Common criticisms of concierge medicine that deserve to be answered

The idea that patients are better off paying their doctor directly and using their insurance only for unaffordable catastrophes is gaining some traction. With implementation of the Affordable Care Act looming in 2014 many patients are looking at their doctor’s already crowded waiting room and wondering how their care will be impacted when their doctor is responsible for even more patients. And doctors who even now are swamped and frustrated with insurance bureaucracy are wondering how much worse things will get when they have less time for more patients.

Bloomberg Businessweek published an article which asks, “Is Concierge Medicine the Future of Health Care?” The headline lifted my spirits because of its happy presumption that healthcare has a future. The article interviews several concierge doctors. It makes the important point that practices in which patients pay doctors directly are now thriving at many different prices. From practices charging tens of thousands of dollars a year targeted to the very affluent to practices charging $50 per month for blue collar workers, doctors have found that they can take better care of patients by caring for fewer of them and by concentrating on practicing medicine the way they were trained, not by focusing on what’s covered by a policy.

The article brings up some very common criticisms of concierge medicine that deserve to be answered.

One objection is that concierge medicine leads to a two tiered system in which the affluent get attentive care and everyone else doesn’t  That’s nonsense. The whole point of the article is that direct-pay care is working at many different prices and that some of the practices are targeted to middle class patients. There are already many more than two tiers of healthcare — the county system and Medicaid for indigent patients, private HMO insurance, staff model HMOs, PPOs, direct-pay practices, etc. How many tiers are there in other marketplaces, like food, housing, or clothing? A practically uncountable number. One characteristic of robust marketplaces is that they offer goods at widely varying prices. That means that those who need to save can still afford some access to the marketplace but those who can afford more can get better comfort, or better quality, or more reliability. I can get across town for the price of a bus ticket or the price of a BMW. (I ride my bike.) How many tiers is that?

Another objection is that by shrinking their practices to only those who can afford them, doctors who switch to the concierge model are exacerbating the coming primary care physician shortage. Of course the opposite is true. The physician shortage in primary care is fueled by the fact that people aren’t choosing to go into primary care. Nothing will attract more students into primary care than examples of happy doctors who are making a living practicing in a way that is both ethical and enjoyable. Concierge doctors are not the cause of the shortage; we’re the fix. What would the critics prefer? That we stay in the insurance model and tell medical students how miserable a career in primary care is? That we drop out of medicine all together?

I think the main barrier to even faster growth of concierge medicine is the name. Another problem is that the insurance model is so entrenched in our understanding that we now think of getting routine care through insurance as the “regular” way it works. We don’t have a name for it anymore. If someone says “I saw my doctor” we just assume that someone else paid for it. If she says “I saw my concierge doctor” we understand that she paid herself. But it should be the other way around. We don’t have a word for an accountant or a plumber or a lawyer who gets paid directly by his clients. They’re not concierge accountants or concierge plumbers or concierge lawyers. We need to get to the point that paying a doctor directly doesn’t deserve an adjective before the noun “medicine”. Paying your doctor is just medicine. Having someone else pay for you is insurance medicine.

The Buisnessweek article quotes Josh Umbehr, a concierge doctor in Whichita.

“Health insurance should work more like car insurance,” says Umbehr. “We have car insurance for all the big stuff, but we pay for gas, tires, and oil changes ourselves.”

He’s right. I wish I’d thought of that.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • http://twitter.com/RHR_Chat RHR_Chat

    The relevance of concierge medicine is the direct pay model. If patients were charged the actual, real cost for office visit then inflated medical costs would start coming down.

    It is irrational that a procedure has 4-5 different costs both within and between medical facilities based on the insurance carrier or private pay. Let’s get back to the real cost of services.

  • ninguem

    Who coined the term “concierge medicine”?
    I’m willing to bet the term was coined by its critics.

  • mellormagic67

    Anything Frenchified sounds high-faultin’…that’s the first problem, so the tag line will suggest elitism. All these various models will worry folks because people simply fear change.They know, too, that the wealthy always gets the sweetest part of any situation. Until we actually live with the different modalities, we’ll not be able to seriously weigh them…

  • Suzi Q 38

    I am having difficulty understanding this.
    Say that I have borderline diabetes, controlled colesterol and hypertension (with meds) uterine pre-cancer, borderline ovarian tumor and a cervical spine blockage. Luckily, I have PPO.
    How would I be able to utilized concierge medicine, thereby getting better service and covered by my insurance.
    Since I pay $850.00 per month for PPO, is that better than opting out of PPO and getting HMO for hospital or catastrophic and paying $450.00 for concierge to augment the HMO???

    • Juliet Mavromatis

      Having a PPO instead of an HMO means that you have more choice in selecting doctors. Having a concierge doctor in many cases means that your personal doctor has more time for you. While a PPO may guarantee choice, it does nothing to ensure that a doctors patient panel size is reasonable, that a doctor will be able to see you promptly, take care of your concerns personally, and give you adequate time. Concierge medicine attempts to address these aspects of the primary care relationship. Remember–paying for “top notch” health insurance is still not the same as paying your physician directly.

      • Suzi Q 38

        I am going to look into my health insurance to see what the HMO side of BC covers and what hospitals and doctors are listed as part of the paid group. If there is not much difference, maybe I can switch to BC HMO and then augment with a concierge doctor/group. $850.00 a month may give me some flexibility, but I am not sure of what my HMO premiums would be.

        Are there concierge physician groups in Southern California?
        I will not make any drastic moves at this time because I need surgery, but maybe later, when my health issues settle down more.

        Thank you.
        I will admit I would not pay $5K per year, but maybe half that would be fine for my needs, since I am somewhat “fussy.”

  • DavidBehar

    Call it a Health Savings Account. For half price, when young, get a policy with a high deductible, such as $10,000. Put the other half of the money into a tax free investment account. Do your own pre-auths for procedures under $10,000. Stay and die healthy, pass that asset, potentially $millions, to the heirs.

    • Suzi Q 38

      Thanks. Too late for us, but good ideas for my adult children.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Sorry, but the numbers don’t quite add up for me. The difference in price between a low deductible and a $10,000 deductible is way less than $10,000, so you’d better not have any major medical expenses in the first few years (or ever, if your investment account falls prey to Wall Street’s whims). Better not have an accident, or a baby, or need anything else that involves a hospital, because if you do, your concierge subscription (which should be deducted from your “investment account”) won’t cover anything substantial. “Stay and die healthy” is not an actionable financial plan.

      • DavidBehar

        Margalit: After 2 years, you can just write a check for $10,000 if necessary. You do not pay for concierge medicine unless you have a chronic condition that is not doing well. Otherwise, it is a total waste of money. You can ask, on the phone, “What is the full price for an evaluation. I am bringing that amount in cash.” You will get to see even the concierge doc for hundreds, not for thousands. I agree with Suzi, this scheme is for the young and healthy to begin.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          The risk may be smaller for the young and healthy and childless, but then again, they don’t really need concierge doctors either.
          For people that hover on the edge of Medicaid, $10,000 is about 5-6 months worth of work. That’s a rather large annual risk, and it’s not really capped until Obamacare and the dismissal of preexisting conditions kicks in.
          I am not opposed to concierge or direct primary care, but I am opposed to steering folks to having outrageously high deductibles.

          People need to understand that, in the current dysfunctional environment, they still need regular insurance and concierge is just an extra perk if you want it, need it, and can afford it.

      • DavidBehar

        Margalit: I realize the public gets the crumbs on Wall Street and only full time insiders do well. Just invest in index funds, ones that buy all stocks, and track the market. When it tanks, buy even more. It is coming back, as it always has.

    • Suzi Q 38

      It is difficult to do that. I have had hypertension since I was 28.
      Of my 5 siblings, 4 of them have full-on diabetes, high cholesterol, and hypertension. Our dad had two bypasses, and died at 68.
      I have uncles and aunts that died in their 60′s and earlier.
      I still have cholesterol challenges even though I weigh 40 pounds less that I used to and I wear a size 6 or 8. “Stay and die healthy,” with my family history and occasional food abuse, is tough to pass on.

  • http://www.thehappymd.com/ Dike Drummond MD

    The concierge and direct care business model is changing rapidly as more and more people become willing to pay a little extra to see their doctor. I have seen concierge premiums as low as $200 a year … and new business models and “franchises” are starting up monthly to meet demand. This is not “just for the wealthy” any more and is a rapidly changing area in primary care.

    And note that there are two main drivers of concierge and direct care … the patients who want to see their doc when they are ill AND the doctors who want to have time with their patients rather than be a gerbil on a wheel in a high volume “patient mill” style practice.

    The main hidden difference in these two delivery models is OVERHEAD. A concierge/direct care doctor has a very low overhead … so they can see far less patients and spend far more time with them and make the same amount of money. The big, high volume clinics are that way simply to feed their enormous overhead.

    Here is an example of direct care for indigent patients that is cash only and supports a doctor quite well while she treats folks who would otherwise slip through the cracks. Pam Wible MD is an inspiration in this area http://www.idealmedicalcare.org/ideal-clinic.php

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

    • Suzi Q 38

      I know for me that it is not an option, but for others, it has “promise.”
      I could see me going for this when I was in my 20′s and 30′s.
      I am learning more about this with our various discussions and I will most certainly “spread the word” if I feel that this model would benefit a friend or family member.

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

        As you get older and your care becomes more complex is exactly when these types of practices that can devote more time and attention to you are of greater value

  • civisisus

    vic,

    Confirm for me that you’re not taking the practice of medicine back to some Marcus Welby fantasyland where the kindly old doc keeps all the info about each patient’s care between his/her ears, or in musty old manila folders, and has no means of readily, usefully conveying what medical wonders s/he’s worked for his/her patients with anyone, and I’m prepared to listen.

    Otherwise, your cash & carry model is no better for patients, or anyone else except maybe the practicing clinician, than the insurance-addicted ‘conventional’ practice model you’d presumably supplant.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Don’t know about Dr. Fuchs, but the few concierge docs I know, have really nice EMRs with patient portals and all sorts of bells and whistles. I think it’s because they have plenty of time to fiddle with computers and gadgets… :-)

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    Honestly, I find most of the critics of this style of medicine are academics who fear that they will be “left out” of it’s growth. But this is just not true. Mayo clinic has started it’s “Medallion” program and most other major academic institutes are going to be rapidly following suit.

    Interestingly enough, most of the “resistance” has come from within medicine. Government and insurance companies have mostly stood by and watched the change. I think they realize it is good business for them to. improved primary care means less ER and hospitalizations. Insurance companies and the government are thrilled to see direct care practices grow.

  • http://www.facebook.com/jamesleeko James Ko

    Great post! This is a very real dilemma facing healthcare providers. You brought out points many dont even recognize. Thank you.

  • http://www.facebook.com/timrichpt Charles Timothy Richardson

    Physical therapists cannot opt-out of Medicare, like physicians can, so there is a huge barrier to the direct pay model for this important group of providers (about 177,000) nationwide.

  • DrNancyHoffman

    I find that most of these discussions about how clinicians manage their practices so they can actually AFFORD to stay in business fail to discuss the elephant in the room — namely the record profits being reaped by the insurance companies. If those billions of dollars “earned” by United Healthcare for instance were used to pay clinicians for providing care rather than to line the pockets of investors, we’d be having a very different conversation.

  • buzzkiller

    I know a guy who knows a guy who tried concierge but couldn’t attract enough pts because of where he lived. Also, what about carrying a pager 24/7/52? Seems pretty nasty to me. How do concierge docs deal with that?

  • 99bonk

    The basis of concierge practice – the retainer fee, is similar to the capitation fee paid in a single payer system, the difference being the additional charges for procedures during an office visit It should be possible to work out what an appropriate capitation fee per patient would be, including procedures, for an office practice with some experience. Getting data of this kind would help to provide a model for a single payer system for office practice. We need some numbers!

  • http://www.facebook.com/profile.php?id=1590806474 Michael Tetrault

    As the author of “Branding Concierge Medicine”, I can tell you first-hand that’s one of the biggest problems the concierge medical industry has had is … brand acceptance. We’ve been trying to educate for years the cost-effectiveness and efficacy of these types of practices. One of the biggest reasons the term has stuck around is its memorable… that has helped pushed the brand to where it is now. If you’d like a good resource about all the educational efforts, I’d suggest you look at the following sites also… conciergemedicinetoday [dot] com ; conciergemedicine101 [dot] com and The Concierge Medicine Research Collective, the data gathering and survey arm of Concierge Medicine Today, an independent and private educational outlet reporting the news of the day in the concierge medical, direct care and private medicine marketplace.

  • Daniel Polowetzky

    My health insuran