Concierge medicine: Winners and losers

By now you’ve probably heard of the concept of “concierge medicine.”

To me, it’s an idea that’s Win-Win-Lose:

Win: Doctors. Those in concierge practices have chosen to forgo the traditional business model in favor of  charging annual fees that range from $1500 to $15,000 per patient. How much you pay depends on the market, exclusivity factors, and amenities, like comprehensive annual physicals with add-ons like a dermatology appraisal and nutrition consultation. Concierge docs see many fewer patients in their practices than regular primary care doctors. As such, they can spend more time with each patient, and practice medicine in a more deliberate, thoughtful fashion. They are freed from the hassles of complying with and filing insurance claims. MUCH more money flows into the practice, since it’s paid in full on a monthly basis. Summary: fewer patients, more money.

Win: Patients that desire this model and can afford to opt in. They get the satisfaction of having a doctor at their beck and call (cell phone access), services like comprehensive annual checkups with amenities, and if anything goes wrong, their concierge doctor can use his network to get streamlined, coordinated specialty care.

Lose: The rest of us. Very few people can or will opt in to this model. And that’s by design. By limiting himself to the market’s high end, the doctor raises the exclusivity (and revenue) bar. Moreover, with every doctor that opts in to a concierge model, we need someone else to serve the rest of us.

Now come the docs who don’t have a taste for the high end. They struggle with the exclusivity of the concierge model but aren’t happy with the status quo–feeling like hamsters on a wheel and having to always go faster. More patients, shorter visit times, more administrative regulations to cope with.

Hence the advent of the “direct practice” model. Direct, because you pay your doctor on a monthly basis to belong to the practice, but at a more affordable price point-a maximum of $100/month, but usually more around $60. No amenities here, other than access and evaluation by a doctor who knows you well.

There’s a guy I admire named Dr. Rob Lamberts who’s in the throes of making such a conversion. Dr. Rob is boarded in internal medicine and pediatrics, and works in Augusta, Georgia. He’s practiced office-based primary care for adults and children for sixteen years. Rob admits to being kind of a nerd; he started using computers in his medical practice way before it was cool, incentivized, or required. As such, he feels that in that regard he was ahead of the curve.

Rob is also a terrific and funny writer and blogger, and he’s been incredibly transparent about his decision-making process as he’s decided to leave his group practice and switch to a direct practice model.

When good guys like Rob start to feel that working ‘outside’ the system will be more fruitful and productive than making change inside the system, I worry that the transformation of health care will be slower and more painful for all of us.

John Schumann is an internal medicine physician who blogs at GlassHospital.  

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  • http://twitter.com/DarrellWhite Darrell White

    “When good guys like Rob start to feel that working ‘outside’ the system will be more fruitful and productive than making change inside the system, I worry that the transformation of health care will be slower and more painful for all of us.”

    That’s one way to think about it. You could also say that Rob is simply returning to a prior, proven system (or modest variation on the same), in his opinion showing that “new and improved” is simply “new.”

    Or you could look at the model and decide that Rob’s solution to the issues the present “system” has is spot on and look for ways to move MORE docs and patients in that direction. Perhaps Rob IS THE TRANSFORMATION of health care.

    D.

  • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

    I recently started a low-cost “direct” (concierge) model and think primary care without middlemen can, should and will be much cheaper in the near future. We charge a membership fee of $10 or $20 per month plus upfront, low prices for visits, etc.
    - Dr. Neu

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      This is a growing model that I think bears fruit. My practice is looking to move to a “Concierge Light” model. We would charge $199 per adult and $149 per child per year for same day/next day (24 hour) scheduling, email access, and 10 minute longer appointment times. At the same time we want to continue to see are normal patient population. It should allow us to collect more revenue (or a least the same revenue) but see less patients (less burnout) per day. I am aiming for a model of 16-18 patients per day rather than 20-24.

      The idea is that they still have their insurance but now have more access. Also we would include free a free flu shot and waive one copay per year.

      It hasn’t happened yet, but we are definitely looking into it.

  • http://www.facebook.com/leilani.allmon Leilani Allmon

    Personally, I don’t blame PCPs who want to cut out insurance. That’s how it used to be back when doctors still made house calls. Everything would probably be much more affordable.

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

    The current market forces in medicine and the coming “pseudo shortages” of physicians make concierge a very viable option for doctors in primary care. Let me ask you … if you could see only 6-12 patients a day in a small office and take enough time with each of them AND not take a pay cut, would you?

    If you are not seriously looking at the business model you are doomed to be in a “patient mill”, at the head of a care team of midlevels, seeing only the sickest people in a high-overhead big clinic. Learning how to maximize the quality of care in the big clinic model is what healthcare reform is about … and concierge/direct care is an alternative to that volume driven system that all primary care docs should take a look at.

    Concierge is NOT an elitist model. I have seen premiums as low as $200/year. Would you pay that to see your doc when you are sick and not be rushed? Just askin’

    Dike

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

    • buzzkillersmith

      Your second paragraph pierces the fog that surrounds primary care reform. I’m going to steal it and use it, but with attribution. You have gotten down to the bones of things, doctor. Very impressive.

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

        You are such a BuzzKiller (NOT) … you are welcome to steal it and I would appreciate the attribution. I see this as a fork in the road. Here is the full article on the subject at my website.

        http://www.thehappymd.com/concierge-medicine-driven-by-doctor-shortage/

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

  • glasshospital

    To be fair, Rob Lamberts responded to the piece over at my blog. Here’s what he wrote:

    Leaving my traditional practice was (is) a scary thing. I don’t actually feel like I am “leaving the system” per se, as I am only leaving how it’s paid. I see concierge as an “escape hatch” for docs (getting out of the system), while what I am doing will hopefully end up being a legitimate alternative path. If I can get the patient numbers close to where it was, keep the cost down, and demonstrate both quality improvements and cost savings, then it may be bigger than just me making my own little corner of the universe better. I’ve got a lot more to write about, to be sure.

  • brian

    My father always taught me, “If your not going to do it right, then dont do it at all.”

    In residency, I was scheduled patients every 10mins because i had to “learn how to maintain a practice”.

    I hated it. My patients hated it. At the end of the day my care sucked. not because I was a poor doctor but simply because I had no where near enough time to “Do it right!”

    That was almost 10yrs ago, I now have a housecall practice where I see 8-10 patients a day giving each my undivided attention.

    I work my butt off and have full days, but at the end of the day my patients are happy and I am proud of the work I have done. I love what I do.

    I’m a little tired of hearing this argument of how “If Primary care docs start only seeing 10-15 patients a day, then who’s going to see everybody else?” This argument always seem to come from academics who have rather cushy pay and benefits with no real worries of malpractice or billing issues as they are shielded by their institutions. Quite disingenuous for such academics to bemoan how “WE all suffer” because some physicians (who don’t have institutional protections and benefits) have decided to practice in a simpler more full filling way. Which, by the way, as Dr Drummond noted does not have to be cost prohibitive…. Why when we talk about PCPs making a little more money we are somehow demonized for it?

    Why should I be forced to see increasing numbers of patients with worsening reimbursement simply because the “system” has done a wonderful job of discouraging people from going into primary care?

    Why is that my problem?

    I love my patients. I love what I do and at the end of the day, if i’m forced to give mediocre care to 20-40 patients a day, well then,

    I just wont do it.

    • southerndoc1

      The idea that the lot of primary care docs is so bad and the job is so unattractive that it’s immoral for any one of us to try for something better is VERY strange.

  • Matthew Mintz

    Agree with your points, but you seem to be separating concierge (I prefer the term retainer) and “direct practice” (also called direct primary care), suggesting the former is more evil (“rest of us lose”) and the later is a savior.

    At $100/month, this is $1200 which is close to a retainer fee. Though you quote $1500 to $15000, the vast majority of retainer fees are between $1500 and $2000. The bottom line is that retainer medicine, direct primary care and even doctors who stop taking insurance (an even better deal for many if you only need to see the doctor a few times a year) are all responses to a broken system that undervalues primary care.

  • ninguem

    Did it occur to people that the doc going private direct-pay is escaping insurance RULES as well as pay scale?

    In fact, should I ever go direct-pay, it will be precisely because of insurance rules, not because of pay.

  • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

    Interesting article. I started the first “concierge” practice in Monterey, CA, subsequently becoming the house doctor for the Pebble Beach Resorts. Later, I created MedLion, one of the fastest growing “Direct Primary Care” practices in the country as a way to help doctors get into Direct Primary Care practices of their own. It should be pointed out that both models have their strengths and their weaknesses. Each can be criticized, and neither is the solution to our nation’s health system woes. Both models, however, reflect the courage and vision of several select doctors who are trying to do something out of frustration. These practice models have their imperfections, but perhaps they will help create other new models. Direct primary care came from concierge medicine. Perhaps solutions will come out of direct care practices? Until physicians stand united in the face of the current status quo, little will be accomplished and our frustrations as a group will continue – if we survive that long. Kudos to every single concierge, direct care, and innovative-field doctor who has the clarity of mind to innovate, challenge, and have the strength to swim upstream.

  • southerndoc1

    Don’t see how in the world you can say “the rest of us” are losers.

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

      Agreed.

      first of all, even at a thousand dollars a year. these innovative practices are hardly for “the rich” and I find it hard to believe Dr Shumann could not afford this, lumping himself with the “poor losers” who pay much more than that for cable, cell phones, cars, and any number of privileges.

      even if the US paid 1000/yr more for EVERY person in the country for primary care, it would only come to ~300 billion dollars.
      a huge number but nothing compared to the 3 trillion dollar yearly US healthcare system.
      Personally, I believe the 300 billion would easily be saved with a drastic reduction in ER and hospital care that would occur with more intensive primary care.

      So Dr Shuman, I ask you. how can we NOT afford to improve Primary care pay?

  • glasshospital

    Yes, doctors who practice in concierge/retainer/direct practices will be happier. Who wouldn’t be happier working less and earning more?

    I do believe that doctors have a right to be happy and be paid what the market will bear. Some will find however, that the market may not bear so much. And you’ll therefore be forced to cater to the high (as in “worried well”) end.

    None of the commenters have any answer for the mass of patients (and I do mean “us,” as I’m one, too) that are and will be excluded from this “innovative” practice model.

    Oh wait. I hear that some of you offer “scholarships” to your low or fixed income patients. That is generous, considering you’re under no such professional obligation to do so.

    • southerndoc1

      “any answer for the mass of patients (and I do mean “us,” as I’m one, too) that are and will be excluded from this “innovative” practice model”
      Maybe patients, employers, and insurers would quickly realize what we’ve been telling them for decades (i.e., that you can’t treat primary care docs like dirt and expect to have an adequate supply) and then actually do something to improve the situation?

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

      If the “systems” reimbursement was equitable and the government would stop throwing unfunded mandates at PCPs, then plenty of people would happily do primary care.

      PROPERLY incentivize good primary care, stop using the stick and you will answer your own question. Plenty of Primary doctors for “the mass of patients.”

      Most of my PCP colleagues are happy with what they make…. just not happy with the job they HAVE to do to make it.

      The answer you seek Dr Shumann is simple. Either raise PCPs pay or reduce the PCPs burdens and unfunded mandates.

      it doesn’t have to be money… but since I see no HOPE that the government will reduce our burdens or stop hunting us with bounty hunters and treating us all like con artist….

      we have to create our own answers.

  • win38

    If I was a healthy person, one who saw a doctor every few years, I wouldn’t pay $1000 retainer fee for a primary care doctor.
    During those years when the diagnosis was hard to find, an appropriate treatment even harder, and I spent most of the time sitting in a specialists office, would I pay $1000?
    Would I pay $1000 after I refinanced my home to pay medical bills?
    Now things are humming along, I saw my PCP only once this year. Would I pay $1000? A $1000 for one appointment? How sick do I need to be to make that worthwhile?

  • lord acton

    I have been doing direct primary care for 2 years. I am charging my patients $50 a month. I have taken a large pay cut to get off the gerbil wheel. My patients come from a wide range of socioeconomic backgrounds and I have many “charity” cases. I love what I am doing. Each year my income is growing, but it will probably take another couple of years before I am making what I made (which was below average for an F.P.) on the gerbil wheel. Being a doc is not about the money to me. I could not continue on the gerbil wheel. Period. So yes, I am seeing fewer patients, but I am practicing and hope to do so for the next 20+ years. So who exactly am I “screwing” by having taken this road???

  • http://twitter.com/mattMD Matt McCord

    Nice article but I disagree that few will opt for such a model. With the ACA the new crisis will be access to care. Big (and smaller) businesses will self-insure to contain costs and look for models of health care that lower costs and improve access for their employees. Just like we have recently seen with Walmart and Darden Restaurants. The concierge model may solve both problems.

    The direct pay or concierge model simply cuts out the middlemen which are the real drivers of cost in medicine. This benefits both patients and doctors. It also allows for innovation and entrepreneurial activity to occur at the point of care which may help all of us scale care and health care delivery.

  • lord acton

    I would also add, by not billing medicare and medicaid (yes, I have plenty of patients on these programs) I am saving the “system” a small fortune. By taking care of my patients 24/7, I am saving the “system” a small fortune in expensive ER and hospital care. I have prevented many ER visits and hospitalizations, funny how you can do that when you are not a 9-5 doc in a box seeing 30+ patients a day. So again, how am I the bad guy??

  • http://www.facebook.com/profile.php?id=1412715500 Ed Sodaro

    Shocking news!
    Highly trained professionals who have sacificed their youth studying don’t want to be the happy slaves of a corrupt quasi-totaitarian federal regime and its crony capitalist insuance company criminal associates.
    Man,who could have ever seen this coming?

    • Molly_Rn

      Give it a break. Every f”ing thing isn’t political. Bet you aren’t a physician or a medical person at all.