Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Concierge and primary care medical home hybrid model of care

Mark W. Browne, MD
Policy
March 21, 2011
128 Shares
Share
Tweet
Share

As a consultant, I spend a lot of time on airplanes and subsequently get to meet a new “person in the next seat” almost every week. Once the small talk is over, the conversation is nearly the same every time. “Oh, you work in healthcare! What do you think about all of this reform stuff anyway? Is there an answer?” I’m always very cautious how I frame my answer. As those of us who work in this world know, there is not an answer so I am very careful not to endorse one model or the other, keeping the conversation turned toward the general nature of reform and the complexities it entails.

Well today I am breaking my own rule. I want to talk about a model that just might work. I’m not sure if my inspiration was generated by the storms this weekend, making me feel a bit like the good Dr. Frankenstein, but I began to consider what a new model of care might look like if we took the best parts of some good models and built an entirely new “beast.” My thoughts are not entirely complete and your feedback is welcomed, but here goes….

The model is based on the following premises:

  • Some of the best and brightest physicians have become frustrated with the complexities of billing, the noise of paperwork, and the inability to care for an unmanageable number of patients to make ends meet. As these complexities worsen, more and more physicians will either leave practice, seek out a partner (read “hospital”) to accept the growing economic risk, or move to a model of “cash for care.”
  • A small number of the sickest patients consume a large share of available medical resources. In many of the new models proposed, safeguards are built in so that physicians don’t select these patients out of the care model as the risk for caring for them poses too great of a financial penalty.
  • Carrots work better than sticks.

So here is the plan. Why not pay the best and brightest physicians to care for the sickest patients as simply and effectively as humanly possible? Let’s take the best parts of a concierge model of care, throw in a bit of primary care medical home and a touch of Dr. Gawande’s hotspotting model and see what we get.

The model would work like this. Take a population of no more than 300-400 patients with at least one chronic disease as their primary diagnosis and assign them to one physician. This physician would be responsible for the care of those patients and those patients only. But rather than pay the physician through any type of complex, CPT driven payment mechanism, pay them cash. No billing, no coding, simply cash up front.

Sound too much like capitation? Here would be the key difference. In a capitated model, it is assumed that too much care is given and the payments are designed to reflect the risk of managing care down to a certain level of payment and reimbursement. Physicians are motivated by avoidance of an undesired negative financial outcome. In this model, the assumption up front would be one of excellent care. Remember, only those physicians who have demonstrated that they are already the best of the best in caring for complex patients would be invited. Physicians would receive payments based on their continued provision of the highest quality care to patients – not just to avoid negative outcomes, but assure positive ones. Payments would be based on the assumption that at least one hospital admission for at least half of the patients would be avoided on an annual basis.

Although current payment structures for hospital care are based primarily on the volume of admissions, this model will set the stage for a value based model of reimbursement that is likely represents the next iteration of hospital payments. If you assume that a hospital admission for a chronically ill patient can quickly add up to $10,000 or more, you would very easily have enough cash flow to run a practice.   In order to assure that excellent care was given, outcome based quality and cost metrics would be measured on all patients. There would be no “quality bonuses.” Quality care is assumed and paid for on the front end. As long as the highest quality is continually demonstrated, physicians would be allowed to continue practicing in this model.

So in the end here is what we get:

  • Patients who need the most care get focused attention from the best physicians leading to better outcomes of care than they can achieve in our current fragmented system.
  • Unnecessary care, in particular expensive hospital based care, is reduced, thus decreasing total costs to the system.
  • Physicians are rewarded (instead of penalized) for caring for complex patients with financial recognition, and by minimizing the administrative burdens inherent in practices currently.

As always, the devil on any idea like this is in the details, but if we are to come up with meaningful solutions we may need to develop a tolerance for living out here closer to the edge of creativity, avoiding the gravitational pull of current thought and the status quo.

Mark W. Browne is Principal, Pershing Yoakley & Associates and can be found on Twitter @consultdoc.

Submit a guest post and be heard on social media’s leading physician voice.

Prev

Evaluating dizziness in the cardiologist's office

March 20, 2011 Kevin 10
…
Next

Prostate cancer from a patient perspective

March 21, 2011 Kevin 2
…

Tagged as: Primary Care, Public Health & Policy

Post navigation

< Previous Post
Evaluating dizziness in the cardiologist's office
Next Post >
Prostate cancer from a patient perspective

More by Mark W. Browne, MD

  • a desk with keyboard and ipad with the kevinmd logo

    Eventually in healthcare, there will be an app for that

    Mark W. Browne, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Is the health quality bar set high enough?

    Mark W. Browne, MD
  • a desk with keyboard and ipad with the kevinmd logo

    What the physician hiring process can learn from the NFL draft

    Mark W. Browne, MD

More in Policy

  • Pediatricians grapple with guns in America, from Band-Aids to bullets

    Tasia Isbell, MD, MPH
  • Health care wins, losses, and lessons

    Robert Pearl, MD
  • Maximizing care amidst provider shortages: the power of measurement-based care

    Tom Zaubler, MD
  • Unveiling excessive medical billing and greed

    Amol Saxena, DPM, MPH
  • Chronic health issues and homelessness

    Michele Luckenbaugh
  • The impact of certificate of need laws on rural health care

    Jaimie Cavanaugh, JD and Daryl James
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Pediatricians grapple with guns in America, from Band-Aids to bullets

      Tasia Isbell, MD, MPH | Policy
    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • AI-driven diagnostics and beyond

      Michael Kirsch, MD | Tech
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Misunderstandings about opioid use disorder

      Amy Baxter, MD | Conditions
  • Recent Posts

    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Debating the role of psychiatric assessments in medical decisions

      Christian Youssef & Francisco M. Torres, MD | Conditions
    • Navigating adulthood in the digital age

      Eleanor Menzin, MD | Physician
    • 5 things to know about weight from a bariatric surgeon

      Maria Iliakova, MD | Conditions
    • Out-of-office infusions in oncology care [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 12 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • AI Not Ready to Replace Radiologists Interpreting Chest X-Rays
  • Study Confirms Better Survival for HPV-Positive Cervical Cancer
  • FTC Sues Anesthesia Group and Its Private Equity Backers
  • Inmates Escape From Hospitals in Recent Spree
  • 'The Last Straw' Driving Workers Out of Healthcare

Meeting Coverage

  • New Schizophrenia Treatments Are Coming: Don't Panic
  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Pediatricians grapple with guns in America, from Band-Aids to bullets

      Tasia Isbell, MD, MPH | Policy
    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • AI-driven diagnostics and beyond

      Michael Kirsch, MD | Tech
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • Misunderstandings about opioid use disorder

      Amy Baxter, MD | Conditions
  • Recent Posts

    • Understanding intersex health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Debating the role of psychiatric assessments in medical decisions

      Christian Youssef & Francisco M. Torres, MD | Conditions
    • Navigating adulthood in the digital age

      Eleanor Menzin, MD | Physician
    • 5 things to know about weight from a bariatric surgeon

      Maria Iliakova, MD | Conditions
    • Out-of-office infusions in oncology care [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Concierge and primary care medical home hybrid model of care
12 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...