Don’t blame doctors for going concierge

Merrill Markoe’s reports that she was fired by her doctor in her article, “My Doctor, the Concierge,” which was both sarcastically entertaining and painfully true.  She writes a powerful commentary on the divide caused by insurance companies between doctors and patients.  She is shocked at the rapidly growing trend of an access fee to see concierge doctor and yearns for the Hippocratic Oath’s “May I long experience the joy of healing those who seek my help.”

Nothing cuts the cord between the doctor and her patient like the mention of money. Yet, doctors all over the country are rushing to become “concierge physicians.”  The more you pay, the closer you can get to the doctor. For $1000 a year, you can be part of the club.  Pay $2000 annually and you can have the doctor’s email.  Pay $3000 and you can text or call her cell.

Our society expects doctors to be healers.  Who doesn’t?  But the Hippocratic Oath does not address the business of medicine, nor does it demand the physician to provide uncompensated care.  The Oath is a covenant to provide the best care possible with dignity.

Society must remember that doctors have to pay back an average debt of $300,000 for 12 years of graduate schooling and not forget related opportunity costs.  Medicine is the only business where every year the overhead increases while third party reimbursement diminishes.  Moreover, a physician can work for thirty years and on her retirement, her practice is worthless.

There are also factors which affect cost of medical care over which doctors have no control.  Insurance companies take some 30% of the healthcare dollars and provide no medical benefit.  The FDA places so many restrictions on drug approval that it costs $1 billion to bring a drug to market.  There are universities such as UCLA which take federal and state dollars to do research while setting up practices in the community, competing unfairly with private doctors and charging hospital rates for office visits.  10% of all gross receipts of any practice is spent collecting monies from insurance companies and patients.  Doctors at their own cost purchase medical supplies and provide them to patients, risking denial of reimbursed by insurance companies.

There are also government mandates which increase costs to doctors.  With the advent of Obamacare, there is increased cost of ensuring valid coverage, to receiving approval for treatment plans.  Populating  electronic health records (EHR)  and generating meaningful use is time consuming with no reimbursement.  Prescribing the most cost effective treatment in a litigious environment remains an oxymoron.  Doctors, too, must ensure proper coding as not to leave a bad diagnosis on the patient’s chart that could affect his eligibility for obtaining life insurance, while picking a good enough diagnosis to be paid by the insurance company.

Finally, there are a number of services that have traditionally been provided by doctors gratis.  These services amount to several hours per day and include returning patient, hospital and pharmacy calls, completing letters written for return to work or disabilities, peer-to-peer discussions to get the prescribed treatment authorized.  Doctors also remain on-call for emergencies and do not get paid for driving to the ER at midnight.

Lawyers have long charged clients for services rendered in their absence.  Writers expect to be compensated for their creativity, wit, style.  Yet, somehow we have developed an attitude that, “If I pay for insurance, I should be covered and should not have to pay my doctor.”  Insurance company payments don’t begin to cover the costs of running a practice.  A typical fifteen minute office visit is billed under a code of 99213 and reimbursed at $40.  That is $160 per hour.  Now remove all the costs mentioned above and the practice is bankrupt.  Most general practitioners make less than the pharmaceutical reps who call on them.

As a healer, a doctor cares for your most important asset, your health.  Should she not be compensated according to her training, abilities and talents?  There is tremendous joy in the practice of medicine, but that joy does not pay student loans, cost of running a practice or for schooling for future doctors to be raised by current ones.

Afshine Ash Emrani is a cardiologist and can be reached at Los Angeles Heart Specialists.

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  • guest

    These are all great points, with which I agree, but unfortunately they do not address the public perception that doctors are “public servants,” educated at public expense, and so the public should expect low-cost, or no-cost medical care from them. Then there is also the question: why should doctors make more than teachers, or other highly educated professionals? Why should doctors make more than the median salary? Until we are able to answer all of these questions effectively as a profession, we will continue to leave the impression that we are greedy.

    • Suzi Q 38

      “…..Then there is also the question: why should doctors make more than teachers, or other highly educated professionals? Why should doctors make more than the median salary? Until we are able to answer all of these questions effectively as a profession, we will continue to leave the impression that we are greedy.”

      So true.

      Dr. Emrani discloses that the average debt for most physicians is $300K.
      That is a lot, but isn’t that amount similar to what a professor with a doctorate owes?
      How about a lawyer with a degree from Harvard or Yale?

      Surely there are other students with other professional professions who owe similar amounts and don’t garner the salaries that most physicians make.

      There is an unemployed lawyer living across the street who owes about $200K in student loans without a full-time job.

      My friend is a pediatrician and has to compete with PA’s and NP’s for jobs. Her salary is not as high as she had hoped when she graduated from medical school.

      Would I pay extra for a concierge doctor?
      Maybe. It depends on who was asking, and why h/she was asking for it.

      My dentist offers coffee, tea, and fruit for his clients.
      I can also put my hands in a machine of wax and it feels divine.
      He calls it a Parafin wax treatment for my aging skin.

      What do all of these “extras” have to do with delivering good dental work? Nothing. I will admit, though, it makes me look forward to my visits.

      • FEDUP MD

        Most pHd candidates are paid stipends during their time in grad school and have their costs of tuition covered. So no,they do not owe similar amounts at all. Also, lawyers have many years less training than MDs. They are able to work independently after 3 years of law school. Med students have another year of tuition and then another 3-7 years of minimum wage job before they can work independently. Granted, there is a surplus of lawyers, and that is because there are 44000 law students entering per year as opposed to 18000 med students. Are that many lawyers really needed? Unless a lawyer goes to a top school or is at the top of their class they run the risk of unemployment due to supply and demand- but this is no secret and they should be aware of this before entering. And teachers again typically have a bachelor’s or master’s. This is between 5-11 years less training than an MD. So comparing all these professions to each other is comparing apples to oranges.

        • Suzi Q 38

          Are these stipends $40K to 50K a year?

          • DoubtfulGuest

            Mine’s 20k…officially that is for half-time work. Full tuition remission and health insurance. In my part of the country, I can live frugally yet comfortably on that. Some days I work like a dog…long hours. Other days I sit around reading papers and I have “meetings”. It balances out to more than half time work, but it’s just not that bad. I can have coffee, lunch, snacks, bathroom breaks whenever I want to, usually. No one yells at me, if I make a mistake I just fix it. I have some debt, but that’s from undergrad years and medical bills, not for lack of PhD support. I can’t vouch for other schools but most people I know are able to get funding. They might have to ask around and do some hourly work for a semester or so. I’d be lying if I said there was no stress, but I’d estimate it’s about 1/10 that of doctor training and I’m not incurring any debt for this.

          • Suzi Q 38

            Thanks. I honestly did not know.
            I agree, being a physician day after day is much harder than most professions.
            It definitely is stressful.
            My job is 2 compared the the physicians 10 is my guess.

    • Dr. Drake Ramoray

      I don’t think physicians can convince the public. The AMA is a cabal more interested in protecting it’s CPT codes than anything else. Even the politicians on capital hill think the AMA is inept for continuing to raise cane about tort reform, but not using that as leverage for their approval of the ACA (before they were against it). You know your in trouble when DC thinks your incompetent. The AMA represents less than 1:5 of physicians. Higher ups from the ACP make fools of themselves on this blog on a weekly basis. The truth is there is no voice representing physicians at this point. My society, AACE, does a pretty good job but only represents about 6000 physicians.

      CNN has described income inequality as the “issue of our time.” We live in an age when pediatricians debate about dismissing patients whose parents refuse vaccinations. I am not blind to the manufacturing to the lowest bidder and quality control from big pharma, but vaccination is one of the greatest medidcal acheivements in eradicting disease and improving health, short of basic sanitation and the development of antibiotics.

      If the general public can’t be convinced on the idea of vaccination and 1:4 people think the sun revolves around the earth,

      http://www.ktvu.com/news/news/national/1-4-americans-think-sun-revolves-around-earth/ndQBb/

      then there is little hope that physicians can make an effective case that they are underpaid. Personally I’d rather find an effective way to communicate to society that a large portion of illness in this country is the result of poor lifestyle choices in the form of lack of appropriate diet, exercise and not taking care of themselves.

      I will take issue however with your stating that physicians are trained at public expense. Education loans are not dischargeable in bankruptcy. I will not deny that the government pays for residency training but given the hours worked (I haven’t done the calculation for current residents as I don’t know current resident salaries) when I was in training (before work hour restrictions), I made less than minimum wage. That’s right the push for a “livable wage” currently being argued is more than I got paid as a resident. I was slave labor, and the academic centers are designed around this model (well that and research grant money). I have no illusions that I can convince the public of that either.

      I think that physicians who decide to go concierge just chalk this up to one of the other battles that they are tired of fighting. And that’s just it. I’m growing tired of trying to convince insurance companies that this is the right medication for a patient, that Mrs. Jones needs to check her blood sugars more than twice a day, that the patient with an elevated prolactin level needs an MRI, and that non-procedural specialists and primary care docs are underpaid. Why does anyone need a doctor? The insurance companies control what I prescribe, the algorithms tell me what to do, and the insurance companies and government will grade me on how I’m doing. Let the beuracrat on the other end of the phone manage the patient, they seem to know what is better for them anyway and it’s much more efficient seeing as they didn’t waste thirty plus years of their life training to be told what to do.

      Like our neurosurgical colleagues down the road who no longer actually perform much neurosurgery and only perform back surgeries (reimbursement and hassles are better), the ENT I know in Florida who only performs parathyroidectomies, and the opthalmologist who only performs cataract surgeries, many in Endocrine are moving to a thyroid only practice. We are an under-represented specialty with a massive shortage that isn’t going to get better anytime soon and there are no metrics for hypothryoidism, hyperthyroidism, and thyroid cancer. For me it’s not about the money as much as it is about the hassles and the number of non-medically trained people who tell me how to do my job. Some of the conciege docs I know make less money (and I know two who failed at the enterprise) but those in concierge making less are happier because of the reduced hassles. But just like physician pay, I probably won’t be able to convince many people of that either.

      • SarahJ89

        Every article I’ve read written by doctors who’ve gone into concierge practices (including the ones who deny that’s what they’ve done and give it another name) make it clear the real reward is “being able to practice medicine the way I want to.” And that rings true to me. Front line workers (teachers, social workers, doctors and many other people providing a direct service) nearly always simply want to be left alone to do a good job. Somehow doctors have gone from being independent owners of small businesses to middle managers. Yikes.

        I’m on Medicare. I can’t afford a large annual fee, but I would happily pay for the rare office visit I make (once a year to get my levothyroxin scrip renewed) if I could be treated as a human instead of a widget in the corporate medicine cog and leave any hospital-type bills to my insurance. For which I pay, by the way–all of my working life and every month through my premiums–so please don’t treat me like a feckless free loader.

        • Dr. Drake Ramoray

          It is currently legal to charge the patient directly for a service not covered by Medicare, but it is not legal to accept Medicare and charge a patient directly for a service covered by Medicare. I have no control over Medicare reimbursement rates. For thyroid Medicare pays pretty well(for now), diabetes not so much.

          I’m not planning on going concierge thyroid (for now) although my group is starting to shield itself from diabetes. We used to have a Medicare wait list. Now we have a diabetes wait list regardless of insurance.

          • SarahJ89

            Dr. Drake,
            By “accept Medicare” am I correct in thinking you mean your accepting any Medicare patients as opposed to my using my insurance to pay you? I know it is illegal to bill patients for amount over what Medicare allows (I had little old ladies in my waiting room almost daily clutching bills from their doctors for this) but have never had to think about whether I (now that I’m on Medicare myself) could forgo using my insurance.

            And yes, it’s almost always about the hassle for anyone on the front lines in any profession I’ve ever seen. The people for whom it’s about the money find ways to climb that ladder out of the front lines rather quickly.

      • guest

        Just to clarify, I am involved in residency education and am quite aware that physicians are not really educated at public expense. But that is the public perception, because CMS and other entities have been much more savvy about image management than our profession or the organizations that purportedly represent us (the AMA for example).

        • querywoman

          Oh yeah? I got no student loans or grants for my undergraduate degree.

    • Kristy Sokoloski

      The public perception is that doctors are “public servants”, educated at public expense so the public should expect low-cost or no cost-medical care from them is a very interesting statement. However, there are people in the public like some of my friends that think that all doctors make a ton of money and live in very fancy, big houses, and drive very big and fancy cars. And they think this because they think that doctors have money stashed away to afford these things even after all the expenses and such to run an office have been taken care of each month. Not sure where some people get this idea, and it caused such an argument with one of my friends who thinks this way. And I saw firsthand about the work it takes (including financially just by looking at all the supplies that are necessary for a medical office) to run a doctor’s office when I went through an externship in a Primary Care clinic when I had gone to school for Medical Assisting back in 2011. It’s not as easy as so many people seem to think. And like I explained to her that the idea of what she thinks (that I just mentioned) doesn’t exist anymore. But then one of my friends also got upset because her insurance billed a Nurse Practitioner visit as if she had actually seen her doctor even though she saw the NP instead. And my insurance pays a bill the similar way for my PCP clinic if I see the PA if I can’t get in to see my regular PCP.

      • NPPCP

        Your insurance paid the physician fee because the physician billed as if they had seen you. NPs have their own provider numbers and are generally reimbursed at 85-90% of the physician rate. There are only a handful of insurance companies who do not credential NPs independently at this point. With ALL due respect to my physician friends here, if you got billed for the physician and saw the NP, then the physician billed the visit that way (unless they are an employee of CorpMed – then they have no choice). If you see a private practice physician, the buck stops with them. There is some good info for you.

  • NormRx

    “Lawyers have long charged clients for services rendered in their absence.”

    Lawyers also have another significant advantage. A lawyer has 48 billable hours in a day.

    • Suzi Q 38

      I know several unemployed lawyers.
      The job market for lawyers is not great right now.
      At least most physicians I know have a job.

      • NormRx

        I know of two unemployed lawyers. One embezzled from a client and spent the money on cocaine. The other was a corporate lawyer who was terminated. It’s just that the 90% of bad lawyers give the 10% of good lawyers a bad name.

        • querywoman

          I’ve written before that most lawyers are corporate paper pushers who work for firms. They work very hard, many hours.
          Most lawyers never step in a courtroom and never have a chance to ripoff a client.

      • querywoman

        I never dated a lawyer who had a job.

  • guest

    I completely agree with everything you say, but so far we have not managed to find an effective enough way to convey that message to the public.

    I know, and you know, that having jobs that are so stressful and risky that we come home completely tapped out and not really able to engage fully with our children in the evenings after work, must come with some sort of material compensation, if people are going to continue to do the work. But somehow we don’t have an effective way of explaining that to non-doctors.

  • Patient Kit

    In an ideal world, I would love to be able to afford a concierge doctor. But in the real world, as much as I value good doctors and what they do, I simply cannot afford to pay out of pocket for all primary care and, at the same time, pay a lot for insurance for specialists and everything else that isn’t seeing my primary care doc. I get that doctors have money problems. But, believe me, my money problems are even worse. I don’t have much of it. If concierge is the way most private practice doctors are headed, I guess I –and the rest of the working and middle class in America — should thank my lucky stars that I am getting excellent care from doctors at the hospital. Because it sounds like private practice docs are deciding not to treat working and middle class patients anymore. I hope there are enough patients with good cash flow to go around. Because a lot of us will be cut out from receiving care from you under that model. You should see what the economics are down here of just trying to survive. It’s not that we don’t value you or want to pay you. It’s just that we can’t afford you.

    • Kristy Sokoloski

      Patient Kit,

      Your post goes along with what I was telling some of the others that also insist that direct pay for Primary Care being the way to go. If PCPs go to the direct pay model or the concierge way as this and some other articles over the years have mentioned there’s going to be trouble. It’s going to be just as you say most of us will not be able to afford to see our doctors as we can now. And this is the case for my relative and I. We are able to see our doctors now thanks to insurance, but if one of the other two ideas comes in to play in the next few years then it’s not going to be just a problem of not being able to see the dentist regularly as is the case now, but we won’t be able to see all our doctors. And then we will get sicker because of it and we will have to use the ER and/or Urgent Care just like everyone else is doing right now. That will create even bigger problems then if people like my relative and I have to go to use the ER and/or Urgent Care for our regular medical care.

  • Kristy Sokoloski

    Arby,

    For many (not all) people the cost of a premium for health insurance regardless of the amount of the deductible is cheaper than concierge healthcare services or having just the catastrophic plan. As I explained in my other comment my relative and I could not afford the kind of care that other doctors think will help. And yes, while I do have insurance I also have a very good relationship with my doctors and yes, it is between my doctors and I.

  • NormRx

    Hi Vladimir, I was going to put the bad lawyers at 95% but I was feeling generous this morning. The reason health care providers has taken over is because of the influx of NP’s and PA’s into medicine. So as not to offend anyone, drug companies, insurance companies etc. refer to everyone as health care providers.

  • Lisa

    I can’t afford a concierge doctor. I believe most people in the community I live in can’t afford a concierge doctor.

    Instead of a concierge practice, I think a model more like that of lawyers makes sense. Charge for the filling out of forms, charge for the time spent getting a treatment authorized, charge for telephone consultations. I have no problem with a doctor’s practice charging for services that he or his staff provide. But to have pay a surcharge, over and above insurance and copays, to have access to a doctor is just too much.

    • goonerdoc

      How much does a concierge doctor charge ?

      • Lisa

        In my area, a concierge practice charges a retainer of about $2,400, which is not reimburseable by insurance. The practices are alos billing insurance.

  • goonerdoc

    1) Patients hate the exorbitant prices of their insurance policies….

    2) Doctors hate insurance company intrusion into their clinical decision making process, one of the reasons that some switch to concierge practices…

    3) Patients and doctors hate insurance company intrusion into their professional relationship…

    Yet doctors are the ones getting ragged on for trying to go concierge?

    • Patient Kit

      Sure, as a patient, I hate the high cost of insurance and the way insurance companies intrude on medical decisions that should be made by doctor and patient. The fact remains that most of us will still need insurance to access healthcare. Concierge/direct pay does not relieve us of the need for insurance. It just makes healthcare even more expensive for us. Hence, the angst! We would still have insurance premiums, deductibles and co-pays to “cover” specialists, lab and imaging, hospital, surgery, etc. PLUS we would have a few thousand dollar out-of-pocket retainer fee just to allow us to see a private practice primary care doctor plus cash fees for each office visit.

      I understand why the concierge/direct pay model appeals to doctors. I’d just like to see some acknowledgement that they would be opting out of treating whole economic and age demographic populations and choosing to only treat patients under 65 with good cash-flow. The more I read about the concierge movement, the more I feel like I’m being told not to bother going to a private practice doctor because they’re all on the verge of flipping to direct pay and abandoning any patients who can’t come up with the cash upfront.

      • goonerdoc

        How much does a concierge doctor cost?

        • Patient Kit

          I’m sure it will vary. But I’m reading ranges of $1,000 -3,000 per year retainer fee just to have the right to see the doctor and then whatever fees there are per visit to actually see the doctor. Guessing $100 per office visit? But maybe more, maybe less. Not sure if they’d charge extra for things like phone calls and paperwork for employers, etc. Part of the problem is that we don’t know exactly how much it would cost. Maybe it’s a better model for patients who see their primary care doc once a year and don’t have any serious chronic conditions.

          • goonerdoc

            That’s the thing though. Respectfully, you don’t know how much you’d have to pay, so how can you make the claim that we’d “[choose] to only treat patients under 65 with good cash flow” and that we’d “abandon any patients who can’t come up with the cash upfront?” I resent that. You’re saying a sliding scale for some patients couldn’t be implemented at all? Why not? Docs would actually have the freedom to charge what they wanted, which we absolutely do not have the freedom to do currently.

          • NPPCP

            $50-$70 a month and a $10-$20 office visit fee. The money savings comes from savings on paperwork, GREATLY reduced lab fees (you would save so much money on routine lab, it would almost pay your fees), EKGs, Xrays, injection, IV fluids – so many places for the patient to save money and easily recoup the cost of the annual fee and office fee. It is a clear winner. Patients just aren’t used to it yet.

          • Patient Kit

            Please bear with me as I ask questions about concierge. I’m not trying to be intentionally antagonistic. I’m sincerely trying to understand how this model works for patients. Maybe I have some misconceptions. And maybe, as a recent cancer patient, I’m coming from an emotional place at the thought of yet another way to lose a doctor.

            First, I’m having a hard time imagining doctors in NYC charging $10-$20 for an office visit. Second, how would patients save money on routine labs, EKGs, xrays, injections, IV fluids, etc under the concierge model? I really don’t understand that part.

          • NPPCP

            You basically pay a monthly fee – set. Then you pay a “per visit” fee. This fee is for those who think they can see their physician/NP 1,000 times per month because they paid $50-$70. The physician/NP provides bloodwork at GREATLY reduced fees (yes it is more money). But let’s say you get a blood count and your ins deductible is $1,000. The cbc will cost you $50 or something like that from the lab, toward your deductible when the physician/NP can charge much much less than that! Maybe $10 depending on the area. Same with xrays. I can develop your xray in my clinic and charge you something like $20 for an xray when it would be much much more when billed through the ins company. Services are marked up SO much through insurance. This type of practice allows you to receive a fair price and save money in the end.

          • Patient Kit

            I understand why you need to charge a per visit fee in addition to the flat monthly fee to deter peeps who like to go to the doctor way more than they need to. That makes total sense to me. But, if I understand what you’re saying, in addition to the monthly or annual flat fee and the per visit fees, I will also be paying cash for lab tests, xrays, etc. That’s where I get lost because if I still am paying a lot for insurance that covers those things, wouldn’t my healthcare costs go up if I’m paying for both?. Maybe I’m missing the financial advantage because I’ve always had insurance that didn’t have a high deductible or high copays. I do, however, realize the trend is rapidly moving toward higher deductibles and copays. Maybe that has been my disconnect point on this where I get lost trying to understand why it’s better for me financially. I do get how it would be better for me in terms of doctor/patient relationship.

          • DoubtfulGuest

            Thanks for asking this stuff. I’m very interested as well.

          • Suzi Q 38

            True.
            And I am one of those who is willing to give it a try.
            I will have to say, we are a dual paycheck family with only the two of us.
            Something like this may work, as things settle down for me health wise, and I keep our insurance for catastrophic illnesses.

          • Suzi Q 38

            How would we save on the lab fees, EKG’s Xrays…etc…?

          • guest

            It won’t work with people who are generally healthy. Why would I pay a monthly fee and a retainer to be seen once a year if that? That would make that one appointment crazy expensive. Concierge would only benefit the chronically ill, I can’t see a reason why other patients would bother. Patients who are rarely ill would be much more likely to pay cash for one appointment than a monthly fee.

          • querywoman

            So why don’t doctors who take insurance lower lab fees? They make them up a lot! That’s where a lot of their profit is.

          • Patient Kit

            Well then, doctors need to get the word out to the public that sliding scale fees will be available. I haven’t read that anywhere in discussions about concierge medicine. How will patients find out how much a primary care doc will cost? Will we call a doctor’s office and instead of asking them if we take our insurance, we give them our financial details and ask how much their fees would be? Based on what? Annual income? Would there be a financial application process to find out how much a doctor will charge before the initial visit? I sincerely and respectfully want to understand how this would work.

          • Suzi Q 38

            I don’t think a “sliding scale” would work.
            It is not the physicians business what my household income is. If a doctor asked me,
            I would not answer.

          • Patient Kit

            Well, working class peeps can’t afford the same fees that upper middle class peeps can afford. And retired peeps can’t afford the same fees as working professionals. So, absent a sliding scale, how is concierge medicine affordable to all? I know I can’t be the only patient out here who is having a hard time grasping how many people will embrace spending an additional few thousand a year for primary care on top of the money we already must spend on insurance and non-primary care.

          • Suzi Q 38

            “….So, absent a sliding scale, how is concierge medicine affordable to all?..”
            This is the point.
            The lower income individuals with families would not be able to afford it. They would have to be on medicare, medical, or Obamacare.

            People with insurance are the ones that will be able to “dabble” or consider a concierge practice. It doesn’t have to be the upper middle class, it can be the middle class that has insurance and insurance options.

          • querywoman

            Private doctors do not need to charge sliding scale fees. That’s for public clinics. The private docs can write off charges that don’t care to collect.

          • guest

            Kit, in another discussion I encouraged you to look up some of Rob Lambert’s pieces on this blog to get some specific information about his direct pay private practice. He goes over how much the cost is to his patients and what the benefits (clinical as well as financial) are to them.

            I would respectfully comment that unless you have done this, you are not informed enough about direct pay or concierge practices and so your angst is misplaced.

          • Lisa

            The model Dr. Lambert is not the same model all concierge practices are using.

            In my area, doctors who are adopting a concierge practice are asking for a annual retainer that is quite a bit higher than Dr. Lambert’s monthly fee. In addition, they are billing insurance for their services. I also noticed that one of the large medical networks in my area is starting a ‘concierge’ group, which will supposedly give the patient better service within the network. They do not disclose the monthly cost on their website – they just have an application. I guess they will tell you the cost after you give them all of your information. I wonder if this means variable pricing.

            When I googled concierge practices in my area, I also got a lot of ads from business whose purpose is to help doctors set up a concierge practice.

            I hardly think Kit’s angst is misplaced.

          • guest

            At the end of the day, what is being proposed is that doctors go back to the practice model that existed before insurance companies managed to coerce us into providing insurance-billing services for our patients.

            There are a couple of different ways to do that: concierge practice and direct-pay practice. I myself (on an MD’s salary) cannot afford the concierge practices in my area, so I go to a direct-pay practice. It works out fine. Paying my doctor is just another expense in the budget, like getting the brakes fixed on my car. You find a way to figure it out. I will also add that I have horrible insurance, with very high premiums, for which my internist is not a provider.

            I don’t think we should be surprised that doctors are going back to this model, since it makes most sense for the person receiving the service to pay for it, rather than having a third party pay. What should surprise us is that doctors were good sports for so long about providing clerical services to their patients, in addition to medical care.

          • Lisa

            I have seen physicians who don’t bill insurance, but they have provided me with a ‘statement’ that I can submit to my insurance. Would that still be considered direct pay?

            My insurance allows me to see any provider; I have low or no copays within network, but pay higher copays and deductibles outside of the network. I like the flexibility.

          • Suzi Q 38

            “…They do not disclose the monthly cost on their website – they just have an application. I guess they will tell you the cost after you give them all of your information. I wonder if this means variable pricing….”

            Interesting.
            I would not hire any concierge physician who was not upfront with h/her pricing.

            As far as an application??I wonder if one of the questions on the application would be “yearly income.”

            I would find another doctor. I don’t care for variable pricing based on yearly income.

          • querywoman

            If they don’t advertise it up front, it’s expensive. I hate buying anything without a clearly labeled price.

          • Patient Kit

            At your suggestion, which I thank you for, I did read a few of Dr Lambert’s pieces before jumping into the discussion on this thread. I’ve also read some other articles about concierge and direct pay models. I do understand the clinical advantage but not the financial advantage for some peeps. Specifically, I worry about all the peeps who are not poor enough for help (Medicaid, subsidies) but don’t have enough cash flow to afford healthcare in this country, be it direct pay or insurance.

            Personally, I had the luxury of a great employee-provided Blue Cross policy for the last 20 years before my layoff. It provided excellent coverage and did not have high deductible unless I went out of network. The network was huge so I never went out of network. Amazingly, my employer paid 100% of the premium. All I had to pay out of pocket were some reasonable copays. I COBRA’d that insurance at $700/month after the layoff for as long as I could. When I was totally broke and newly diagnosed with cancer, I qualified for Medicaid which got me excellent care at one of NYC’s academic medical center with no out of pocket costs. Now that I’m healthy and about to jump back into the job market, odds are I will finally experience this high deductible insurance so many peeps have. Although, if I have a choice, I’d pay a higher premium for good coverage with small deductible, given the baseline of care I know I need to somehow access. So maybe that skews my view on the cost of direct pay. I’m assuming my out of pocket costs for direct pay primary care would be in addition to at least $700/mo insurance premium. I need good coverage because I know I need to see my GYN oncologist 4x a year for starters. Sigh. Where I will land next in our healthcare system does angst me out bigtime. I think I may be scarred and scared for life by the experience of being diagnosed with cancer right after I lost my insurance.

            Regarding Dr Lambert’s pieces, I read his “Why I made the change to direct care”, 10/30/12, in which he says: “…These changes make it impossible for me to continue a doctor-patient relationship with most of my patients…there are many people, some of which have already expressed this, for whom my departure will be traumatic…” Hence my abandonment issues, although I do not at all debate a doctor’s right to switch to this model, it does hurt some patients. Maybe many patients. I also read Dr Lambert’s “Successfully Starting a Direct Pay Practice: Trickle Up Economics”, 4/10/13 and “A year into direct pay: it doesn’t suck to be a doctor anymore”, 1/8/14. They didn’t defuse my angst though. I don’t know. Maybe angst about our healthcare system and how/whether I’ll be able to access care I need is the new norm for me along with the Big C new norm.

            My main point about direct pay/concierge medicine is that it won’t be good for some patients. I can see how it could be good for doctors and some patients though.

          • querywoman

            A cancer patient is probably not appropriate for a concierge practice.

  • http://laheartspecialists.com/ Afshine Emrani MD FACC

    Thank you for all your support and responses. If you need to reach me directly, my email is doctoremrani@gmail.com. Thank you.

  • http://laheartspecialists.com/ Afshine Emrani MD FACC

    I should make it clear that I am not a concierge physician but feel that need to support the ones that have decided to go that direction.

    • Patient Kit

      I don’t “blame” doctors for going concierge/direct pay. But doctors shouldn’t “blame” all the patients who will be abandoned by that model for feeling abandoned.

      • Suzi Q 38

        True.

        And many will leave momentarily, or forever.
        Some will leave initially, only to return because it was just too frustrating to be treated as if you were nothing.

        Others will stay, try paying the yearly fee, and see it works out better for them. If so, they will stay. If not, they will move on after their year is up.

        I think that healthcare will continue to evolve into whatever the marketplace will bear.

        I look at the various ideas that creative physicians have come up with, and marvel at it all.

        I am slightly concerned, but I will try not to worry, since I don’t know exactly what I am worrying about.

        I refuse to worry when I am getting decent health care today. Right now my PPO insurance is still valid and working. If my premiums skyrocket, I may have to look into a concierge model for my heath care and tie it into basic catastrophic coverage.

    • Suzi Q 38

      I agree.
      I think it is any physicians right to charge what h/she wants.
      The patient will decide if h/she can afford it or wants to pay more.

      • querywoman

        That sums up American capitalistic pricing.

  • NPPCP

    The MD can’t be “in charge”; they have to BE THERE to do this. Lots of them aren’t. If you see an NP, ask if the physician is in the office today. Then check your bill.

    • T H

      I’m not arguing your point; I’m saying that if there is an MD present in the clinic that NP can bill at the physician payment level.

      Of course, if the MD isn’t present…. surely the NP in question would know this and not commit insurance fraud.

      • NPPCP

        It wouldn’t be the NP defrauding. They would simply be a provider seeing patients and coding as they always do. It would be up to the physician and their billing department as to whether they want to bill “incident to” if the physician isn’t on the premises. The NP almost never has access to this information unless they own the clinic. They are an employee seeing patients – nothing more, nothing less. In the “in charge” situation, all of the onus would be on the physician owner or the corporation they both work for.

        • NPPCP

          As I re-read your post and reply, I am assuming “in charge” means on the premises to you. :)

  • http://laheartspecialists.com/ Afshine Emrani MD FACC

    Here’s what I wrote about the importance of doctor-patient relationship: http://www.kevinmd.com/blog/2014/01/large-part-healing-listening-caring-imparting-hope.html Please note that all doctors want to spend time with their patients and connect with them properly and heal them- the challenge is when the reimbursement is cut, so is the time that is allowable with patients.

  • Suzi Q 38

    I would have to agree with you as far as how much longer an MD has to study before making any decent money.
    You are getting paid for the years in residency, right?
    I am not sure a PhD can do the same and get paid while training.
    Also, it may be $50K for the tuition at Harvard or a similar private ivy league school, but that does not include the living expenses, which are also added in on top of the tuition as far as student loans.
    Conceivably, an advanced college graduate could end up with a similar total at the end of their years of education and owe a similar amount of money without having the earning capabilities of a physician.

    That being said, I think that compared to other specialists, the GP’s are underpaid.

    • FEDUP MD

      I am not really understanding your math here.

      We have just made it clear that at the least pHD students usually get tuition forgiveness, and often does get a stipend during grad school. During this time, a med student is getting no money and typically is averaging about $170,000 in debt. This is in addition to whatever undergrad loans they had to pay. So when the grad student finishes, they owe from undergrad – average $30,000- and nothing from grad school. The med student owes the total – $30,000 + $ 170,000 = $200,000. That’s a mortgage there before owning anything else.

    • FEDUP MD

      Won’t let me edit but a continuation.

      So after grad school, one generally can start work. You cannot be a licensed physician in the US without at least one year of residency, and realistically no one will hire you or any insurance panel take you without 3 years of residency at least.

      I did 6 years of residency and fellowship. Do you know the fast food workers striking for $15 an hour? I started at $8.40 an hour and finished at $12.15. At 32 years old, with a family, having to rack up credit card debt between residency and fellowship for thousands of dollars to fly around the country to imterview. Mind you, all that med school debt is still accruing interest.

      • Suzi Q 38

        Thanks for your insightful information and clarification.

        So you are talking 4 years of undergrad, then 6 years of residency and fellowship.
        10 years?
        You had no money to help pay for your education?
        You could not work part time to help put yourself through?
        I guess it is all what you want.

        If you want the huge salary ($300-$400K +)
        then you have to specialize.
        Doing so will cost you more in student loans, if you do not have the money sitting in a bank account somewhere.
        The plus side is that you have the salary to pay it off faster when you finally graduate.
        Since these loans ca not be discharged until you pay it off or die, paying it off ASAP makes a lot of sense instead of allowing the debt to grow with the interest.

        • FEDUP MD

          No. You again cannot do math. 4 years of undergrad, 4 years of med school, 3 years of residency, 3 years of fellowship. That is 14 years. I did work part time during college. The idea of working during med school is laughable if you know anything about it ( my surgery rotation topped out at 110 hours per week). Residency an fellowship? Worked 90+ hours, moonlighted when I could, but not often since it was hard to fit in. This experience is typical for any MD.

          I make nowhere near the numbers you quote. And I did specialize.

        • FEDUP MD

          The math is way off. 4 years undergrad, 4 years med school, 3 years residency, and 3 years fellowship. That is 14 years. Working during college is feasible. Working during med school is not (my surgery rotation was about 110 hours per week, for example, and there is no real summer break). I worked 90+ hours most weeks during residency and fellowship and moonlighted when I could, which was not often. One does need to sleep eventually.

          I did specialize and see nothing like the salaries you quote. I make the same as my husband, an engineer with a master’s he managed to get part time while working full time.

          • Suzi Q 38

            What is your specialty?
            Gastroenterology, neurology, radiology, anesthesia, oncology, cardiology, all pay what I quoted.
            Am I far off on that, since I live in California?
            Is the pay higher here?

          • FEDUP MD

            Pediatric subspecialist.

            Web salaries are always skewed. This is because they include “teaser” salaries. For example, one of my friends took a 250K neurology job, which is unusually high. Once he signed the contract, it turned out the hospital was supporting that salary, and the next year his salary would be “production based”- meaning much much smaller- once that was withdrawn. He ended up leaving because they treated him abominably as far as expectations of how frequently he could see patients (5 min for a return, 15 for a new for a neurologist!). This is not unusual, but those salaries skew the average published but are not in any way representative of what most actually get paid.

    • FEDUP MD

      I think the timeline of different degrees may be confusing.

      For grad or med school (or law school) one starts with 4 years undergrad. They all owe on average 30K now. The pHd student gets a tuition waver and often a stipend. After 4-5 years they come out owing…. $30K. The med student takes out loans that on average total $170K. At the same point in their life, the phD student owes $30 K on average and the med student owes $200K. The pHd student can now work. The med student needs 3-7 more years to work independently.

      • Suzi Q 38

        How do you figure?
        Both our kids went to Berkeley, which is a state school in California.
        The tuition alone was about $8-10K each year, plus $10K for the dorm or apartment (with roommates), and about $5K for books, food and other things. That totals $25K per year times 4 years, so $100k in SL for undergrad alone.
        Also, the student has not even started with graduate training. The tuition astronomically increases in graduate school.
        Masters or doctorate in Psychology or Sociology? What is the final pay per year after graduation? Not much. You are lucky if there is a job at all.

        • FEDUP MD

          The $30K is a national average for bachelor’s. I’m sure it is skewed by people living at home, some percentage of people who got scholarships and grants, some who transferred from community college, etc on the lower end.

          I agree that the pay for certain master’s degrees may be poor. Just like many undergrad degrees. However, I was simply addressing closer to equivalent levels of education, which is doctorate level.

          • Suzi Q 38

            Another anecdotal story:
            Our friends sent their son to Harvard, at the cost of about $35K+ a year for the tuition alone.
            The living expenses were really high, at about another $15K+ a year. Then you have to add the other expenses: food, books, transportation, flights home to California for the holidays, etc. Anyway, they owed $200K after 4 years of business school.
            Guess what? Their son was unable to get a job with his degree in Business.

      • DoubtfulGuest

        Sometimes it’s longer than 4-5 years for a PhD. Otherwise I agree with you.

  • Lisa

    McDonald’s is not good solid food. It is junk, plain and simple. You should come up with a better analogy.

    • guest

      Sorry to say, most employed physicians these days are offering junk medical care, because that’s all they have time to offer….

      • Lisa

        The analogy would work in that case.

      • Patient Kit

        Most? That’s extremely depressing. Well, there’s always the Self Treat Movement led by patients who fell through the cracks. On the other hand, when I self treated what I thought was a sprained ankle, I ended up in major surgery for a ruptured Achilles tendon. Healthcare is filled with dilemmas and angst. My Y membership is one of my personal best healthcare strategies.

    • Patient Kit

      McDonald’s is very crappy food. I don’t eat it. I don’t want crappy healthcare either. What can I say? Our healthcare system is one big angst fest to me sometimes. But at least, actual McDonald’s has stopped selling burgers and fries in most hospital lobbies. And by lobbies, I mean ground floor entrance areas of hospitals, not the Washington DC kind of lobby. :-p

  • Suzi Q 38

    I agree.

    As i have personally found, some doctors are liars.
    At first it shocked me. In the past, I always thought that doctors were honest and above lying to a patient.

    If I were 89 and senile it would have been easy for them to continue, unchecked.
    Thank goodness I had good documentation and proof of email correspondence.

    That being said, it really doesn’t matter. You could be so right, and the CEO is so afraid of a lawsuit by a couple of errant doctors that h/she will defend their errors and lying like a parent defending h/her young. Add to that, other doctors, turning a blind eye to what these doctors do.

    Nothing happens to the bad 15%, unless they maim or kill someone. Even then their bosses and physician friends help them out.

    Thank goodness not all doctors are this way.
    I had one tell me not to let the other doctors ignore my medical problems. She told me what I had was serious. She was a good one.
    Another good one was a neurosurgeon who listened to my story and then called my doctor personally. Apparently, he made an impression on my former doctor, because the errant doctor called me within a couple of hours.

    At first I was so angry that I filed a complaint.
    I was so naive that I actually thought that the patient advocate was advocating for me LOL. I got to meet the advocate, who was hired straight out of college with a sociology degree. I think she was about 22 or 23…anyway, I had to advocate for myself, as she was worthless with respect to advocating for any patient against the wishes of the CEO.

  • guest

    I certainly support doctors who want to have a concierge practice, but I would avoid it because I’m rarely ill. It wouldn’t make sense to pay monthly to be seen once a year if that. It would make more sense to direct pay – and I have done that even with health insurance if the doctor was booked and I needed to be seen more quickly (i.e. for a UTI). If I had a chronic illness that required more frequent visits, then a concierge practice might make sense, but it doesn’t make a lot of sense for people who are generally healthy.

  • Deceased MD

    One problem though is that concierge doctors are mostly PCP’s. They refer to specialists who are probably not concierge and take medicare, say for example cardiologists. So even though the concierge may get you in faster and perhaps give you better attention, I question how much they have control over mangled care. I have seen pt’s willing to pay out of pocket to get better attention for unusual presentations, but in the mangled care system where I am, no amount of money brings you that attention (unless you donate a wing onto the hosptial.)

  • Lisa

    Well, if I am hungry and on a budget, I’d go to the store and get peanut butter and bread, before I’d go to a MacDonald’s. That said, the analogy, as you explained, holds up.

    I don’t think all employed physicians practice junk medicine. I think there is a certain amount of junk medcine practiced out there, on the part of employed physicians and on the part of physicians in private practice. However, I have had more unnecessary tests and procedures pushed at me by physicians in private practice than I have by employed physicians. In many ways, I don’t mind what you are terming a McMedical model because I know I will be able to recieve care and it most likely will be appropriate. Much of medical care is very routine and a model that can handle the common problems quickly and efficiently is a good thing.

  • Anthony D

    A large percentage of doctors will find that they will be unable to survive financially…so many have huge loans to repay from their time in school, and with the 6-digit cost of malpractice insurance thrown in, they won’t be able to pay their bills, let alone make an income…it’s simply an extension of what’s going on now with the way medicare/medicaid programs limit what they can charge, making it necessary for them to depend on other patients’ ability to pay and the insurance they carry…which in turn becomes problematic because ObamaCare or any national healthcare program will severely limit those insurance payments, making it then necessary to charge even more to the patients who pay on their own…and there won’t be many, if any, of those anymore…in short, or severe doctor shortage in this country today will become even more of a problem, and a lot of the treatment now available simply won’t be available from truly qualified personnel anymore, and thus will become rationed, and of course that will make it even more difficult for doctors…Because they’ll be stretched so thin…

    In effect, what ObamaCare does is create a situation in which there will be many fewer highly qualified physicians and a tremendous amount of your medical care will be m administered/prescribed by minimally trained/educated/experienced people making, for all intents and purposes, minimum wage…think of it this way…when you go to have something fixed on your car, you want someone working on it who has a bit more idea about your car than where to put the gas in.

  • Jason Simpson

    It is SOCIETY AND GOVERNMENT that has “elevated” physicians. In fact, they have elevated us so much they demand that we provide our services for free. Apparently the government thinks that physician services are so valuable that it had to be enshrined access into law in the form of Medicare and EMTALA.

    You dont see the government doing that with bricklayers do you?

    • querywoman

      I saw a great article on this shortly after the internet net started sprogging. The professions, like law and medicine, used to keep the masses in control because the professions had secrets they needed.
      So the professions charged us money for their secrets.
      The internet has opened up the secrets of the professions to the public.
      I can’t write an antibiotic prescription for myself, but I can research and fire a doctor who I feel is not treaing me adequately and get another.
      I can write a legal will for myself in any state.

      I’ve seen articles that state licensing doctors protects provider income more than it does patients.

  • FEDUP MD

    I would be happy if I made the same amount per hour as a plumber.

  • Patient Kit

    That’s really the main point I was trying to make: that concierge/direct pay is more expensive for patients and it depends on our budget whether we can afford it. And a lot of us can’t. It was starting to sound like all primary care docs were being encouraged to switch to the direct pay model. And if that happened, I would feel abandoned by private practice doctors. I’ve gotten excellent care from excellent doctors here in one of NYC’s many teaching hospitals. It didn’t at all feel like McDonald’s care to me. I’m grateful to live in a place that has that option.

  • FEDUP MD

    To address your points:

    1. Yes, the tuition is only for 8 years (undergrad and medical school). However, recent changes in the law make it now impermissable to defer interest during this period, so they are building up interest this whole time. Also, don’t forget that now that it is much more difficult to get Pell, etc loans, now these may be private loans with exorbitant interest rates.

    2. The average resident works in excess of 80 hours per week. That is more than twice as much as full time. As I have noted before, the most I ever made was $12.15 an hour after 6 years of training. I started off at $30K for 90 + hours of work. I don’t know what to say more about this except for why not just suggest everyone else making the median salary work the same number of hours as a resident? Clearly it can be done and you’d make twice as much as a resident! Why complain about income inequality when one can just get another full-time job? Or can you realize that perhaps that is unreasonable to expect, and that maybe residents are underpaid compared to the amount of work they do?

    3. $100, 000 a year does not even begin to match the amount of money that Medicare and Medicaid save by having the resident provide care for this population. Residents are providing hours of largely unbilled care that otherwise would be provided by a hospitalist or NP/PA at a much higher rate. An attending supervising a resident code is at a much lower rate than an attending alone code. There is a reason, for example, why many resident clinics are now Medicaid-only. Also, the money paid is only intended to be used to help pay for the resident’s time during training to care for Medicare/Medicaid patients, it is not intended to be in perpetuity.No one signed up for involuntary servitude to the government, the agreement is only during the time of training.

    4. Most docs make nothing even remotely like the numbers quoted here. I make the same as my master’s degree holding engineer husband. We aren’t struggling but by no means are we wealthy.

    5. Where does one find this “free” EHR? My practice spent a tremendous amount upfront and I know the hospitals are paying millions. $64000 over 3 years is laughable compared with the startup costs needed to implement it.

    6. You are going to get what you pay for. If you want to pay American docs the same as EU docs despite the fact that EU docs get free schooling, have no malpractice to worry about (either premiums or by defensive medicine), and have a guaranteed social safety net (retirement, etc) than you are going to find a shortage of doctors here. If I made $40-50K like in the EU I would have to quit medicine because I would be unable to pay back my loans and pay my malpractice insurance at that rate. I love my job but I can’t afford to spend money to do it, I do have to eat and pay my mortgage and clothe and shelter my kids, etc. I know many others who are not independently wealthy who would also have to quit medicine in that situation. Good luck.

  • querywoman

    The United States is still a free capitalist country with free enterprise. Let ‘em do it if they want.
    In my urban area, the concierge docs can and do get big bucks.
    I question some of their hype. I researched one local concierge team. They have current passports and are ready to go to their patients anywhere in the world at anytime.
    Oh really? Does they mean they licensed in Czechoslovakia, Mexico, or Uganda? What about North Korea? Does that mean the docs in other countries will listen to their opinions?
    How about the patients the wandering docs are leaving at home?

  • querywoman

    My father said doctors just practice medicine. He said you have never seen a sign that says, “We cure.” They advertise medical “practices.”

  • querywoman

    Kristy did not specifically state that she has a $400 car payment or any car payment.

  • querywoman

    I graduated from high school in 1974. I have needed a ton of health care to keep me going since my early 20s. I know what it costs, especially in the old days of $200 deductible, then 80% reimbursement after I paid in full.