quickly. None of these features is fiscally feasible in our current fee-for-service model. Looking to the future, if more and more patients have a $2500 deductible, we in primary care will be in cash medicine anyway.

  • soloFP

    I’ve noticed the higher the deductilbe, the less likely the patient will come in for follow up visits. I also have a higher percentage of unpaid bills in the patients with higher deductibles, even though the high deductible patients are saving a lot on their insurance premiums.

  • gzuckier

    What doctor is going to sit still for not being included on the “best and brightest” panel? The insurers just got over their alienation of the medical community from the managed care and capitation follies of 20 years ago, they’re shy of repeating the error.

    On the other hand, the modified capitation tying reimbursement to the patients’ general state of medical decrepitude part of your idea seems attractive; definitely better than the current models where the road to better outcomes is best served by avoiding sick patients. Could be useful at another level, to induce insurers to take on sicker members, via government reimbursement.

  • Mamie Troy

    I have been trying to figure out a way to fit the concierge model to the specialist’s environment. The current systems penalize those who insist on high-quality care of high-risk patients, and incentivizes the quick and dirty approach to the healthiest. The best docs feel isolated, exhausted, and disillusioned…

  • Steve Hohf MD

    I think there are physicians out there who could do this very well and make it cost effective. I work with some of them. To commit to this, an experienced physician would have to give up most his or her existing practice and enter into a new practice model. He or she would need a solid income guarantee over an extended period of time, several years at least. So who pays? Perhaps an ACO as another commentor suggested, or en enlightened Medicare Advantage plan.

  • Alex Fair

    While I like the concept, I see one significant problem. Patients do not like to be assigned a Physician. Physician selection is based on word of mouth, convenience, cultural background and other factors. If people can afford to pay directly, they will prefer to choose. Perhaps I missed your plan for this. I, of course, would recommend a listing service such as my own for docs to indicate their model for this care by disease state – like a DRG group. If anyone wants to pilot this with us we can try it out.

    I do agree, the ACO model has high potential for leaving the chronic disease patient out in the cold and this needs a great idea. This idea hangs on the available docs being inarguably the best, or at least among the best, a metric that is hard to convince people of.

    Dr. Hohf – We construct primary care offerings like this on our site for providers regularly. Physicians can accept cash paying patients for part of their practice without giving up their regular panels. Just define your services clearly and you have direct pay contracts. To SoloFP’s point, these contracts do make it easier to collect from the 25-30% of your insured patients that have high deductibles these days. The number of HDHP patients went up 27% in 2009. 2010 data is not available yet but I am certain it exceeds the rate of the previous year so HDHPs are not going away soon, especially with PPACA’s provisions.

    “I am not bothering to collect beyond the co-pay” is a phrase I have been hearing quite a bit this year. Especially when the co-pay exceeds the allowed charges and would generate a credit towards the “payer”.

    Finally, the ACA does have provisions for this type of arrangement. Dr. Garrison Bliss, a direct pay activist physician helped craft the provisions in the law that allow for this. A summary is in this doc:

    There is hope, but it seems that we are on our own in defining how to create a model of medicine that works for Physicians and Patients. For all that want to experiment with new models, we have thousands of patients searching for offers on our site every week. If you (like Dr. Marvomatis) have a great model that is working and you want to share, we would love to include it for other docs who might find it useful. Better yet, we also enable cloning and mutation of offerings so that models can continue to evolve and adapt successfully to the current environment. We think of FairCareMD as a laboratory for care models, an apt place to turn words into actions and continue this discussion.

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