Concierge medicine

Concierge medicine (also known as retainer medicine) is a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges. In exchange for the retainer, doctors provide enhanced care, including principally a commitment to limit patient loads to ensure adequate time and availability for each patient.^[1]

The practice has been referred to as concierge medicine, retainer medicine, membership medicine, cash-only practice, and direct care. While all "concierge" medicine practices share similarities, they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the fee charged. Estimates of U.S. doctors practicing concierge medicine range from fewer than 800^[2] to 5,000.^[3]

Business model

There are typically three primary types of concierge medicine business models practiced today. Variations of these models exist, although most models usually fall into one of the following categories.

The Fee for Care (‘FFC’) is an annual retainer model, where the patient pays a monthly, quarterly, or annual retainer fee to the physician. The retainer fee covers most services provided by the physician in his/her office. Often, vaccinations, lab work, x-rays and other services are excluded and charged for separately on a cash basis.

The Fee for Extra Care (‘FFEC’) is similar to the FFC model, however, the additional services are charged to Medicare or the patient’s insurance plan. Some of the benefits and services typically included in these two retainer models are: same day access to your doctor; immediate cell phone and text messaging to your doctor; unlimited office visits with no co-pay; little or no waiting time in the office; focus on preventive care; unhurried atmosphere; cell phone, text message, and online consultations; prescription refills; and convenient appointment scheduling. Many FFC or Retainer plans may be purchased with pre-tax dollars utilizing HSA and/or FSA accounts attached to patients' insurance plans.

There is also a Hybrid concierge model where physicians charge a monthly, quarterly, or annual retainer or membership fee for services that Medicare and insurers do not cover. These services may include: email access; phone consultations; newsletters; annual physicals; prolonged visits; and comprehensive wellness and evaluations plans. For all covered services, these providers will bill Medicare and insurance companies for patient visits and services covered by the plans. .^[4] This model allows the physician to continue to see their non-retainer patients while providing their “concierge” patients a fee for the increased or “special” services. Some concierge practices are cash-only or ‘direct’ primary care practices and do not accept insurance of any kind. In doing so, these practices can keep overhead and administrative costs low, thereby providing affordable healthcare to patients.^[5]

Concierge physicians care for fewer patients than those in a conventional practice, ranging from 50 patients per doctor to 1,000, compared to 3,000 to 4,000 patients that the average traditional physician now sees every year.^[6] All generally claim to be accessible via telephone or email at any time of day or night or offer some other service above and beyond the customary care. The annual fees vary widely, ranging, on average, from US$195 to US$5,000 per year for an individual with incremental savings when additional family members are added. The higher priced plans generally include most “covered” services where the client is not charged additional fees for most services (labs, xrays, etc).

An informal one-year summary of findings related to the concierge medicine marketplace in the US was released in February 2010.^[7] The summary of the study concluded that at the end of 2009, over 66% of current U.S. concierge physicians operating practices were internal medicine specialists; and the second most popular medical specialty in concierge medicine was family practice. The study also noted that the number of concierge dental and pediatric practices increased markedly since February 2009.

In 2004, the Government Accountability Office counted 146 such practices, mostly concentrated on the US east and west coasts with practices such as MDVIP, 1 on 1 MD, and Signature MD being among the oldest. The American Medical Association does not track the number of concierge practices because the concept is so new.^[8] Lower-cost concierge medical business models have also been attempted, such as GreenField Health in Portland, Oregon, which charged an annual fee between $195-$695 depending on age. Another is One Medical Group, the first major low-cost concierge medical group to attempt this model in a large scale, which requests a $199 annual membership fee.^[9]

Concierge doctors seek to provide four common benefits to concierge medical patients: personalized care, direct care, quality care, and affordable care.^[10]

Concierge medicine vs. direct primary care

Both are variants of the traditional practice of medicine or primary care most common in the United States during the twentieth century. They represent a financial relationship that changes the sole dependency on a traditional insurance model.

Direct primary care (DPC) is a term often linked to its companion in health care, 'concierge medicine'. Although the two terms are similar and belong to the same family, 'concierge medicine' encompasses many different health care delivery models, 'direct primary care' being one of them.

Similarities

Direct Primary Care practices, similar in philosophy to their concierge medicine lineage, bypass insurance and go for a more 'direct' financial relationship with patients and also provide comprehensive care and preventive services.^[11]

Differences

DPC practices remove one of the financial barriers to accessing care whenever it is needed: the DPC annual fee often includes most or all physician services. This model does not rely on insurance co-pays, deductibles, or co-insurance fees, in contrast to models such as MDVIP and 1 on 1 MD, where the annual fee is structured to cover a wellness plan^[12][13] so that doctors may charge insurance or Medicare for most other services.

DPC is a mass-market variant of concierge medicine, distinguished by its low prices. Simply stated, the biggest difference between direct primary care and retainer based practices is that DPC takes a flat rate fee whereas models usually charge an annual retainer fee and promise more access to the doctor.

History

The origins of concierge medicine are often traced to MD² International ("MD Squared"), which was launched in 1996 in Seattle by Dr. Howard Maron. Dr. Maron has said of the term: "...I only came up with the concept—not the term concierge medicine. I know what a concierge is, but to describe what I do as simply opening doors and directing people.... I prefer highly attentive medicine."^[14]

Other consultancies assisting physicians in the marketplace also include OpenHospital, MDVIP, MyConciergeMD, 1 on 1 MD, and RingMD.

Timeline of Concierge Medicine:

• 1996 - Dr. Howard Maron and Scott Hall, FACP established MD2 (pronounced MD squared) located in Seattle, Bellevue, WA and Oregon and charged an annual retainer fee of $13,200 and $20,000 per family.
• 1999 - Medical Professionalism Project-consisting of members of the internal medicine community, including representatives of ACP and the American Board of Internal Medicine, set out to draft a charter that could serve as a framework for understanding professionalism.
• 2000 - Virginia Mason Medical Center in Seattle, WA began operating concierge medical services within its facilities and used some of the profits from the 5 physician practice to subsidize other programs and indigent care services.
• 2000 - MDVIP, founded by Dr. Robert Colton and Bernard Kaminetsky, in Boca Raton, FL. A brand of concierge medicine practice and management firm which has set-up more than 300 concierge medical practices with offices from Arizona to Rhode Island.
• 2001 - American Medical Association writes PRINCIPLES OF MEDICAL EITHICS concierge physician guidelines
• 2002 - Centers for Medicare and Medicaid, CMS, outlined its position on concierge care in a March 2002 memorandum. The memorandum states that physicians may enter into retainer agreements with their patients as long as these agreements do not violate any Medicare requirements.
• 2003 - American Society of Concierge Physicians, was founded by Dr. Johon Blanchard. The association later changed its name to SIMPD, Society for Innovative Practice Design.
• 2005 - Concierge Medicine Today, a concierge medical news agency opens its doors to be an advocate for news pertaining to the concierge medicine, retainer-based, boutique, private medicine and direct care industry.
• 2006 - MDVIP, a concierge physician practice management firm, reports that 130 physicians within their network treat up to 40,000 patients worldwide.
• 2008 - Boasting an estimated 35 concierge physician practices, Orange County, CA appeared to be a leading hub of concierge medicine.
• 2009 - Procter & Gamble Acquired MDVIP in 2009 – No less a respected corporation than Procter & Gamble (NYSE: PG) has staked out a major presence in concierge medicine. In 2007, P&G acquired a 48% stake in MDVIP, a concierge medicine company that was formed in 2000. Then, in December 2009, Procter & Gamble acquired 100% ownership in MDVIP for an undisclosed sum. This acquisition was reported by Dark Daily. (See “Boutique Medicine Venture Generates Marketing Intelligence for Procter & Gamble”), April 5, 2010.)
• 2010 - Concierge Medicine Today, reveals the affordability of concierge medical and private medicine practices across the U.S. stating that over 60% of the programs offered to patients cost less than $136/mo.
• 2010 - According to a 2010 American Academy of Family Physicians survey, three percent of respondents practice in a cash-only, direct care, concierge, boutique, or retainer medical practice.
• 2010 - The ‘’’Affordable Care Act (ACA)’’’ was enacted in March 2010 by the President Barak Obama Administration^[15]
• 2014 - MDVIP has over 700 doctors across the United States.

International presence

Although the practice of traveling abroad to receive medical procedures is decades old in Europe, and has been practiced for hundreds of years in Asia, it is still quite new to Americans.

In 2012, American owned company, International Medical Concierge, Inc., entered the international concierge market.^[16] Another United States company, Medical Concierge Tourism International (MCT), was founded in 2013.^[17]

Growth

According to the Association of American Medical Colleges (AAMC) estimates, the United States faces a shortage of more than 91,500 physicians by 2020.^[18] The Patient Protection and Affordable Care Act (PPACA) or “Obamacare” will expand coverage to more than 30 million Americans in the next decade. After incorporating insurance expansion, the United States will require nearly 52,000 additional physicians and 8,000 primary care physicians (PCPs) by 2025. The total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025.^[19][20] The federal government requires over 68,000 charging codes with the upcoming ICD-10 diagnosis coding system a fivefold increase from the current ICD-9 diagnosis coding system. In addition to these government requirements, physicians have the usual insurance filing.^[21] The 22% increase in office visits, the shortage of doctors and the increased paperwork requirements will increase the demand for concierge medicine. Patients want guaranteed service and doctors do not want to deal with the overwhelming paperwork of insurance paid medicine.

The Physicians Foundation found that 9.6 percent of “practice owners” and 6.8 percent of all practices were planning to convert to cash/concierge practices in the next three years.^[22] The industry is changing drastically. Doctors will offer the very same services at lower costs. A new type of practice called “blue-collar concierge” medicine has emerged.^[23] In 2012, there were 4,400 private physicians - a 25% increase from 2011.^[24]

On the cusp of the Affordable Care Act mandating most Americans to have health insurance next year, a rise in doctors who don't take insurance might seem paradoxical. But health-care experts say the two forces go hand in hand, as patients may find concierge doctors more accessible, especially if traditional doctors get flooded with more patients. Also fueling the trend is a little-known clause tucked into the health-care law that allows direct primary-care to count as ACA-compliant insurance, as long as it is bundled with a "wraparound" catastrophic medical policy to cover emergencies. "All of a sudden our market went from the uninsured to everybody," Dr. Qamar says..^[25]

Controversy

The concept of concierge medicine has been accused of promoting a two-tiered health system that favors the wealthy,^[26] limits the number of physicians to care for those who cannot afford it, and burdens the middle and lower class with a higher cost of insurance. Detractors contend that while this approach is more lucrative for some physicians and makes care more convenient for their patients, it makes care less accessible for other patients who cannot afford (or choose not) to pay the required membership fees.^[27]

One physician in a CNN.com article noted that he might not be treating patients at all if he hadn't made the switch to concierge medicine: "… many doctors are becoming so disillusioned with primary care that they are quitting altogether." Others physicians feel like they can't abandon patients who are unwilling to pay the additional fee. Proponents of concierge claim that it meets consumer demand, allows physicians to provide the treatment they deem necessary, and improves quality of care by increasing the amount of time spent on preventive medicine.^[28] Preventive care such as lifestyle advice and follow-up phone calls and emails are not usually reimbursed by insurance. Physicians significantly reduce the number of patients they see in a day, which allows them to spend extra time and attention with each patient. It has also been noted that while some concierge medicine practices do not accept insurance, all of their patients are encouraged to carry health insurance for services utilized outside of the practice. Some practices offer several membership packages with and without insurance coverage.^[29]

The hybrid model is an alternative approach to concierge medicine and does not disenfranchise patients or exacerbate the physician shortage. Physicians with a hybrid practice accept from a few to up to three hundred patients from their current practices who choose to join the concierge option. Patients who do not want to join the concierge model, do not have to leave the practice and can still see their primary physician as they always have. In these practices, doctors continue to be highly productive and take care of at least the same number of patients as they would in a traditional practice. While concierge patients get a special contact number, dedicated appointment time, and various other benefits that enable the doctor to offer more advice and advocacy, the quality of the care remains the same for either group of patients. There is a difference in the service level in the concierge program. The increased face time with the physician in the hybrid concierge program enables the physician to deliver the services that are often identified with the "medical home" model. One medical ethicist said that concierge medicine will not be the solution to managed care, because "it will most likely always remain a very small part of the system".^[26]

In early 2008, it was reported that one health insurer was dropping from their provider networks some physicians who charge an annual fee. Another insurer also expressed opposition to annual fees. Other insurers do not oppose concierge medicine as long as patients are clearly informed that the fees will not be reimbursed by their health plan.^[30]

The trend caught the eye of MedPAC, a commission created by Congress that advises lawmakers on Medicare and watches for problems with access. It hired consultants to investigate. Their report, (March 2010), found listings for 756 concierge doctors nationally, a five-fold increase from the number identified in a 2005 survey by the Government Accountability Office.

The study showed that some physicians noted that the quality of their care had not fundamentally changed however, burnout and stress were reduced due to the increased amount of time they have available to spend with their patients. The study further reports that the higher fees allow these physicians more personal time and less time spent on the job; the continuity of care is higher because the physician knows the history of their patient and can provide this information readily in emergency situations. However, in the process of transitioning from a conventional practice to a “concierge” model, there exists the probability that some patients who choose not to purchase this new level of service will drop from a physicians’ list and lose the continuity of care.

Because retainer practices are structured differently than other medical practices, physicians must be sure that the financial arrangements they use do not violate state and federal laws and regulations. Any retainer physicians who treat Medicare patients must be aware of the limitations imposed by Medicare’s policies on balance billing. States have also created laws and regulations on insurance and balance billing that have implications for retainer medicine; in a few cases, states have acted specifically to allow or restrict this kind of practice.

Many states also have patient abandonment laws that impose requirements, such as adequate notice, when a physician terminates a relationship with a patient. Guidelines established by the American Medical Association also impose an obligation on physicians to assist patients who choose not to remain after a conversion to a retainer practice. The guidelines call for physicians to help with transitions to new physicians and to continue treatment until a safe transition can be accomplished.

Retainer physicians who wish to see Medicare patients have two basic options. One is to take the formal step of opting out of Medicare entirely. The other is to maintain a relationship with the program, but take the steps necessary to stay within the restrictions imposed by Medicare’s billing limits.^[31]

In 2003 and 2005, several members of Congress introduced or cosponsored bills that would have prohibited physicians from charging retainer fees. No action was taken, and it appears that no similar bills have been introduced in more recent Congresses. In the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the Congress directed the GAO to study concierge care and its impact on Medicare patients. The GAO report, published in 2005, concluded that the “small number of concierge physicians makes it unlikely that the approach has contributed to widespread access problems.”43 In its comments on that report, DHHS noted its agreement with GAO’s findings and stated that it would continue to monitor the trend. No specific information is available on monitoring activities.^[32]

Concierge medicine in popular culture

The USA Network television series Royal Pains focuses on such a doctor's introduction to the practice of concierge medicine. A young doctor becomes a for hire physician for the wealthy residents of the Hamptons.

Also on USA Network television series Rush focuses on a doctor who serves a very specific clientele, the kind with a lot of cash and a lot of secrets.

The Robin Cook novel Crisis focuses on a medical malpractice trial involving a doctor practicing concierge medicine.

See also

• Direct primary care
• House call

References

External links

• Fee-based concierge practice troubled link
• Concierge Medicine Blog
• Concierge Medicine Journal- News Blog