THCB UPDATE Get email updates of new posts and industry news. 
January 24, 2008
Concierge Medicine From A Doctor’s Perspective - David R. Donnersberger, MD, JD
Call it boutique medicine. Retainer medicine. Platinum care. Evoking the pastoral image of a sturdy black doctor’s bag and spectacles, concierge medicine is a small but growing trend among over-worked and over-booked physicians. The practice essentially offers a limited number of patients the opportunity to pay a fixed annual fee in exchange for premium services and attention. Fees can range anywhere from $1,000 to $20,000. Concierge medicine has been dubiously received while transition necessitates limiting a physician’s patient base significantly. Imagine receiving a letter from your doctor of 30 years demanding an annual fee on top of the cost of your normal visits. Hurry your check, and you may be one of the lucky ten percent the practice will keep. Thousands of patients have been outraged to receive just this kind of letter from their family doctor.
I believe concierge medicine can indeed offer significant advantages if mixed with a dose of good, old-fashioned business practice. There exists a happy medium that allows physicians to spend increased time with patients without alienating long-term clients. In our practice, we demand no annual fee. We ask that Medicare patients pay out of pocket for their wellness visit; such payment is only covered when the patient turns 65. The patient can in turn be reimbursed on the insurance provider’s schedule.
If the patient is unable to pay, we will still provide the visit. In considering a concierge practice, physicians should continue to accept patients with Medicare or other third-party payers, but may ask for payment directly before the patient files their own claim. The benefits of a direct payment structure to physicians means a less bureaucratic or “quota”-driven practice. The benefits to patients include same-day appointments, complete and continuous physician access via cell phone, on-site laboratories in clinics, and no anonymous hospitalists in the event of a stay. Increased attention for patients leads to a much higher rate of satisfaction and comfort.
Concierge medicine, from a doctor’s perspective, is a more gratifying and fulfilling way to practice medicine. Today’s doctors take on patient loads of up to 2,500 to 3,500 patients annually. Longer appointments with concierge physicians means a thorough discussion of patient questions and concerns. More time also translates into a real ability to monitor wellness screens such as mammograms and colonoscopies.
There exists the fear that concierge care will result in a two-tiered medical system based upon economics. In the beginning, this may have in fact been true. But as the practice has evolved over the past decade, so have individualized billing plans. Ideally, physicians should maintain long-standing relationships with patients regardless of their ability to pay out of pocket. About 250 concierge physicians exist in the United States today. Participating physicians report more time to devote to patient care and advocacy, as well as continuing medical education and family life. The result is a revolution in preventative care and a return to a more personal relationship between doctor and patient.
January 24, 2008 in Concierge medicine, Physicians | Permalink
Comments
Back to the future. What the good doctor is describing, but for some reason declines to name, is a return to a "business practice" wherein the financial relationship between the doctor and patient is not contaminated by either an insurance company or the government. This could be called traditional, or pure, fee-for-service. As he implies, but again declines to say outright, this "business practice" of direct payment and full-fee charge would require the medical practice to decline to participate in any contractural relationship with any third party payer, including medicare.
Calling this "business practice" a concierge practice is disingenuous; nothing in the core principles outlined supports "same-day appointments, continuous physician access...". One could certainly CHOOSE to practice in this manner, with or without direct patient payment. It is precisely the contracual arrangement of a classic concierge practice, cemented with an annual fee, that guarentees the patient services noted above while permitting the physician to enjoy "patient care and advocacy, etc."
My objections to Dr. Donnersberger characterization do not mean that I disagree with the principals or his "business practice". Who among us practicing medicine in America would not rejoice in the ability to determine the value of our care, and to remove the specter of third party payers from the physician/patient relationship. But simply returning to a pure fee-for-service business model does not make one a "concierge practice" I'm afraid.
Posted by: bingo | Jan 24, 2008 11:49:34 AM
Who among us would not like to conduct a "concierge" style business of any kind. It takes the bother out of dealing with the masses while letting us concentrate on the joy of the business. I wonder if the docs who do this are still able to retain their client base developed through their contracted insurance partners? Have your cake, and eat it too? I also wonder if their upscale patients get reduced rates for services they now need to do themselves to collect insurance reimbursment? There are docs that have started concierge style practices but have done it without using insurance to attract patients. Their patients get reduced fees as the savings are passed on. This is a solution for docs, it is not a solution for healthcare.
Posted by: Peter | Jan 24, 2008 12:34:56 PM
Bingo - Exactly or more like a return to the 1970s (FFS payments coupled with a cottage-industry delivery system of independent physicians). Been there and it was basically a failure on multiple fronts - cost containment, quality and safety deficiencies, lack of coordination, etc.
Posted by: MG | Jan 24, 2008 4:29:12 PM
Okay great...What happens if you have a very large family? I could end up paying a ton for this.
Posted by: mjones | Jan 25, 2008 2:23:29 PM
CM Response:
The post by Dr. David R. Donnersberger; JD reinforces some excellent, although not necessarily novel, points about concierge medicine; as do the prior comments.
However, the statement about patient outrage may be a bit hyperbolic, and is not borne-out by our experience in the “big city”. No doubt it may be a real concern in rural areas, but such locations may not be fertile grounds for this evolving business model anyway.
For example, in Atlanta, there are about 4 million of us. The census bureau suggests that the average “hot-atlantian” moves about every 2.7 years. If this is correct - and my heuristic gut does seem to suggest we are a city “on the move” - then there are very few 30 year physician-patient relationships.
And so, CM represents just another medical practice format – much like retail clinics, ASCs, specialty hospitals, etc – that still seek to fine-tune a business model as well as solidify credibility.
All the best!
Dave
Dr. David E. Marcinko; MBA
CEO: www.MedicalBusinessAdvisors.com
Editor: www.HealhcareFinancials.com
Publisher: www.HealthcareFinancials.wordpres.com
Editor: www.HealthDictionarySeries.com
Atlanta, Georgia, USA
Posted by: Dr. Marcinko says | Jan 26, 2008 7:39:11 AM
Bingo and Dr Marcinko and others: Thank you for your comments. Indeed, this is really a FFS business model that allows for a doctor-patient relationship that may be different from what other business models allow. We have no contractural relationships with any insurance carriers. We do however electronically submit to patients' insurance companies, but that is where the relationship ends. Uncovered or rejected fees are the patients' responsibility, a contingency that the patient knows in advance. If a patient has a plan that covers lab work drawn at a specific site, we gladly use that option in order to contain costs. Our practice has been operating in this fashion since the 1970's, so there was no alienation of patients.
We do see patients every day who have received letters from their doctors telling them that they are cutting their current practice down from 2700 patients to 400. In order to stay in the practice the patient is told that that there will be a mandatory annual fee of $1500 and $2000 per couple, etc. These letters commercialize the doctor/patient relationship, alienate long-standing patients, and give "concierge" medicine a bad name (understandably). There are several very slick companies that help practices morph into these models.
Patients, in my experience, understand paying out of pocket for care as they utilize it, rather than writing a check for an "entrance fee" every year on Jan 1. (Indeed, although we consider Europe a bastion of universal health care, a significant percentage of Europeans pay out-of-pocket to see specialists, avoid long waiting rooms, get the MRI, move appointments sooner, or see a doctor who is perceived as having better training or personality.) Many of my patients live part of the year in warmer climates. Their doctors in AZ and FL require annual fees of $1500 for a relationship that lasts from mid-Jan to mid-April and includes no screening or health maintenance. Such a requirement engenders considerable ire in my patients, but allows for a doc/pat relationship that hopefully redounds in better care than at a walk-in clinic (I hope).
Although we work in a 5 million+ urban area, 60% of my practice includes the siblings, spouses, grandparents, children, and grandkids of other patients. We practice generational, small-town medicine in a metropolis. My partners of different faiths and I attend the churches and temples of our patients. We work out, buy groceries, and use the same dry cleaners that are frequented by our patients. We try to know the patients when they are well, so that we can take better care of them when they are in the ICU. (Pressure to use the hospitalist serivice by our hospitals is making this more difficult.) While writing this I recognize how Pollyannaish it sounds; although it is what happens. I offer my thoughts not as a way to get rich practicing primary care medicine. Rather it is an alternative that allows for financial survival while practicing medicine and building relationships in a way that we think is best and without having to double-book or see 37 patients in a morning. Obviously, the model is intensely demographic-dependent.
Posted by: David Donnersberger | Jan 29, 2008 8:31:13 AM
Dr. Donnersberger's intuition of the way this patient felt when I received my physician's letter announcing his move to a concierge group is definitely right on target ...
As a health care lawyer, though, I need to offer a caveat in response to the statement that "In considering a concierge practice, physicians should continue to accept patients with Medicare or other third-party payers, but may ask for payment directly before the patient files their own claim."
Physicians who intend to accept annual access fees should make sure they've cancelled all of their contracts with third-party and governmental payors, AND checked the by-laws of facilities where they privileges AND consulted state laws on point AND know that some patients may receive no reimbursement, even if they do file their own claims.
I'd be delighted to discourage docs from moving into concierge practices, but I'll settle for pointing out that the transition may be a little more complicated than it seems.
Larry Rose
San Francisco
Posted by: Lawrence J. Rose, Esq | Feb 6, 2008 6:43:23 PM
I am a senior (I hate that word but have to use it) and have just signed on to a new concierge practice. Six months ago I would not have guessed I would do so, but events occurred that made it easier to make the decision.
Six months ago my then primary care doctor went into a concierge practice out of the city. I had been assured I could get another doctor within the same practice, but when I tried to get prescriptions refilled, I found the transfer to the doctor they had named was not done, and my files had been sent to another doctor out of the practice. So much for choice. In ensuing weeks I found myself beating my head against the wall to (1) get the office manager--a non-medical person, and consultant who had recently been hired--to answer my calls (after the 4th message she did talk with me and was exceptionally rude), and (2) to get the prescriptions filled for which I had waited more than two weeks. I am on Medicare, with supplemental, and frankly at my age I was now feeling like I had been left swinging out there with no assurance of help when I needed it.
I talked with my former primary care doctor who had transferred my files. She recommended the new doctor highly so I agreed to go with her. And lo and behold she was also starting to slowly transfer her practice to a concierge one. I looked into it carefully, and have just had my first checkup and long preliminary meeting with one of the docs in the practice. I am satisfied that I can continue as a Medicare patient and they will handle the billing, and I am also satisfied that if I terminate my agreement with 30 days written notice and the fee may be pro-rated (I paid half, with the other half due after 6 months). If they terminate the agreement I will receive a refund of the processed portion of the paid fee, based on the number of days that have elapsed.
The bottom line is I reacted out of a need, as a senior, to feel secure that I would get medical attention if and when I need it. If the fee had been very high I would not have signed up. If they were not prepared to handle the Medicare and supplemental paperwork, I probably would not have signed but. And if I had not felt comfortable with the doctor after our getting to know you visit, I would have opted out. The fact of the matter is that I am comfortable with the decision and hope it works as well as I am projecting it to work.
Posted by: Teresa Middleton | Feb 7, 2008 2:34:26 PM
I left a busy group practice in Fort Myers, Florida in 2005 to start my house-call based concierge practice. Originally I tried to deal with insurances but since none pay for house-calls, and Medicare only reimburses minimally, I couldn't make it viable. In our area it's not uncommon for me to drive 30-45min between visits and I typically spend 45-60min with a patient. Hence I was drawn to the concierge business model. I am still the ONLY concierge physician in South-West Florida exclusively making house-calls in Lee and Collier counties.
No mistake, my services are a luxury item and convenience for most of my patients. I charge $2000-$6000 a year per person, depending on age, size of family, and location.
I know it's not the answer to our health care crisis, but I certainly love my job again! Besides I get to see my kids more.
Two other key points for the lay-person to understand. Just because I charge above what insurance pays, doesn't make me rich. I actually made less than our city pays bus drivers for the past 2 years, although admittedly the potential is significant. Also, even though most of my patients are the "rich and famous" of our area, doesn't absolve me or any concierge physician of our responsibility to the community. In fact this is a responsibility of each of my patients as well.
I continue to be an active office in the US Army Reserve, chair the Health Advisory Committee of the Lee County School District, volunteer as a Guardian ad Litem serving abused and neglected kids, teach Head Start program moms about child care, etc...
No, concierge medicine isn't for everyone, but it certainly has worked for me and my patients.
Andrew Oakes-Lottridge, MD
Personalized Health Care, Inc.
(239)694-6246
www.DrAndy.us
Posted by: Dr Andy | Apr 7, 2008 2:26:12 PM
Thank you for sharing this growing trend. I believe that our health care system is very vibrant, notwithstanding its shortcomings and challenges. Consumerism and capitalism play a big part in our health care system. Consumers want choices, and service-providers seek returns. Boutique medicine or concierge medicine meets both expectations. I am not suggesting that financial reward is everything in our economic system, nor is the only deciding factor in a supply and demand equation. For a physician, a small client base means more time devoted to patient care and advocacy, along with continuing medical education and family life. While a care-giver may have to sacrifice financial gains, getting greater satisfaction from long-standing doctor-patient relationship offers a different kind of gratification, which an over-worked, over-booked physician will miss. A reduced patient load for physicians often translates into longer and same-day appointments, better coordination with specialists, and more emphasis on preventive care. Concierge care may potentially result in a two-tiered medical system based on wealth of the patients. Some decry concierge care as another step toward a medical system in which the rich get no-wait examinations and the poor sit for hours just to see a HMO doctor for 15 minutes. This is simply the nature of a free market. According to one comment on your blog, in Europe, where the universal health care system is long established, a significant percentage of people pay out-of-pocket to see specialists, avoid long waiting rooms, get MRIs, more appointments sooner, or see a doctor who is said to have better training or personality. While the concept sounds ideal, my concern is that physicians who choose to take part in this boutique medicine business model may not cancel all their contracts with third-party or government payers. As a result, doctors simply commercialize the doctor-patient relationship, and patients who pay the fixed annual fee in anticipation for premium services and attention will not get their bargains. Such business model is not widely available. According to the General Accounting Office, in 2004, there were just 146 concierge physicians in the U.S. My other concern is what will happen to the established doctor-patient relationship when one party has to relocate, especially for a patient who is very accustomed to a concierge care moves to a new region where such service is not available.
Posted by: DHL | Apr 14, 2008 11:25:56 PM
Wayne M. Burr, MD, PL
(239) 333-DR4U(3748)
9407 Cypress Lake Drive, Ste. C
Fort Myers, FL 33919
http://www.concierge-physician.com
Some interesting concerns are brought up in the previous comments. This practice model, although attractive to most people, is still not for everyone. It has been my experience that those who are frustrated with the typical office of long waits, appointments that are not on-time, and calls that are never returned finally see the value in the concierge model. I often ask persons who I sit down with to discuss joining my practice "How much is your time worth"? Even if you have good insurance, is that worth the aggravation and inconvenience that some have to go through to get their medical care?
I provide a choice for clients to receive their medical care when and where it best suits their needs. They can come to my office, or I can go to their home/office. My staff is available to meet these needs as well. I belive in a wellness approach to healthcare which is why I include visits with a Registered Dietitian, personal fitness trainers, and massage therapy with the concierge fee. These services can be performed in the office or in the home depending on the client's need. In fact, my practice is the only one in Southwest Florida to provide this comprehensive approach with all of these ancillary services, and give clients the choice of how they wish to recieve their medical care (all of this for less than other concierge physician's annual fees in this area). What I have found to be true is that in most cases, clients prefer to have their medical care delivered at my office where laboratory testing is also available.
Concierge medicine provides another choice for medical care. I do not think that this will in any way take over the current establishment, but more practices like this one will be available.
Posted by: Wayne M. Burr, MD | Apr 25, 2008 1:00:01 PM
Hi
it is a very good and great post and I really appriate it.
Posted by: Θεμις Μαντζαβινος | Apr 28, 2008 1:20:15 AM
Does the FL state insurance commission consider a concierge practice to be an insurance company? What regs apply?
Posted by: clb | May 29, 2008 8:42:01 PM
This day and age more and more people are using a personal concierge to “buy back” their precious time. A personal concierge works on the most basic of premise: people want things done and just don't have the time to do them.
Posted by: Conciant | Aug 22, 2008 1:30:37 AM
Does anyone know of any concierge physicians interested in hiring another physician to join their practice?
Posted by: Mike | Oct 4, 2008 2:17:02 PM
Mike, our practice is looking to hire two already established physicians to operate in a new concierge location. Look at www.letssimplify.com
Posted by: Stacey | Nov 6, 2008 11:25:05 AM
Mike, I am looking for a partner in a concierge practice in the WashingtonD.C/Baltimore area. Our clinic is already in existance as a Medical Spa. We plan on formally opening our Wellness Center in Jan/Feb timeframe. We have been transistioning our clinic to a concierge model. contact me through our website at www.atlantismedispa.com. We are currently redesigning/configuring our website to reflect our future practice.
Posted by: Ben Gonzalez | Nov 11, 2008 8:16:51 PM
I'm a physician practicing in Southern California and looking to start a new internal medicine practice. The concept of concierge model of providing care really appeals to me due to a number of reasons, some of which have been mentioned by previous writers: enhanced doctor patient relationship, improved standard of care, compassion, accountability and availability. The only fear I have is the bureaucratic jungle I'll be facing with insurance carriers and government programs like Medicare. If anyone knows of ways of getting around this problem, please write back.
Posted by: nasimeh yazdani | Nov 14, 2008 3:36:01 PM
In concierge medical care, patients are not paying for the usual care, they are paying for a health advocates who will navigate the health care system for them. Waiting times for physician is nil. Respect for the patient is paramount.
I recently joined Enhanced Medical Care with Mark Costa, M.D. in Newton, MA, what a transformational experience.
Posted by: Marilyn | Nov 16, 2008 7:51:03 AM
There is no difference is quality of care between doctors who are participants in health care plans, and doctors who don't take insurance.
It would be nice if the patient could at least get quality health care by paying cash, but the doctors are just as rushed, negligent, rude as plan participants.
Concierge medicine is just another rip-off gimmick by this increasingly detestable profession.
Posted by: Alex | Nov 17, 2008 2:49:28 PM
Concierge services has become quite popular these days. Hotel employed concierge services
attract many potential hotel guests and bring in good business. Corporate concierge services
have gained popularity and are also demanded in the market.
Posted by: concierge services | Jan 11, 2009 11:25:55 PM
Concierge Medicine in Demand, Even in Difficult Times
Healthcare is a top priority for Americans, even in continually difficult economic times. With people all around the country cutting back on everything from eating out regularly to family vacations, it seemed only a matter of time before reductions on healthcare spending began. But that just isn’t so.
Take concierge medicine for example, an avenue within the healthcare industry in which you can find personalized, quality care. Concierge medicine has barely been touched by the recession.
Studies show that Americans value their high quality healthcare and are not eager to give up visits to their concierge doctor, even when money is tight. They see top healthcare as a necessity, not a luxury. And it’ll take more than hard times to change that.
Posted by: Elite Health | Nov 18, 2009 9:51:42 PM
MOST COMMENTED
