Solutionist medicine: How the concierge model can reinvent primary care

Call it concierge, call it direct care, boutique, fee-for-service, call it what you will. I call it a solution. As physicians, we’re all solutionists, are we not? With every differential diagnosis, assessment, and plan, we are creating solutions.  In accordance, one does not become a doctor for any reason other than changing the world. Perhaps this change happens one patient at a time, but working toward a greater cause and putting other’s needs before our own are the key components that help to define us as physicians.

As a young(ish) physician, I enjoy speaking with other doctors from around the country and world, who impart advice on me not just about business, but about “the shape of things.” I especially love speaking with other concierge physicians to learn about their model, their infrastructure, and how they provide the best care for their patients. In speaking with some colleagues, their words of wisdom all too often seem to revolve around how to keep your head above water in a high cost, low reimbursement rate industry.

Yet, all of our personal statements for medical school and residency in some form gave endless prose to how we wanted to care for the sick and change the world for the better through improving health. Somewhere along the never ending road of learning, student loans, managed care, and shrinking insurance reimbursements, some doctors are still searching for the solution of balance between business and altruism.

How can concierge medicine reinvent primary care?

Let’s look to other types of insurance that many people also have, such as car insurance and renter’s/homeowner’s insurance. We all purchase car insurance, yet, for routine maintenance (oil changes, tire rotation, even new tires), you probably do not submit a claim with your car insurance company. Rather, we pay “out of pocket” for routine care which keeps the cost of our annual car insurance premium low.  Similarly, when it comes time to change the air filter in your home or patch a nail hole, you either do it yourself or hire a handyman. You do not submit a claim to homeowner’s/renter’s  insurance company. If we started asking for reimbursement for these routine maintenance type services, aka: primary care for our cars and homes, the costs for insurance would become astronomical and the system would not remain sustainable.

Using a concierge model for primary care, where physicians are paid for the relationship they have with their patients, doctors are incentivized to do things for their patients, rather than to them, and time spent counseling is not only paid for, but also rewarded (with improved patient health and fewer middle of the night phone calls). Insurance coverage would remain an essential part of a patient’s care, using coverage for prescriptions, labs, radiology, hospitalizations, surgery, or consults. Concierge medicine can reduce reliance on insurance reimbursement not only by reducing overhead, but also helping to improve the health care crisis and lower costs.

But what is true concierge medicine? Is it house calls? Telemedicine? Allowing patients to have access to your cell phone or email? Is it having a smaller patient base, enabling a doctor to spend more time with their patients? Or is it removing the insurance reimbursements to physicians for primary care visits to let doctors make a statement and take back control of their own industry?

Clearly, concierge medicine is not the only way for patients to receive the best care. And certainly there are millions of patients who are unable to afford any additional costs to their already costly health care. There cannot be one “all-encompassing” solution, but rather multiple options and solutions that best serve each individual and family.

How can we all be on the same page within concierge medicine?

Concierge medicine involves all of the above questions referenced above, but also can help to provide a solution to the bigger picture, the primary care health crisis. Ultimately lowering insurance coverage costs to the patient, while keeping and most often times improving physician salary, the tomorrow of primary care can begin to improve today. Concierge medicine can reinvent primary care by allowing doctors to reinvigorate who they are at the core, solutionists.

Chad Rudnick is a concierge pediatrician and practices at Boca VIPediatrics, Boca Raton, FL.

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  • Lisa

    The author admits that admits there are millions of patients that can’t afford any additional costs for their medical care, such the cost of belonging to a concierge or direct care practice. I hardly think it is ‘solutionist’ to develop a model of medicine that excludes so many patients due to costs or one that encourages people not to carry insurance. ‘Solutionist’ medicine would look for models of medicine that would serve everyone, doctors and patients, regardless of economic class.

    • Kristy Sokoloski

      Exactly correct Lisa. That’s what I have been trying to hint at as well on multiple occasions.

    • Ashley

      There already is a solution to that, Lisa. It’s called Medicare.

      • Lisa

        If you have a major illness or suffer major injuries in an accident, you will know the point of paying for insurance.

        Medicare is not a solution to medical care for everyone as it is only available to people who are over 65 or disabled. Perhaps you meant that medicaid is the solution for those who can’t afford insurance. The only problem with offering that solution is that many states have not expanded medicaid. Therefore, you can have an income below the federal poverty level and still not quilify for medicaid.

      • Patient Kit

        If Medicare and Medicaid solved the problem, we wouldn’t even need to be talking about this issue of so many millions of Americans unable to afford and access healthcare in this country. In your opinion, does this problem not actually exist? If that is what you really believe, I think you must be living in a bubble.

  • Patient Kit

    Wow. “…..One does not become a doctor for any reason other than changing the world…”. A pretty lofty goal.

    But then this sentence is quickly followed by multiple uses of those heady words “business” and “industry”. And “solutionist”. And I find myself asking once again: SOLUTION FOR WHOM? The more I read about DPC and concierge models, the more I become convinced that it is a model that is primarily a solution for unhappy primary care doctors in our quickly changing world, but is not a “solution” for millions and millions of patients in the US. And then the doctors who are so enthusiastic, almost evangelical, about DPC, seem genuinely baffled that many patients are not quickly embracing this model. They think we just don’t “get it”. Could it be that we get that this model benefits primary care doctors far more than it benefits many patients?

    • rbthe4th2

      You hit it dead on the head. That and docs want to care for the sometimes sick, the more wealthy ones.

  • Lisa

    I disagree with the contention that concierge medicine reduces costs. I am pretty sure it does not if you also maintain insurance, even high deductible insurance. I have run calculations on my costs if I were to buy into a direct patient care practice and carried high deductible insurance, instead of purching my current PPO insurance. If I only used primary care, my costs would be approximately equal to my current costs. But, under a scenario where I needed care beyond primary care my costs would be quite a bit higher than my current insurance costs, due to the high deductible and the fact that I would have to pay for both the DPC and the deductilbe on the insurance.

    DPC practices are touted as a way of saving money, but I don’t think they make financial sense until a way is found to give people who buy into such a practice credit toward their insurance deductible.

    One of the supposed advantages of a DPC is immediate access to your doctor. I do not see how that can be gauranteed in a small practice. What happens during a flu empidemic? Do people who have scheduled appointments get bumped for people who are really sick. Regarding after hours calls, if the practice does not limit them in someway people will take advantage. Seriously, at some point, I would expect to see DPC doctors complaining about being sleep deprived because they are always on call.

    • concierge doc

      Lisa,

      A small practice is exactly when access can be guaranteed. When a physician does not have 1000s of patients, care can be provided during a flu epidemic as you referred to. In those seldom instances, I stay in the office later (as late as needed) to accommodate the patients that need me. Luckily, flu outbreaks are not every week and the patients and families understand that I am there for them and will provided the care when they need it. My patients understand that if they need me at 3am, it is going to ring directly to my cell phone and will wake me and my wife. They are cognizant of that and reserve those calls for when they truly need care, not just for a chat.

      I am not sure what your specific insurance rates are or what type of DPC practice is in your area, but there are countless articles written on the exact subject which show how a family of 4 (or just a single person) can save thousands by changing to a concierge practice and/or changing their current insurance plan. Nevertheless, just because your specific situation and your local DPC practice doesn’t make you save money, it does not change the numerous benefits to having a concierge doctor (see above comment). Having a high deductible or “cadillac” insurance is all about RISK. The insurance companies have that figured out very well, and can make the most money possible off of YOU.

      Also, you reference having your deductible credited by using a concierge doctor. That is EXACTLY what concierge medicine should be able to provide. You are paying for the care, and can submit the visit charges for reimbursement or credit towards your deductible. That is the exact statement that the author makes in the article, “Or is it removing the insurance reimbursements to physicians for primary care visits…” by having a concierge physician not receive reimbursement from YOUR insurance company, you are entitled to those credits towards your deductible or payment back to YOU!

      • Lisa

        At this point, I am unaware of any mechanism that allows you to receive credit for a monthly retainer (paid to a concierge or DPC practice) to be credited towards an insurance deductible. I know how my insurance works and while it covers for my primary care it would not credit a monthly retainer towards my deductible. I can also submit specific charges to them for reimbursement, but that entails a properly coded super bill. How can a concierge practice or DPC practice provide me with that if there are no specific charges, just a monthly fee?

        There may be countless articles stating how a family of four can save money by belonging to a DPC practice. I think the analysis holds up if the mythical family does not have major medical issues. But as soon as they have a major medical expense analysis falls apart, due to the need to pay a large deductible.

        When my son was little, we had a high deductible plan. He broke his leg while we were traveling so I had to take him to an ER, When we got home our family doctor referred us to an orthopedist for follow up. All of our medical expenses for that year, including primary care, came to an amount under the deductible for that plan. I can imagine how I would have felt if I had also been paying a month retainer for a DPC practice.

        At this point, I have insurance through my large employer. The monthly cost for my insurance is $658 a month. I pay $108 of that amount. If I see a doctor with my network, I pay a co-pay. My co-pay for an ER visit is $100, and my cop-pay for a hospitalization is $250. Outside of my network, my insurance pays either 80% or 70% of charges, with a maximum deductible of $1,500. A DPC makes financial sense for me as it would cost me several thousand dollars a year more than I pay now. And when you consider the fact that I can see either my pcp or another doctor in his group practice on the same day basis if necessary, paying that much for access does not make sense. My employer offers several other health plans that cost less per per month, but they do not offer one that will coordinate with a DPC plan or a concierge practice. Perhaps that is because the only concierge practice is the immedicate area is run by a large, corporate medical group. The medical group does not disclose what the charges are and does not specify exactly what the benefits are until after you have applied for membership. Smacks of elitism to me.

        • concierge doc

          You are missing what many concierge practices are already providing, mine included. A “retainer fee” is often not concierge (regardless of what the website says), especially when the practice also charges insurance companies for your visit. These are often referred to as “hybrid” concierge practices.
          Concierge practices which provide care for an annual fee (whether paid monthly or not) can be submitted for reimbursement when the charges are provided on the superbill, those charges are already paid by you. You should discuss this with an office manager for a true concierge physician that offers this so you can see how it can be used towards your deductible or for reimbursement. Even the insurance company won’t know (or won’t tell you) what you will be reimbursed for. They are not in the business of saving you money. And I am sure they love that $658 per month they receive when in-turn you still pay a co-pay for every visit. Shouldn’t visits with your doctor be unlimited and without co-pays? Concierge medicine can provide all of that. Concierge medicine can also provide you with pre-negotiated rates for labs and certain radiology tests which are sometimes less than your co-pay. This provides you better service (provided by the work of your doctor) while your insurance company still gets that lovely $658 per month [sarcasm]
          Seeing “another” doctor in the practice doesn’t have to be an issue for a family with concierge care. They want concierge care because they would like THEIR physician to be available when they need it (not including extenuating circumstances) not just another doc in the practice.

          • Lisa

            I diagree that annual fees for a concierge practice are reimbursable by insurance if submitted on an insurance bill. They are not. My insurance covers actual services, not annual fees.

          • The_MDiva

            Most concierge doctors can break down the costs of the annual fee, by providing a copy of the billing codes of each visit. The bill is then submitted to your insurance company, and patients are reimbursed directly based on their out-of-network percentage rates.

          • Lisa

            The only concierge doctor in my area, who charges a high annual fee, specifically states that the fee is not reimbursable by insurance.

          • concierge doc

            There are many differences to how a concierge physician chooses to provide care to their patients within their own business model.

        • concierge doc

          Regardless of reimbursement/deductible credit, the author referred to concierge medicine lowering insurance premium costs. Why shouldn’t YOUR insurance company lower your monthly payment if they know you are receving your primary care from a physician who will not bill your insurance company? YOU should be entitled to those savings, not your insurance company. Why do they get to keep collecting money if you receive care elsewhere from a concierge physician? Ask an insurance company how much money they spend per patient per year for PRIMARY CARE services only (the ones referenced by the author above), not labs, radiology, specialists, ER, hospitalizatons, etc. See if you ever get a real answer. If you are able to get an answer from the company that you pay every single month, a company that is supposed to be working for you, ask them for that amount of money to be credited to your annual premium, because you won’t be using once you switch to concierge medicine.
          Concierge medicine is not an enemy. It should HELP you and millions of other hardworking folks who pay obscene amounts of money to an insurance company that may or may not pay for something when you need it.

          • Lisa

            When you purchase health insurance, you are purchasing a plan that reduces the risk you will have to pay high medical bills out of pocket. Insurance companies will charge a lower premium if you purchase a high deductible policy, as you are assuming more risk. As I have said before, the model for DPC works if you do not have major medical expenses. Once you do, i think it becomes more expensive as you have meet the deductible before the high deductible insurance policy kicks in. And you still have to pay the monthly retainer.

            I know how much my insurance company spent for my primary care last year, based on the EOBs I received. That amount was less than the annual retainer for a DPC practice. It was also less than I would have paid if I was a cash patient as most doctors in my area do not offer discounts for cash payments. Personally, I think one of the reasons the DPC model works for doctors is that many patients don’t have frequent needs for primary care.

          • Patient Kit

            Do people who are covered by employee-sponsored group insurance plans have the option to change the terms, including lowering their premium, of that group plan if they decide to try DCP? I don’t think so. You have to keep paying the premium that is the same for everyone covered by that group plan. And, unless all of your co-workers also want to switch to DPC/catastrophic plan, that’s not going to happen in an employer-based insurance situation. I know that I would be very pissed off if any of my co-workers started trying to get our employer to change from a comprehensive plan to a catastrophic plan. In this case, are you suggesting that people opt out of their employer-provided group plans and purchase their own individual catastrophic plan instead so they can pair that with DPC?

  • Patient Kit

    A lot of medical care, especially with specialists, falls in between the area of primary care and the area of catastrophe (surgery, hospitalization). What covers all of that in-between specialist and testing territory? Do the barebones catastrophic policies that you advocate cover all that sort of specialist medical care too? Or would that be out of pocket?

  • Patient Kit

    Of course, not only docs, but we all should be trying to make our world better. That’s why I have fought hard on a lot of social justice issues and advocated for people less fortunate than me over the years. That is why I am willing to fight for a comprehensive national healthcare system in the US — because I believe it will make our country a better place.

  • Patient Kit

    I can actually see how concierge medicine could work well in Boca Raton, home of three of the most expensive gated communities in the US.

    • concierge doc

      I think you are missing the point of concierge medicine. It is not only for people living in “the most expensive gated communities in the U.S.” [your words]. Perhaps some time should be spent researching and contacting concierge practices around the country, in all different types of cities and communities and see what the costs of their care truly are. I think you will see that in the majority of instances, concierge medicine costs less than your cell phone bill each month.
      Or drive by your local Starbucks each morning, see the people who are on line every day, that daily latte would likely cover the cost of having a concierge physician.
      A common rebuttal is that not everyone can afford Starbucks or drinks it every day, but I think their success and location on basically every street corner would beg to differ.
      Let’s not get away from the overall point in the article, concierge medicine can be ONE of the models/solutions to the US primary care healthcare crisis. Not specialists, not surgery, not pharmaceuticals, not radiology… but PRIMARY CARE. Counseling, guidance, routine exams, check-ups, etc. Concierge medicine can improve YOUR relationship with YOUR physician, not some “other” doctor in the practice who does not know you or will just read through your last notes in the chart.

      • Lisa

        My need is not just for primary care, but for comprehensive medical care. I care less about the relationship with my primary care doctor than I do about access to specialists and how much I spend for medical care on an annual basis.

        • concierge doc

          But that is your specific, personal situation. For millions of people, a relationship with a great primary care doctor is what they want/need.
          A primary care doctor who will help to coordinate the care with all of those specialists you refer to. You should not “care less” about the relationship with your primary care doctor, but rather, seek out a relationship with a primary care doctor who will help you with access to specialists and try to obtain less expensive testing that you are likely to need with all of those specialist visits.
          Please don’t put down primary care, it is an absolute neccessity for the US healthcare system, and the only way for any healthcare to be provided to millions

          • Lisa

            I care about my relationship with my pcp. He has helped me with access to specialists, by providing referrals, and has risks and benefits of various tests with me. He doesn’t need to try obtain less expensive testing for me because my insurance covers such costs at 100% if they are in network (one reason I pay a relatively high montly premium for my insurance). And when I said that I care less about a relationship with my primary care doctor than I do about access to specialists that is not putting down primary care, rather it is a reflection of my needs. And I think it is a need that many patients have.

      • Patient Kit

        I have been reading every pitch on KMD for DPC for months now and reading about this model outside of KMD. But, you’re right. I should do some research about actual concierge and direct pay doctors.

        So, I decided to do just that. And I started with where I live — NYC. Google’s first hit for concierge medicine in NYC gave me Goldberg & Yadegar, two internists who have partnered here in Manhattan to form a concierge practice. There website doesn’t reveal any costs. You have to call to talk about that. However, the NY Times did a piece on them on December 6, 2013 in which it was revealed that Dr Goldberg & Dr Yadeger charge a $25,000 annual membership fee. You have to pay extra if you want things like house calls and lab tests.

        The same Times article said that 5 years ago, there were 28 concierge doctors in the NY metropolitan area and now there are 124. Not a lot of concierge doctors for a city of 8+ million plus all the patients in the surrounding suburbs. But I will start searching for them to see if any have more reasonable fees than the Drs Goldberg & Yadeger. But I have to admit that the first concierge doctors I found here haven’t made me newly hopeful about that model saving me money.

    • The_MDiva

      Clearly you’ve done more research on Boca Raton than you have the actual cost of direct primary care.

      • Lisa

        I don’t know what research Kit as done, but I’ll tell you what I have found about the cost of direct primary care in my area. There is a ‘micro medical practice.’ It offers $80, 25 minute primary care visits with a PA. Cash at the time of service only. The web site in says the practice is temporarily closed. I strongly suspect the truth is it failed.

        There is also a concierge practice that costs $3,300 a year per person each person to carry non HMO insurance plan. Their website says that the annual fee is not a reimbursable (by insurance) expense.

        One of the large corporate medical groups, also offers Concierge medicine, to people who are insured through them at an additional fee. They do not disclose the fees online.

        If I am willing to travel 40 miles to anther community, I can find fair number of concierge medical practices (they have annual fees and bill your insurance) including one with multiple locations that accepts most insurances and offers services such as emails from doctors and same day visits for $149/year. That might actually be interesting to me except for the location. But no direct primary care practices. operating on an annual fee only.

        • The_MDiva

          Perhaps if DPC models are more supported by patients who have done research like you are now doing, you will see more and more start to spring up in every community. However, there are a lot of “haters” who don’t do their research and assume DPC is only for the rich and famous. It is still a new concept, and over time, we will see more and more doctors transitioning to DPC with all different options available. Just like everything else in healthcare (and life), there are options. There are “Cadillac” plans, and “Cadillac” concierge doc plans. There are also many other options of DPC doctors that are extremely affordable and can help to save money and time, no matter which community you live in. If it’s not in your community yet, it will be soon – but it requires quite a bit of patient education and certainly the support of community members that it is A solution. Again, it is not an “all-encompassing” solution, but it does help millions of people by providing better access. By regarding DPC as ONE of the solutions, now we’re actually getting somewhere.

          • Lisa

            If people can purchase plans that include DPC and a high deductible insurance plan on an federal exchange, that are eligible for federal subsidy, that would really be a game changer. If the cost for DPC models actually save people money, they will support them. If they don’t save people money they will not support them. That really is the bottom line.

      • Patient Kit

        I actually have not done much research on Boca Raton. But Boca Raton is where the OP practices, so….I just thought I’d mention that Boca’s demographics might be favorable to concierge medicine.

        But now that I’m beginning to grasp the basic concept, I’m starting to do some research on specific concierge and DPC docs here where I live. See below for my not so encouraging first finding — $25,000 annual fee with extra charges for things like house calls and lab tests. And this would save me money how?

  • Patient Kit

    So, bottom line: You’re saying that any specialists will also be direct pay, out-of-pocket too?

    • concierge doc

      I don’t think that is the “bottom line” at all. Concierge medicine can lower costs. That is the bottom line. Concierge medicine can enhance the patient-physician relationship, that is the bottom line. Concierge medicine is NOT the ONLY answer, but rather one solution in what needs to be a whole box full of solutions to best care for our nation. That really is the bottom line!

      • HJ

        RE: Concierge medicine can lower costs

        I don’t see how someone with insurance saves any money by paying an additional funds for what seems a lot like an insurance premium.

        I went to the doctor once last year to fill my prescriptions. The concierge practice in my area is $170 a month for someone my age. What type of patient saves money.

        I recently had a urgent medical issue on the weekend. I went to the urgent care practice and it was determined I needed imaging. I was referred to the ER. That $2000 in concierge fees would not have saved any money. In fact the services provided by this doctor are 24/7 on-call availability. It doesn’t sound like he would open his office on Sunday morning…and I would guess a radiologist wouldn’t either. If I had needed to be admitted to the hospital, my concierge doctor would not have been in charge of my care.

        I have five chronic medical issues. My primary care doctor is not qualified to treat four of them.

        For the most part…those with limit funds would be better off buying quality food and engaging a personal trainer or a life coach.

        • concierge doc

          I cannot speak for your primary care doctor. Perhaps you need to solicit care from a physician who can help to care for your chronic conditions. Concierge care is NOT the only solution. Please read through my comments above and below.
          Why wouldn’t a concierge doctor open the office on a Sunday? 24/7 means 24/7.
          Concierge medicine is not only about saving money, while it can help to save money for many (again, read comments above and below), it is more about access to care, access to YOUR doctor, who knows you well, who will coordinate care should you need to be admitted to the hospital.
          While concierge care may not be the best option for you, in your community, that doesn’t mean it isn’t a great option for many people.

          • HJ

            Concierge medicine does not save money. It is an additional expense on top of insurance premiums or it is an irresponsible replacement for insurance. I would guess there are a few people…not many.

            I agree that a concierge can provide a more satisfying doctor-patient relationship. I have not seen any studies that show the care is better.

            As for hospital care, I have been around the block a few times…with independent providers, small group, large non hospital group and large hospital based medical center. The best care I got was from the hospital based medical center. All my records were available to all my providers…this was when I had a paper chart. It was a medical team with true collaboration across different specialties.

            I am just interpreting “24 X 7 on-call availability” to mean phone. My copay for the urgent care was $25. The urgent care coordinated with the ER.

          • concierge doc

            You need to read more on the cost savings for many people with concierge care or direct primary care. There are numerous articles written on the topic.
            I don’t know why you interpret 24 x 7 on-call availability to only mean by phone. I am on-call 24 x 7 and while I may not be in my office at 9pm or 3am, if one of my patients needs care and needs an evaluation for something urgent but not emergent, I will meet them the office, or make a house call, no matter the time or day. For many people, convenience is worth a lot.
            I am not alone in providing this level of care and service. I coordinate with any ER should that be required.
            Again, concierge medical care may not the best option for everyone, but is certainly an option for many. Only you can determine if the care you would receive with concierge medicine or DPC and the costs or savings associated are worth it to you. That is the beauty of this model, you have the choice!

          • HJ

            I have seen the posts on KMD in the cost savings of concierge practices.

            Convenience isn’t cost saving. I think the concierge discussion should not use cost saving as a selling point because it is not a very good one.

            I, at one time, considered a concierge practice…the only one available at the time was an executive plan that cost $3000. I guess primary care doctors weren’t miserable enough to open concierge practices back then. That year my in-laws paid for a trip to Disneyland and that dark cloud that was my existence was lifted and I experienced so much joy, I decided that $3000 was better spent elsewhere. I now manage my own.

            There are several posters that indicate that a concierge practice would cost more money. I haven’t seen any posts where people saved money…The only example I could think of that would save money is someone with a chronic medical issues that needs lots of basic lab work and frequent office visits…Like my 90 year old grandmother, who is the process of slowly dying and every little something means a trip to the ER.

          • concierge doc

            I am sorry to hear about your grandmother.
            There are several other instances where the 24/7 access is cost saving. Take a parent with a sick child one evening, receiving care, a diagnosis, and treatment plan from their concierge doctor at night. Saves a visit to the urgent care or ER (cost saving) and potentially enables the child to feel well enough to go to school the next day (parent doesn’t have to miss a day of work) [cost saving for family and the parent's business in missed productivity].
            Adult receiving treatment for pain, infection, etc on a Sunday, no urgent care co-pay, no ER visit, and not having to take off of work on a Monday for a doctor’s visit [cost saving]. Not everyone has the benefits of tons of paid sick days.
            Missing work 1 day for an office visit, and then having follow ups done via telemedicine during a break of the work day. [cost saving].
            Just because a type of care doesn’t work for you or because you would not see savings, doesn’t mean others can’t benefit and save from it.
            I will say it again, concierge medicine is NOT the ONLY answer.
            Just one solution in the boat of many that our health system needs.
            You can search for articles referencing a family of 4 changing to a concierge practice and utilizing a higher deductible plan to see what their savings are. Again, that is only 1 example.

          • HJ

            This really sounds like catering to the worried well.

            My trip to the urgent care cost $25 on a Sunday. The trip to the ER would not be prevented unless a radiologist would open for business on Sunday. I have been to the ER twice in the last 10 years…both times sent because imaging couldn’t wait until Monday.

            If I pay $2000 in concierge fees in a year for 5 years, I will have paid $10,000 for primary care.

            If I go to the doctor an average of 4 times per year at $100 per visit and have one trip to the ER because I didn’t have anyone to talk to in the middle of the night…lets say a $3000 visit, I will have paid $5000 with insurance covering some of that catastrophic year. Let say I make $50 an hour and I miss a day at work, my total becomes $5400.

          • concierge doc

            Not everyone is as fortunate to have an insurance policy with such a low urgent care copay. Not everyone has a great urgent care in their city or town. Some people want to talk to their doctor in the middle of the night when they are ill, because they have a great relationship and trust with their primary care doctor, and don’t want an urgent care doctor who has no idea about their medical history to care for them unless absolutely necessary.
            Because each person’s specific health situation is different, offering many different insurance plans and having concierge style coverage for those who want the benefits is what we need.
            You seem to have the numbers worked out for your specific situation, but not everyone is the same as you. Medicine is not practiced with a “cookie cutter”, every patient is treated differently, treated with what would be best for them at that particular time. Allow people to choose a health plan, choose their doctors, choose how they receive care, the way that they see fit.
            If we can’t agree on the merits of concierge and DPC medicine, we should agree on the right to choose which doctor and practice you would like to be a part of.

          • HJ

            We are not discussing the merits of a concierge we are discussing price. For this type of care, it is more expensive for most people. The scenarios you suggested just don’t make sense. You say my situation isn’t right for a concierge and then describe a situation very much like the one I just experienced.

          • Lisa

            I think doctors who favor direct practice first tout cost savings. Then when pushed on the fact that such models don’t save money for many people, given the fact it is necessary to carry insurance to cover care beyond primary care, they tout other things – convience and a relationship with a primary care doctor. The problem I see with this is for most people cost is a major factor.

          • concierge doc

            People are joining concierge practices, at a very high rate year over year. For some actual numbers, I hope you’ll read this article:
            http://online.wsj.com/news/articles/SB10001424052702303471004579165470633112630
            Please go back and read the author’s article, encourage insurance companies to lower monthly premiums for everyone who sees a physician who does not collect reimbursement from insurance companies. This is about the entire US Healthcare system, a system that is searching for answers (plural). Not just one answer, but multple solutions to satisfy millions of people, all of whom are different and have different needs.

          • Lisa

            I’d have to suscribe to the WJS to read the full story. Nothing is more frustrating to be led to a link that requires a subscription to read the link.

          • concierge doc

            Just google “Pros and cons of conierge medicine wall street journal” and you should be able to read it for free.
            It works for me, no subscription required.

          • Lisa

            okay, that worked. Quick comment: Basically the article encourages people to go through calculations such as I have to determine if a concierge practice would be cheaper. And I still think for many people, membership for such practices would not save them any money over using their insurance policies, high deductible and all.

            I still would like to see actual examples of membership in a DPC or concierge practice bundled with a wrap around catastrophic meical policy that are avaiable for purchase on an federal exange (that means such plans may be subsadized depending on income).

          • concierge doc

            You may have to search to find the people who fit those purchase criteria.
            Just trying to show that concierge medicine and DPC can be ONE of the solutions. This is NOT the only solution. It will not be for everyone as we have discussed in detail over the past few days.
            I am glad you were able to get access to the wall street journal and read an article with data and referencing studies showing cost savings.
            Regards.

          • Lisa

            The article referenced one study, of people who already belonged to one practice. One study and you can’t read the actual study?

          • concierge doc

            I encourage you to read the study. If you can’t get access, your local library should be able to get it for you.

          • Lisa

            I’ve done that before; you need to know several things to get your hand on a paper – the title, the author and where it was published. Not in the newspaper article.

            Look, the article supports my contention, concierge or DPC models can work financially for some people, but certainly not everyone, and wrap around policies that include a DPC component and high deductible insurance plan are not widely available. I don’t think these models are a solution for many people and I get tired of hearing them presented as such.

          • JD

            It doesn’t need to work for everyone, and no one is saying that it should be the only option. The thing is, there are multiple policies in place that prevent it from being an option, when it should be allowed to exist and compete fairly with non-concierge practices. Again, what are you afraid of? I don’t see how another person going to a concierge doctor affects you, and it doesn’t have to be the best choice for you. It only has to be the best choice for some, or even a few. The key word here is “choice”.

          • Lisa

            What policies are in place that prevent membership DPC combined with a high deductible or wrap around insurance policy from being an option? I don’t know of any. Such plans would be allowable under the ACA and I have finally seen one that is offered on the Nevada exchange (See the Neighborhood VIP clinic):

            http://nevadahealthcoop.org/

            Per ZDoggMD, the premiums are competitve and the exchange pla are eligible for federal subsidies. I’ve looked at the package benefits and the plan sounds attractive. If I lived in Las Vegas I’d be quite interested.

            I truly am not afraid of DPC practices. As I have said, I think they would be more expensive for most people and I get tired of seeing them presented as a solution rather than a niche product.

            -

          • JD

            The fact that plans have to be “allowable” under the ACA points to the very essence of the problem. The ACA does not have to strictly prohibit DPCs to interfere with the ability of DPCs to provide care. The ACA simply offers incentives for patients to go through the usual, insurance based, channels. As a result, insurance-based health care plans get an unfair edge that has nothing to do with the quality of product they put out. The incentive is completely generated by politics, not quality, and not cost. Again, I don’t think that anyone is really presenting DPC as a solution, but rather to have the option of a DPC as part of the solution. My only point was that DPCs should compete on a level playing field with the usual, ACA approved, health care plans. If DPCs can lower cost and improve quality, then insurance based plans will also have to lower cost to keep up with the DPCs. In that case, everyone wins. If DPCs cost more without improving quality, they will not survive. I am not supporting DPCs….I am supporting fair competition.

          • Lisa

            I do not see how the ACA is interfearing with the ability of the a DPC practice to provide care or giving more traditional insurance based plans an edge. What is really giving more traditional insurance based plans an edge is the total cost of paying a DPC plan and a high deductible insurance plan.

            DPC plans are an allowable alternative under the ACA when combined with catastrophic insurance plan and they compete on a level playing field with other plans offered through an exchanges – if they are offered. People can get income based subsidies. Seems totally fair to me. Remember however, that most insurance in this country is still employer provided and so far most employers don’t offer plans that combine membership in a DPC plan with wrap around insurance either. I suspect that cost is one factor why they don’t.

          • HJ

            RE: “You may have to search to find the people who fit those purchase criteria.”

            Now we are making progress. There are only a few people that save money and you really have to search for them.

          • concierge doc

            Wrong. There are many that save money. They just may not be the ones posting on different blog sites.
            The success and ‘year over year’ growth of concierge and DPC practices says patients love the model and the care they receive.
            At the end of the day, shouldn’t you be allowed a choice for your healthcare? Shouldn’t you be able to choose your doctor and the type of practice you want to be a part of?
            You don’t have to agree with the data on cost savings and you don’t have to sign yourself or your family up for DPC. But others are allowed to make the choice for themselves and do their own calculations on the savings. Savings, cost, price, and value mean a lot to people.

          • HJ

            Perhaps you could give me a specific example from your practice of someone who spent less money by being in your practice.

            Comments from google search “pros and cons of concierge medicine…

            From Susan…”My husband and I faced this dilemma when our GP went concierge. We did not opt in, because we each have a medical condition that requires a specialist, and we would be going to our GP mostly for occasional respiratory infections or UTIs, which didn’t seem worth the extra fees. But under certain conditions I do believe it would be worth it, especially as our doctor would have provided substantial wellness support.”

            From tom…”My husband and I left our last doctor as he became a concierge doctor actually with 2 tiers ; concierge and non-concierge. We very much disapprove of that type of practice, which we consider very greedy and poor medicine, and he’d never been all that responsive to our needs prior to his becoming a concierge doctor…”

            I didn’t find any comments from patients that saved money. I did find this in one of the articles…

            “I asked Bett Martinez, a health insurance broker and consultant in Albany, California, whether she thought people could actually save money by using a concierge doctor. The retainer is hard to recapture in dollars and cents, she observed. But given the peace of mind people obtain for that money, she added, it might be worth the extra expense.”

            Notice it says “extra expense.”

          • Patient Kit

            Isn’t “peace of mind” the same thing that insurance is supposed to provide?

          • Patient Kit

            Thank god for back doors! ;-)

          • rbthe4th2

            Well remember you have to pay a fee for the concierge service.

          • rbthe4th2

            Our work based insurances are not going to drop that fee for a few. Ever. They need those people in the pools to help out the others.

          • concierge doc

            Your work based insurance does not need “those people” to help out the others. That insurance company that you think is on your side needs “those people”. There are numerous companies who are choosing to provide their employees with DPC/concierge type coverage (google Qliance).
            Also look into concierge practice Turntable Health in Las Vegas. These are a few examples of what we will see in the coming years, more options, for more people. Less reliance on the traditional insurance model, improving healthcare and improving our nations health crisis.

          • Lisa

            And insurance products that combine DPC with wrap around insurance make sense. But unless the DPC can be combined with insurance in a way that at very leaast is not more expensive it will remain a niche product.

          • rbthe4th2

            Exactly. It is also in the big name cities and I do not live in one or the capital of my little state.

          • Lisa

            I am nearing retirement age and have thought about moving to a rural area but don’t think I will, in part because of the difficulty in accessing medical care.

          • rbthe4th2

            Cost is HUGE point. That’s where when the rubber meets the road, the issue comes in regarding all the other items. The fact is, most can’t afford the extra dollars and that’s where it stops.

          • concierge doc

            That is the problem, you see concierge medicine as only a price. Price, value, access, personal choices, that is why people choose DPC or concierge care.

            For many people, it saves money.

            You have lost sight of the author’s statement that patients who choose a concierge practice should be credited with lower monthly premiums because their primary care doctor is not going to charge their insurance company for visits. Whether one visit per year or 50 visits per year, physicals, follow ups, etc. That is the goal of the article. To lower insurance costs for EVERYONE who chooses to use a DPC model.

            In your experience, you give no value [i.e. no price] to having to drive to an urgent care on a Sunday, wait in a waiting room for who knows how long (maybe you were lucky and you waited only a few minutes). For some people, that is worth actual $$$ to not have to do that. Especially parents with multiple children, having to bring all of the kids to an urgent care or ER when only 1 is sick, waiting, waitng, waiting, to be seen, there is a dollar value associated with that. The value of which I am sure an economist would love to discuss with you. If you think that doesn’t happen often, look up the stat that 1 in 5 children are seen in an ER or urgent care every year!
            You should talk with patients of concierge practices to see their savings and the value they receive.

            If you would like to see actual numbers with costs savings and how charges can be put towards your deductible, please look at: http://online.wsj.com/news/articles/SB10001424052702303471004579165470633112630
            There are numerous articles like this, you just need to look for them.
            Concierge medicine is not being forced on anyone, it is a choice, a choice that thousands and thousands of patients are making every year.

          • HJ

            I waited an hour at urgent care with my book in hand…Considering the gas and the time reading…Is that worth $2000 a year. Are you saying that paying $2000 a year to possible avoid a trip to urgent care is a good financial investment?

            I have waited with my children and it was hard. It wasn’t worth $2000 a year.

            The article states, ” If doctor visits typically cost $150 and the patient has six appointments a year, a concierge practice offering the same services for $40 or $50 a month might be cheaper.” Does this really exist for anyone?

          • rbthe4th2

            Exactly. Not everyone has young kids. If they have multiple kids, chances are they can’t afford the extra fee for concierge. That’s the point.

          • rbthe4th2

            Take a parent with a sick child one evening, receiving care, a
            diagnosis, and treatment plan from their concierge doctor at night.
            Saves a visit to the urgent care or ER (cost saving)

            ?? How so? If I pay $25 for urgent care and your fee is above that, doesn’t cover the tests (which insurance w/urgent care does), how am I saving $$$?

            and potentially
            enables the child to feel well enough to go to school the next day

            ?? Potentially is the kicker. Could be the same dx.

            (parent doesn’t have to miss a day of work) [cost saving for family and
            the parent's business in missed productivity].

            ?? Could be same dx and I dont have to miss a day off.

            Adult receiving
            treatment for pain, infection, etc on a Sunday, no urgent care co-pay,
            no ER visit,

            ?? How do you get that if I’m paying a monthly fee? If I pay $35 for a monthly fee, and I have to pay bloodwork, etc. while at urgent care I only pay $25 for everything, how is that cost effective?

            and not having to take off of work on a Monday for a
            doctor’s visit [cost saving].

            ?? Go Sunday night to urgent care.

            Not everyone has the benefits of tons of
            paid sick days.

            ?? That’s why we have urgent care.

            Just because a type of care doesn’t work for you or
            because you would not see savings, doesn’t mean others can’t benefit and
            save from it.

            ?? True but who exactly benefits in terms of patients? So far it is those who can afford it quite frankly.

          • rbthe4th2

            Agreed. The touting of benefits come from the doctors. I want to see patients and their circumstances in life, whether or not insurance was available to them, what $$$ they have, etc. (basically in my same situation) because so far I’ve not see that it would be cost effective. Urgent care & ER fills in where the PCP isn’t available.

  • Lisa

    If DPC and high deductible insurance are a workable model, how come you can’t buy a plan that combines both through a federal or state exhange?

    • concierge doc

      Great question for the federal and state exchanges. Why can’t you do that? Why can’t you have the options?
      We agree on a lot of points.
      Another question to ask is, “Would the insurance companies want that”? Or would some of the solutions above cut into their profits?

      • Lisa

        I read that that DPC and a high deductible insurance plan would be allowable under the ACA and theoretically eligible for federal subsidy. I have no idea why such plans aren’t offered as an option on a federal exchange. It may be that relatively few people would want to buy such a plan. I suspect one reason is such plans have a donut hole, like medicare part D. Another reason that you have to have a lot of DPC doctors to offer such plans on a larger scale. I think this is more likely.

        As insurance companies profits are limited to a certain degree (They get to retain 20% of the fees they take in, the rest has to be spent on medical expenses or returned to customers) I don’t think such plans would really effect their profits that much.

        • concierge doc

          In my area and many cities and communities around the US with concierge practices, the 20% of your hard earned insurance premium [the numbers you referenced] that stays as the company’s profit would just about cover the annual fee, whether retainer or not, with a concierge doctor.
          What did the insurance company do for you to earn that $1579.20 of profit last year and each year you’ve had that plan?

          • Lisa

            1) based on my annual medical costs for the past six years, I doubt that my insurance company has made a profit on me. Overall, yes, but on me individually, no. Pre ACA, I would not have been able to buy an insurance policy due to my health history – cancer and multiple joint replacements. So my insurance company serves as a mechanism to spread financial risks. This is the purpose of insurance.

            3) My insurance company has the power to negotiate with hospitals and specialists to bring down the cost of my medical care. Example, the bill for each of my hip replacements was around $100,000. When I received the EOB, the amount paid to the hospital was around $30,000. We can argue about how much the hospital should be paid, but I see evidence in the form of advertising that the hospital is actively looking for joint replacement patients and I assume they are making money. I think this ability is important – as a cash paying patient, my overall medical costs would have been unaffordable.

          • Harry

            But looking at the overall cost of your medical care, from what it sounds like, ends up costing others more than it costs you, as insurance is working in your specific favor. But what about someone who doesn’t require the same level of care that you do? Is it really fair to spread your health care costs to them, just so you can benefit? If all patients utilized healthcare equally, then I guess it wouldn’t be much of an issue. But the truth is that most people don’t require very costly medical care regularly, yet still pay hefty monthly premiums for a policy that truly doesn’t fit their specific needs.

            And as far as your insurance company negotiating lower prices with hospitals and specialists, it really isn’t much of a negotiation. They unilaterally set contractual reimbursements for services, to benefit the insurance company itself and not necessarily the patients. If insurance companies really had the patients’ best interests at heart, co-pays/deductibles/co-insurances wouldn’t exist. Sure, insurance companies talk about controlling health care costs, but the truth is that they need those costs to remain high enough so that people feel there’ll be no way to receive care w/o insurance, which allows the insurance companies to continue to command higher and higher premiums. Because most DPC practices no longer contract w/ insurances, they’re free to contract w/ wholesale pharmaceutical suppliers, commercial labs, and imaging centers, to get better prices on those products and services than even the insurance companies get. So when people are looking at the cost effectiveness of DPC practices, they should look at te cost savings that they can achieve by purchasing generic medications for literally pennies per pill, labs that cost upwards of 90% off retail prices, and imaging studies that offer substantial savings (for my patients, for example, an MRI for $300), to see what the true cost of a DPC practice is. In many cases, I have patients that save more than the cost of their monthly membership fee.

            And, to echo some previous comments from others, DPC’s save insurance companies money b/c these docs are not billing/collecting payments from insurances for their service. Also, the insurance companies are not having to pay for the prescriptions and labs that these patients are getting through these practices, which is a huge cost savings for them. As a result, patients should expect, even demand, lower premiums from their insurance companies, as they are now providing less coverage.

            Finally, for all of those who support the ACA, they might be surprised to know that membership in a DPC practice, coupled w/ a qualified high-deductible wrap around insurance plan, is a qualifying option that satisfies ACA mandates.

          • concierge doc

            Very well stated!
            Cheers!

          • Lisa

            I know that membership in a DPC practice, coupled with a qualified high deductible wrap aaround insurance plan is a qualifying option that satisfies ACA mandates. However, I have only seen one example of such a plan available through an exchange (so subsides could be available depending on income). Until such plans are widely available, they really aren’t feasible for people with low incomes. And therefore, imo not really a solution to giving people access to medical care.

            Insurance works be spreading financial risk. If you say it is not fair to have insurance pay more for people with higher medical cost than others, you will take us back to pre ACA days where people with pre-existing conditions couldn’t buy insurance and insurance companies routinely kicked people off their plans when they became ill and needed the insurance.

          • HJ

            So you believe that patients in a concierge practice that have expensive conditions should be charged more that a healthy person?

      • Lisa

        I found this quite interesting:

        http://www.dpcare.org/#!blank/c1op5

        Once you get DPC and high deductible insurance plans to coordinate, the model becomes more attractive.

  • concierge doc

    Don’t lose sight of the article’s goals. It is meant to show ONE way that primary care can be improved for MANY. Note that I am not saying that concierge medicine is the ONLY way to provide primary care, nor am I saying that it will work for EVERYONE. Once we stop trying to fit every person into the same healthcare boat, we will see that our system can not only float, but also thrive!
    Your personal health situation is unique and your relationship with your PCP and specialists is unique. No single person has the same issues, concerns, or needs as you do with YOUR healthcare.
    Concierge medicine and DPC is a way to provide better care for patients. See all of the comments I wrote below and in the author’s article. Medicine is not “cookie cutter”, treating patients should never be done with a “cookie cutter” approach. I care for each patient individually and provide the services they need, when they need it. I hope your PCP does the same in the manner in which provides the best care for their community, whichever model they choose to run their practice.

  • Lisa

    Except you have it wrong, I pay a high monthly premium for an insurance plan because I know, with my medical history, that I am likely to have high medical expenses in any given year, so my total out of pocket costs are less.

    • The_MDiva

      We keep circling over this…the matter at hand is not ONE person’s issues or medical history. You pay a higher premium, because you know you are going to get more out of it, and it works for you. That’s great. And you are right – most people cannot afford to pay sky high premiums AND a retainer fee for DPC. This article is not about that – it’s about making DPC accessible to anyone who values time, relationship with their PCP, and, in many instances, saves money. In the WSJ article, it mentions that in the DPC model, patients were diagnosed earlier in some cases because of the access & “all-inclusive” visits to the doctor. We cannot solve the healthcare challenge with only looking at one person’s situation — which is why options are so imperative. DPC is an amazing option AND solution for many. Not all. The bottom line truly is: it’s another solution that CAN work for millions of people.

  • HJ

    We took two trips to the ER when my children were young. One was when we were traveling. Both times we were able to contact a nurse line provided by our insurance

    Once again, if I pay $2000 a year for 5 years and it saves one ER visit, my cost is $10,000.

    If I have a ER visit once in 5 years, it probably doesn’t cost anything close to $10,000. My insurance deductible is $3000.

    I went to the ER on the weekend because I needed imaging…something my concierge fees would not include. An examination did not keep me from the ER.

    It has nothing to do with saving money. It seem like a poor selling point.

    It feels a lot like insurance premiums…But it’s like I bought car insurance that costs $2000 per year on a car that cost $5000.

  • Lisa

    I don’t oppose concierge medicine, per se, but I get tired of hearing it proposed as the solution to medical care in the US. Rather than blanket statements on how such models will save people money, enough to maybe even pay the retainers, I would like to see a true discussion on the costs belonging to such a practice and carrying a high deductible insurance policy.

    Someone on Kevin MD posted a good analysis of the costs of belonging to a DPC practice, backed up by a high deductible insurance plan, with a standard insurance plan available on a state exchange, using different scenarios – low medical expenses, high medical expenses. The DPC model was more expensive overall.

    Don’t tell me competition is a great thing. Right now, I see competition among hospitals trying to attract patients. I see advertisements for waiting times in ers. I see advertisements for joint replacement surgery. I see advertisements for hospitals offering robotic surgery. I don’t think this competition is about lowering costs to the patients and providing the best medical care. I think it is about increasing the hospitals revenues and it is not good for patients.

    • JD

      Competition is a great thing. What you are seeing is not competition….it is a LACK of competition. The reason why the hospitals that exist get to increase their revenues is because they have leverage….patients do not have a choice. They either go with these hospitals, or they get sick. But, suppose a new hospital came along, that did not work with insurance companies, but was willing to accept out of pocket pay? Or, suppose some other system of providing care was conceived? If these other options are truly better, then they will compete and succeed. If not, they will not. What you are seeing is “competition” after a whole bunch of competitors have been unfairly eliminated due to health care policies. It’s virtually like having contestants compete for the “best car in the world” award….except that only American cars can be considered. Our current health care system is the same way. That’s not competition….it’s an oligopoly.

    • HJ

      I posted that…here it is based on numbers from my area…

      A membership practice in my area costs $170 per month.

      For $294 a month I can get a bronze plan with a $5000 deductible and a $6350 out of pocket max.

      For $475 a month I can get a gold plan with a $1500 deductible and $10 primary care visits. With an out of pocket max of $4500.

      Gold plan…
      a good year…$5710
      a bad year…$6150

      Bronze plan with DPC
      a good year…$5568
      a bad year…$11918

      Bronze plan without DPC…
      a good year…$3538
      a bad year…$9878

      • Lisa

        Thanks!

  • HJ

    There are limited resources available and concierge medicine takes those limited resources for a few people…Everybody can’t have a concierge doctor…and not matter how you spin the cost, lower income people are the ones that suffer.

    Perhaps the shortage of primary care doctors will be mitigated by nurse practitioners. Physicians will complain they are not qualified but when that is your only choice… When I discover the great care I get with that nurse practitioner after 10 years because I don’t have access to a concierge doctor, are you going to tout competition when that nurse practitioner opens her own concierge practice at half the price?

    Or when I can see Dr. Watson any time anywhere for $10?

    • JD

      So….me buying a Mercedes somehow hurts you? No one is saying that everyone needs to buy one….only saying that people should have the CHOICE to have one.

      • HJ

        Not having access to a doctor because there are not enough to go around is not the same and not having a Mercedes.

        Do you feel medical care is optional?

        • JD

          I feel that CONCIERGE medical care is optional. And doctors are people too, which means that it should be their choice about how many patients they want to see. You talk about them as though they are servants, with a duty to cover a minimum number of patients. One of the most often cited reasons for our physician shortage is early retirement or increase in part time work…both of which are attributed to physician burnout. The OPTION of a career in concierge medicine may help alleviate some of this. Besides, the effect of concierge practice should not be any different than that of a doctor working part time. If you have no problem with a part time doctor, then I do not see why you would have any issue with a concierge doctor.

          • HJ

            I don’t see many posts touting the virtues of part time doctors as a solution for our health care problems.

          • JD

            And no one is touting the virtues of concierge doctors as a solution for our health care problems, either. Rather, they are touting that concierge medicine might be the right option for some patients, and some doctors.

          • HJ

            From the post above…

            ” In accordance, one does not become a doctor for any reason other than changing the world. Perhaps this change happens one patient at a time, but working toward a greater cause and putting other’s needs before our own are the key components that help to define us as physicians.”

            So how does concierge medicine help the greater good when it’s really for just a few?

          • JD

            Because by offering a choice/alternative for patients, it forces non-concierge practices to optimize their quality/cost so that they will not start losing their patients to concierge practices. It is not concierge practice that helps the greater good, it is the OPTION of concierge practice (and any other business models that anyone can suggest) that helps the greater good. By the way, if concierge medicine is really for “just a few”, there would be no way for concierge practices to survive, and we would not be seeing the boom in concierge practices that we are seeing. Like it or not, there is a very real, very significant percentage of the population who receive concierge care, and that percentage is growing.

          • HJ

            There is not cost control for patients…it costs more to belong to a concierge practice….all it does is make it harder for the rest of us. Why are we talking about price again?

          • JD

            It may cost more, it may cost less, but it is none of your business, because it does not come out of your pocket. This is the typical erroneous thinking….that when the wealthy spend more, the poor get suffer. The bottom line is, how the wealthy spend their money, on health care or otherwise, is their business, not yours.

          • HJ

            So you agree the option of a concierge practice doesn’t help the greater good? Or perhaps the it’s the greater good that is none of my business?

          • JD

            I just explained to you (2 replies ago) how concierge medicine helps the greater good…by offering CHOICE, and therefore offering competition to non-concierge practices.

            However, you are correct that the greater good is none of your business. It is also none of my business. By definition, the greater good is not the business of any single individual. If you look at the atrocities that have been committed by individuals in the name of the “greater good”, you would probably hesitate before trying tell everyone what is best for them and what is bad for them.

            I, on the other hand, have no particular alliance to, nor am I against, concierge medicine. I am only in favor of competition, and keeping options open. The greatest good comes from me NOT trying to say that any one solution is best, or that any one solution is worst. I only say that people should get to choose for themselves.

          • HJ

            So you can promote your ideas because your ideas the greater good but I can’t because it’s none of my business? I don’t believe that concierge does not for the greater good. You asked me, I answered. If you feel the need to promote it, I certainly can point out its flaws.

          • JD

            1) I did not ask you.
            2) I did not promote concierge medicine….I promoted CHOICE
            3) As I stated above – the greater good is none of my business either

          • HJ

            from the top of the thread…

            “For those who oppose concierge medicine, what are you afraid of?”

          • JD

            But that is not the question you answered. You answered a question about how to achieve the greater good…which I never asked. Now, if you are afraid of it making it harder for others go get medical care, let me ask you this…how does it make it harder?

          • HJ

            And I have never said that the choice shouldn’t be available. I have said it does not save patients money and makes it harder for those that can’t afford it to get medical care. If someone wants to make that choice, I think that someone should have this information…whether a doctor or a patient. These posts are prevalent on this blog on how it is such a great thing…don’t you think people should make an informed choice?

          • The_MDiva

            Great response! I sometimes feel the best response to those who want to solve healthcare issues by telling physicians how they should practice, or that “there is not enough care to go around,” is to simply tell them to go to medical school, complete residency, obtain hundreds of thousands of dollars in loans, and then by all means, “practice the way YOU wish!”

  • JD

    I find it interesting how when doctors want to work part time, we hail their ability to achieve work-life balance, and celebrate their choice. But, when a doctor wants to practice concierge medicine, they are criticized for taking resources away from others. How is concierge medicine any better or worse than being a part-time physician?

  • rbthe4th2

    What happens when you have epidemics? Several people need you? Who waits? Someone does – and now you see what happens with just 1 doc compared to multi doc practices with physician extenders.

    • concierge doc

      In my practice, we cap the number of patients/families that we have. This enables me to provide true concierge level service. Thankfully, epidemics as you referred to are very few and far between. And in those instances, I stay open and in the office as late as necessary. I know their medical history, I know what type of care they require, and my patients don’t mind waiting in case of an epidemic (I have a very comfortable waiting room, more like a living room… much more comfortable then urgent care chairs).
      Do you think that ERs, urgent cares, or any other practice for that matter is capable of handling epidemics without any wait?
      Their wait times during an epidemic would far exceed anything that would happen in my practice.

      • rbthe4th2

        True but we don’t pay extra for that (as in insurance and a fee). Also, in a group practice, as I have with my PCP and GI, they have other doctors and NP’s/PA’s that I can see in a pinch. No extra charge. I’m also not interrupting someones’ anniversary or child’s recital. While I do want to have my doctor available, I do want and believe that my docs need downtime and should be spouses and parents too.

        • concierge doc

          Not everyone is as fortunate to have that type of primary care practice. But for those who think that an urgent care visit (despite a sometimes low co-pay) provides the same care as your primary care doctor are often mistaken.
          Urgent cares and for that matter, ERs will often perform extra tests (sometimes unnecessary) in order to practice CYA medicine. Despite what some may believe, medicine is not practiced with a “cookie cutter” approach, patients are all evaluated and treated differently. Doctor “A” may not order the same tests as doctor “B”. Especially if one of them does not know you outside of that 1 urgent care visit.
          Your personal physician/their practice may be more likely to follow evidence-based guidelines and avoid unncessary costs, tests, and procedures to you. Not only would that save you money (in unnecessary non-approved laboratory tests) but also may avoid the too-often “incidental finding” or laboratory error, causing even more testing to happen to you just to prove what should have never been done in the first place.

          • rbthe4th2

            Interesting I’ve never had the urgent care here do that. The ER’s yes but not the UC’s.

  • rbthe4th2

    No, they may be seeing fed up docs who want to get away from that sort of medicine. Frankly, there isn’t a person I know of in the middle class or below bracket that isn’t trying to watch their pennies. People do value things but the fact remains an 11 year old car getting you to work, buying you food, is going to be more important than paying for concierge.

  • rbthe4th2

    What happens when the doc is sick? What happens when the doc has kids to take care of? What happens if there is a failure rate or the doc becomes disabled or hurt in a car accident with a long period of rehab? https://atlas.md/blog/2013/12/aca-homogeneity-direct-primary-care-doc-closes-up-shop-in-wisconsin/ doesn’t say anything about the causes of closing. In http://atlas.md/blog/2013/10/research-shows-top-10-states-and-top-25-cities-to-practice-insurance-free-medicine/, there is nothing that shows areas that aren’t major cities with a group of affluent population that could afford this.
    http://medicaleconomics.modernmedicine.com/medical-economics/news/direct-pay-medical-practices-could-diminish-payer-headaches?page=full ““If you’re not already the guy who is taking the calls late at night, if you’re not the guy who is visiting your patients in the hospital…don’t do it because you will fail,” Jacobson says.” How many of these doctors are really going to be doing this, with the younger generation opting more for working with hospitals because they want more predictable hours?
    http://thepromiseofprimarycare.org/2011/03/26/concierge-medicine-and-the-future-of-healthcare/ “Many of these benefits sounded strangely familiar, as they are similar to some of the principles of patient-centered medical home (PC-MH), only PC-MH does not require the payment of a significant “franchise fee” to the provider. While the movement also touts the restoration of the physician/patient relationship – not unlike PC-MH – they fail to mention that some of these franchises are owned by corporations with non-physician stock holders who expect to profit from their investment. The plans also promise that the routine care of the patient will continue to be paid by their insurance company. This latter proposition is not certain.” If you read the whole article, some of these practices are owned by corporations expecting a profit.
    There is also no addressing what happens to fee raises by the doctor in the terms of the agreement. This means is the fee going to be $50 a month until you die or not? What if the physician wants to retire or go part time? What happens then?

    • The_MDiva

      The beginning of your comment is very silly questioning. OF COURSE concierge doctors get sick, take care of their own kids, and yes – even go on vacation. Typically, they have a plan for another concierge doctor to cover for them, just like they would in a regular practice. What happens if a teacher gets sick? Do all the kids just not get an education? Or if an OB/GYN gets sick? Does a baby just not get delivered? Clearly, doctors are PEOPLE too. And I’m not sure what numbers you are looking at, but younger doctors are jumping into concierge at a rapid rate — because medical professionals want to practice medicine without all of the ridiculous red tape of insurance companies. If your physician retires, how is that different than your non-concierge physician retiring? Newsflash: concierge doctors are people, not robots. They typically have 1/4 of the patients in a traditional practice, in order to make time for their own lives. In our practice, we see only 5-6 patients a day. Because we don’t HAVE to see 30 patients a day. It’s a great lifestyle, and some of what we do can be done using telemedicine — giving us all more flexibility in our schedules.

      • rbthe4th2

        Right. I’m looking at if a single doc or two (two is what I’ve seen in some practices) have their 5-6 patients a day, when they get another set of patients from another who is out, say for a week vacation, that’s 10-12. What happens when you’re moved out and around because your doc isn’t there? How about following up in the hospital, etc. do you do anything different than regular docs do for their patients? The other is does your fee change? What happens when people pay and there is a change (doc moves or something)?

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