Friday, February 17, 2012
Retainer, concierge and boutique medicine comparisons are apples to oranges to bowling balls
Health care is in crisis. Reimbursements from insurance companies continue to dwindle, while the expenses of running an office continue to rise. Looming cuts in Medicare are only weeks away, and many physicians may stop taking Medicare. If these cuts go into effect, it is possible that primary care physicians could lose up to 50% of their salary. Just recently CNN reported that some doctors are going bankrupt.
How to fix our health care system is an ongoing debate, but not surprisingly, many physicians have decided not to wait for the government to solve this problem and have taken matters into their own hands. One solution is to simply stop taking insurance altogether. "Cash only" doctors are now commonplace in many major metropolitan areas.
Another solution is charging a regular, out of pocket fee (usually) in addition to what insurance will pay for treatment. A version of this model that is becoming popular is called retainer medicine. Sometimes, retainer medicine is referred to a "boutique" or "concierge" even by physicians and others involved in health care (as evidenced by this article in the AMA News, which prompted me to post on this topic).
However, "retainer," "concierge" and "boutique" are not the same thing. Names are important, and the terms "concierge" and "boutique" tend to have negative connotations. Thus, it is important to describe the differences.
In a retainer model, patients pay a fee (not covered by insurance) to be part of a physician's practice. This is similar to clients paying a retainer fee to hire a specific lawyer. With reimbursements from insurance companies being so low, the only way an insurance based physician can increase revenues is to increase the volume of patients they see. Unfortunately, when physicians increase the number of patients they see, it leads to rushed patient visits, long waits in the waiting room, and decreased access to physicians including difficulty in getting appointments or responses phone call messages.
By accepting a retainer fee, the physician no longer needs to rely on insurance revenue alone, and in fact can decrease the amount of patients he or she sees on a regular basis. This allows for increased access (usually same day or next day appointments and 24/7 phone access) and longer appointment times (usually 30-60 minutes) for patients willing to pay a retainer fee. The typical insurance based primary care physician has about 2,500 to 3,000 patients in their practice, and sees about 25 patients a day. The typical retainer physician has about 500 patients and sees only a handful of patients each day. Retainer fees and the amount of access patients get for what they pay vary widely, but the average retainer fee is about $1,500 per year.
Some have argued that retainer medicine is unethical because not everyone can afford $1,500 a year. First, the typical retainer fee amounts to about $4 a day, which is what many Americans pay (or more) for a Starbucks coffee. Secondly, one could also argue that it is also unethical for insurance based physicians to see complex patients in brief visits and/or not being able to see them in a timely fashion due to lack of access.
Concierge medicine is somewhat different, and in my opinion, should not be used synonymously with retainer medicine.
According to Wikipedia: "A concierge is an employee who either works in shifts within, or lives on the premises of an apartment building or a hotel and serves guests with duties similar to those of a butler. The term "concierge" evolved from the French Comte Des Cierges, The Keeper of the Candles, who tended to visiting nobles in castles of the medieval era."
Just like the concierge at a hotel, who can get you good seats at a ticketed event, a reservation at a popular restaurant, or even run an errand; a concierge physician can get you timely appointments with the best specialists, usually doing the scheduling themselves. Many concierge physicians will even accompany patients to procedures or diagnostics tests, and some will even make house calls.
Though some retainer practice physicians may perform concierge services (usually the ones charging well over the usual $1,500 fee), the terms are not the same. Many retainer physicians will assist in coordinating specialist appointments, but this is as far as they go. In fact, some "cash only" physicians perform concierge services to attract more patients, and some doctors (even insurances based physicians) will charge an extra-fee for some concierge services, such as a house call.
Boutique medicine is also completely different. Again, from Wikipedia: "A boutique is a small shopping outlet, especially one that specializes in elite and fashionable items such as clothing and jewelry. It can also refer to a specialized firm such as a boutique investment bank or boutique law firm. In the strictest sense of the word, boutiques would be one-of-a-kind but more generally speaking, some chains can be referred to as boutiques if they specialize in particularly stylish offerings."
I think the key words in this definition are "specialized" "stylish" and "elite." The first word is something commonplace in medicine, but the latter two words are something usually not associated with medical practice. "Luxury" is also implied in the word "boutique."
Thus, in my opinion, a boutique doctor is one that specializes in unique, often luxurious services, that are not offered by others and which will therefore cost a little extra. These services include, but are not limited to, cosmetic procedures (Botox, laser hair removal), medical spa services, comprehensive screenings (i.e. body scans), and herbs or supplements. Though both retainer and concierge physicians may provide boutique services, this is generally not the norm. In fact, many insurance based primary care physicians have started to add these services as a way of keeping their practice running. (Ethics could be questioned here as well).
I am not arguing that retainer medicine is the solution for all of our nation's health care woes. It certainly is not. However, given that it solves some of the issues with third party payers, is a model that continues to grow, and patients and providers enrolled seem to be very satisfied; it is something that deserves attention.
Another model that is garnering some attention is direct access primary care. In this model, patients pay a monthly fee (usually about $70/month) and receive enhanced access and communication as well as primary care and urgent care services. Though the cost is slightly less ($1,500/yr vs. $840/yr) and access to your personal may not be 24/7, this is a similar model to the retainer concept. (Proponents have called this retainer medicine for the masses).
Thus, using terms "concierge" and "boutique" that have connotations of elitism, luxury and unnecessary care synonymously with retainer medicine discredits a potentially viable health care model for many Americans. I would request that physicians, policy makers and journalists no longer use these terms as if they were the same.
Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.
Labels: concierge medicine, Dr. Mintz' Blog, guest post, health insurance, Matthew Mintz, patient satisfaction, practice management, reimbursement
posted by Matthew Mintz, MD at
9:00 AM
Contact ACP Internist
Send comments to ACP Internist staff at acpinternist@acponline.org.
Previous Posts
- QD: News Every Day--Amoxicillan doesn't help colds...
- Patients like the idea of owning their medical rec...
- QD: News Every Day--Video offers simple explanatio...
- Notes on Wendell Potter, and why insurers support ...
- Losing weight is hard because of one's 'set point'...
- QD: News Every Day--14 quality measures endorsed f...
- ACP's Ethics Manual spurs debate about costs of he...
- 'Unneeded' stents become a criminal offense
- QD: News Every Day--10 saltiest foods are hard on ...
- Diet, diabetes and Paula Deen: Southern fried comf...
Blog log
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.
Controversies in Hospital
Infection Prevention
Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
FACP, practices infectious diseases, clinical microbiology, and
hospital epidemiology in Iowa City, Iowa, splitting time between
seeing patients with infectious diseases, diagnosing infections in
the microbiology laboratory, and trying to prevent infections in
the hospital. Michael B. Edmond, MD, FACP, is a hospital
epidemiologist in Richmond, Va., with a focus on understanding why
infections occur in the hospital and ways to prevent these
infections, and sees patients in the inpatient and outpatient
settings. Eli N. Perencevich, MD, ACP Member, is an infectious
disease physician and epidemiologist in Iowa City, Iowa, who
studies methods to halt the spread of resistant bacteria in our
hospitals (including novel ways to get everyone to wash their
hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
decision-making from the perspective of an active primary care
physician, and offers behind-the-scenes portraits of hospital
sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an
interest in basic and clinical science and education, with
interests in noninvasive monitoring and diagnostic testing using
novel bedside imaging modalities, diagnostic reasoning, medical
informatics, new medical education modalities, pre-code/code
management, palliative care, patient-physician communication,
quality improvement, and quantitative biomedical imaging.
Informatics
Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical
Informatics & Clinical Epidemiology, Oregon Health &
Science University, posts his thoughts on various topics related to
biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics
in medicine, health care news and culture. Her views on medicine
are informed by her past experiences in caring for patients, as a
researcher in cancer immunology, and as a patient who's had breast
cancer.
Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
Education (CME), and a Program Director in Medicine-Pediatrics at
the Indiana University School of Medicine in Indianapolis, where he
blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
medicine, life, armadillos and Sasquatch at More Musings (of a
Distractible Kind).
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections of a Grady
Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.
Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.
Other blogs of note:
American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical
Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS Blog
The Public Library of Science's open access materials include a
blog.
White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.
0 Comments:
Post a Comment
Subscribe to Post Comments [Atom]
<< Home