Blog | Wednesday, June 6, 2012

What the critics of concierge medicine do not understand


We need to define terms:
--Concierge medicine: paying a large (more than $3,000 a year) fee to contract with a physician (usually an internist) to provide same day appointments, phone access, email access, comprehensive and continuous care
--Retainer medicine: paying any fee to receive the same access as concierge medicine. Generally concierge practices have smaller panels, i.e., the more you pay, the fewer patients the physician has to follow
--Direct primary care: retainer medicine for a lower fee

These definitions are arbitrary and mine only. Here is the big point: These patient care strategies are growing rapidly, because patients and physicians do not like our current payment system. As I have written for 10 years, if we do not carefully understand the success of these relationships, then we cannot learn from them.

The development of the various retainer relationships shows that patients find the current state of outpatient medicine unacceptable. Patients only pay because otherwise their primary care access (here I use the expansive definition of primary care, comprehensive, continuous, complex, caring, etc.) has major flaws.

Folks, this is 2012! Patients expect to communicate with us through a variety of strategies. They would like to text us, e-mail us or talk on the phone. They want to come at their convenience, not our convenience. They want one excellent physician to coordinate their entire care.

Our current payment system discourages physicians from providing excellent service to patients, because the payment system only recognizes the office visit. This payment system has unintended negative consequences.

Today's New York Times has a wonderful article about one such arrangement that I have previously discussed.

Policy wonks have ignored this movement for too long. Retainer medicine is a fast growing start-up industry. It grows because it fills an unfilled niche.

We ignore its growth at our own disadvantage. We must consider whether this is a better way to provide complex, comprehensive, continuous care.

Call it concierge medicine for the masses. The idea is that routine, mundane primary care should not require expensive insurance and can be cheaper without it. Direct primary care practices charge $50 to $60 a month for adults, with lower fees for children. Depending on the practice, the monthly fee also may cover certain lab tests, basic X-rays and stitches for cuts.

But the fee does not cover anything beyond primary care. Typically employers combine direct primary care with high-deductible insurance plans, needed to cover hospitalizations and visits to specialists.

"Health insurance is supposed to protect you against risk, like car insurance does," said one doctor in the article. "We don't insure our cars for tire changes and tune-ups."

Even though one company owner interviewed in the article pays Qliance for primary care and pays half of each worker's $5,000 annual deductible for insurance, the company's costs dropped 11% in 2010. Costs had been rising about 14% annually.

This emperor is fully dressed.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.