Concierge medicine model delivers small practice physicians from below the margin

Direct, private, boutique, concierge -- a recent movement in medicine has been sanctioned all these titles by marketing gurus and advertising tycoons. But rather than concentrating on the kitsch and the catchphrases, most physicians who opt into the new model are calling it one thing: effective.

As the healthcare industry continues to slither through the motions of a most languid evolution, many doctors have been caught between the rumples of the industry's half-shed skin, working longer hours with less time for patients. Frustration from within the folds has already driven more than 5,000 physicians running smaller practices across the nation to don the colors of the direct medicine movement -- an infrastructure of care which allows physicians to charge patients an annual fee that will guarantee them more time and attention.

Incepted during the 1990s at opposite sides of the country (Seattle, Washington and Fort Myers, Florida), the number of practices utilizing the concierge medicine model has increased fivefold since 2005, according to last year’s MedPAC study.

"In just 15 years, this movement has grown from a couple of outlier practices in opposite corners of the country to thousands of them in the mainstream throughout the land," Gary M. Price, MD, FACP, president of the American Academy of Private Physicians (AAPP), wrote in an update to his concierge constituents. "Today, even medical schools are including direct practice in their curricula. And the momentum continues to build."

This theory perpetuating the AAPP -- an organization Price heralds as the “voice” of direct practice -- provides a firm foundation for the solo physician practice scaffolding, which has been teetering under heavy patient volumes and unforgiving insurance relations.

"I was just spending more and more hours working and finding that the revenue was decreasing and my overhead was increasing," Michael T. Duffy, MD, Beverly Hills, told the Los Angeles Times. "I felt I needed to make a change."

Duffy's decision to uproot his practice after nearly 20 years was by no means simple, but when confronted with the far more grizzled alternative of going broke, he chose the snappy boutique method over snapping his prescriber’s pen in two.

"Going broke is not the solution to serving more patients," he said.

The annual fees range in price from doc to doc -- some physicians charge their patients as little as $600 while other rates climb into the high $5,000s. Naturally, with an extra medical expense that could potentially lead patients to part with thousands of dollars a year, patient pools often shrink to puddles under the direct practice archetype. Duffy went from seeing 2,000 patients to 400 patients after he made the transition. And although losing patients due to the severity of a concierge fee is certainly not a "victory" according to Duffy, it's a necessary evil to secure the longevity of one’s practice.

But while physicians like Duffy subscribe to the Price logic that "direct practice restores the doctor-patient relationship to the lofty level it enjoyed before being constrained and degraded by government and insurance," some experts claim that the epitome is not a top-tier solution; it’s more reminiscent of two-tiered medicine, which bars patients from their preferred doctor if they cannot pay the inessential, additional fee. Furthermore, as more Americans will soon qualify for health insurance come 2014 by way of national health reform, specialists are concerned that the shortage of primary care physicians will only worsen if concierge medicine takes prominence.

"Concierge medicine is a product to be sold, not unlike an expensive car or a high-end kitchen appliance," Michael Stillman, MD, Boston, wrote in an essay published for the March 10 edition of the journal Annals of Internal Medicine. "It is simply a way for physicians to have a much more reasonable lifestyle and for patients to feel (whether or not this is true) that they are getting the very best care."

American Medical Association guidelines also say that retainer practices "raise ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care."

Matt Jacobson, founder of concierge-supporting service-provider SignatureMD insisted that those patients who pay the fee are given a host of perks such as 24 hours access to their doctors, more testing opportunities, more time with their physician and less time spent in the waiting room. He also noted what direct practice says about the physicians who opt-in: They are individuals who don't want to align themselves with "production line, seven-minute visit medicine." Jacobson gauged patient participation methodology on the collegiate level.

"Some people view going to a private school as the most important thing," he said. "This is the same thing. Some people view healthcare as very important. They are going to cut their cable bill to see the exact doctor they want."

The direct practice dilemma is multifaceted, rubbing all levels of care a different way. It’s hardly surprising then, that while the American Academy of Family Physicians does not condone concierge medicine as the best model for PCPs, President Glen Stream can still understand it’s appeal.

"It is an adaptation to a dysfunctional healthcare environment," he told the Los Angeles Times. "We recognize people's need to adapt, to be able to provide services to their patients. As long as they are providing good-quality care, then it is something we understand."

Comments (2)

Paul Kaye, MD: The principles underlying concierge medicine are the same as the Joint Principles of the Patient Centered Medical Home movement. Paying primary care providers a base fee for managing all of a patient's care allows primary care physicians to get off of the hamster wheel treadmill of high volume, short visits that are not sartisfying to patients or doctors. The payment has to be high enough to make a difference, and the doctors have to be held accountable for delivering on the same promises about access and quality that concierge patients expect when they part with their hard earned cash. Instead complaining about a two tiered system, let's redesign payment so that everyone gets concierge style treatment. Maybe that will finally cut the ridicuous anount of money we spend on high cost testing and unneccesary procedures.
Gary M Price MD FACP: Excellent article. Appreciate the author's vivacious style and accuracy (quoted me exactly!). Well done.

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