Is it a crime that retainer physicians make more money?

Many readers know that I co-authored an Annals of Internal Medicine article on retainer medicine.  The article has received (as expected) mixed reviews, because the concept causes angst for some physicians.

I believe (and I will not speak in this rant for my co-author) that retainer medicine emerged because of the current payment system.  Retainer medicine is a response to burnout.  Yes, many retainer physicians are making more money.  Is that a crime?

I pose this question for opponents.  Where is the professionalism of having to see patients in 15 minute blocks?  Where is the professionalism of seeing too many patients in one day?

Some critics want data.  I would argue that even if we had presented data (which are available), they would argue that the data are tainted.

We are unlikely to get universal agreement on this issue.

We tried to explain (given a limited word count) that retainer medicine is ethical and may represent a better practice model.   I doubt that anyone believes that you can provide quality care of complex patients in 15 minute blocks.  I believe that every good physician will admit that more time equals better care (up to some limit).

Primary care (which I do not do any more) is in crisis.  The crisis has emerged from the combination of payment structures and every increasing overhead.

If we do not learn from the retainer medicine movement then we are ostriches.  Perhaps some observers enjoy suggesting that a growing number of physicians are practicing unethical medicine.  That opinion carries a world view that I find narrow.

Talk with physicians considering the switch to retainer medicine.  Talk with practicing physicians and understand their frustrations.  Learn from a bottom up movement.  Perhaps through an understanding of why physicians and patients find this movement attractive we can all understand how we must restructure our health care system.  Our current payment system is badly broken, we should look for ideas for a new payment system from every successful experiment.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Anonymous

    I got 10 minute appointments. Where does that factor into all this?

    • http://twitter.com/NMJUNCTION NeuroMuscular Jct.

      Are you a physician or patient? If physician, how could you possibly learn anything about a patients issues in a 10 minute appointment?  I think its absolutely wrong for a patient to schedule an appointment, wait in a big waiting room for an hour PAST their scheduled appointment time, then be called to go into the smaller waiting room (recalling Seinfeld episode) and wait for another half hour , all the while not having had anything to eat because I needed some kind of test, or bloodwork, just to see a doctor for 10 minutes. I have walked out on my doctors appointments after seeing drug reps walk right in to speak to the doctor ahead of me.

      I am a Manual Therapist, I schedule appointments with clients far enough apart so I get plenty of time to consult with them, perform posture & biomechanical assessments, and palpate/perform bodywork on muscles & connective tissues, to learn all I can about a client/patient’s condition and figure out what will be most effective in helping them solve their aches and pains. I typically schedule in 2-hour sessions for new clients, to allow time for all of this.  I also allow time between clients just in case they require more time, and allow time for rest, time for writing notes and time to prepare next client. and yes, I charge for those 2 hours of my time. Much like physicians have specialties they practice in, I am a specialist in my field of Manual Therapy. I do not accept insurance, and ask for money up-front.

      People will pay out of pocket, if they feel that you can help them resolve their health problem, and that you will listen to them, not treat them like they are part of a herd of patients.

      I take care of most payments over the phone (via credit card) before they ever get into the office. I try to reserve their office visit as a therapeutic session. When they are scheduled, they fill out their intake form (if not pre-filled out) and once this is done, i start their consultation and client education part of their session, I don’t make them wait.

  • http://twitter.com/#!/CloseCall_MD Close Call

    No.

  • Anonymous

    Robert ~

    I have noticed that many physicians respond adversely to innovative disruptors. I do not have a retainer practice though subscribe to a low overhead ideal medical practice model. I do not turn anyone away for lack of money. I work a humane schedule and I am happy. Patients need happy doctors. We are role models to our patients.

    I would like to think that we are role models to our colleagues as well. We can all learn so much from each other in a spirit of camaraderie. Why tear each other apart and point out all the flaws of others’ practice models? Why not celebrate others’ successes? 

    Neither patients or physicians want one-size-fts-all healthcare. Physicians, like all other human beings, deserve to be happy. I celebrate any physician with the guts to give up the victim role and practice medicine with joy. 

    Follow your bliss.

    ~ Pamela

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      I knew Dr. Centor was thinking about you when he wrote that post.

      • Anonymous

        So when do we get to meet in person ninguem??

        • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

          You’re going to buy lunch, you’re one of those rich retainer physicians.

          • Anonymous

            not rich. not retainer. but I do want to buy you lunch!  Come to Cafe Zenon at 3:00 pm on Dec 11th. I am hosting a holiday party for patients & community. . .  mediterranean buffet. . . introduce yourself . . .

  • http://twitter.com/chasedave Dave Chase

    I’m written a lot about Direct Primary Care (i.e., what I call Concierge Medicine for the masses) interviewing many retainer-based docs. See http://www.delicious.com/chasedave/DPCArticles for posts here on KevinMD and elsewhere. Just this week I was speaking to a retainer-based doc (AtlasMD). Among other things, he shared how one of his retainer patients lives in a storage unit but pays his retainer as it’s less costly than what she would pay at the public health facility in co-pays and he’s providing greater access. Every DPC doc I’ve spoken with has nearly 1/3 of their patients who have been uninsured — most with chronic conditions that were getting worse. 

    If DPC is unethical, so was just about every family doctor in the 60′s. Many of them operated on a retainer too. We don’t pull out our insurance card when we replace a furnace at our house or get our car tuned up. Why on earth would we want to pay a 40% “insurance bureaucracy tax” for similar day-to-day healthcare. Use insurance for what it does best – rare stuff you hope never happens. Introducing insurance in day-to-day medicine introduces all kinds of distortions. 

    The other striking comment from the DPC/retainer docs I speak with is how they described practicing medicine while in an insurance-centric practice before switching. They have said they were using 40% of their medical training as that is all the 7-15 minute appointments allowed. As a byproduct, the patient that would have gotten the CT scan for migraines before when there was no time for a longer discussion, now finds out that some lifestyle changes addresses the issue. I liked the quote from one doc. He said that a great scalpel helps make a better surgeon and great communications helps make a better primary care doc. Naturally, more communication can happen in 30 minutes rather than 7.

    If you don’t believe it, just talk with the doctors practicing this way. I could give you a long list of them. Some of the articles linked to above expand on what I shared here.

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    It’s my understanding that these doctors earn their retainers from patients who willingly and happily pay the premium amount by their own free choice. This ensures that the patients are quite satisfied with the quality of care they are getting. It should be quite fulfilling for the doctors to know that their labor is valued. If the doctors stop giving exceptional care to the patients, then it would stand to reason that the patients would go to some other, more desirable, retainer doctor or even just go to some non-retainer doctor. A system like this gives the physician plenty of incentives to make the patient happy, with the patient being the ultimate judge of quality of care.

  • Anonymous

    Along the same lines – is there anything unethical about accepting a “tip” from a patient. Never happened in the mill, but now patients want to pay me MORE than I ask for & some leave tips. Maybe we should all
    have tip jars in the office. One way to save primary care – sort of. . .  

  • http://www.facebook.com/people/Joe-Ketcherside/100000137792301 Joe Ketcherside

    One of the first things unions did when they entered many industries was to eliminate piece work since it was so abusive to the workers. And yet physicians vehemently defend their right to be paid by the part! And then they wonder why the payers steadily drive down the price per piece so that they are forced to increase their work rate to the point that quality of care and life suffer. 

    Just as was written about work hours for healthcare, there are things that are considered macho in medicine that are illegal in other industries.

    • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

      Whether piece work is abusive to workers or not, shouldn’t that assessment be decided by the worker for himself/herself, not by some union boss. Besides being macho, as you say, remember that there are many things that are good, moral and beneficial to people, but yet are illegal in certain industries.

  • Anonymous

    Greed is not the main thing here. Retainer medicine is, at bottom, a reaction to underpayment, overwork, and, frankly, the abandonment of primary care medicine by the rest of medicine and by society as a whole.  Under stress, people seek shelter.  Primary care is more stressed now than it has been in my 22 years of doing this. 
    Expect increasing attempts at self-preservation by physicians in the future, until or unless things get better.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Well written and far clearer than the co authored piece you refer to. Thanks .

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