Concierge care: Does it benefit everyone or a few?
Concierge care: Does it benefit everyone or a few?
How will retainer medicine affect access to care?
In 2000, literally a handful of physicians were practicing what has become known as concierge medicine — they had slashed their patient load to a fraction of the number of patients seen in a traditional practice, and were charging their remaining 300 to 400 patients a retainer fee that gave them access to the doctors' services around-the-clock and for as much time as they needed.
By 2004, the U.S. Governmental Accountability Office (GAO) reported there were 146 concierge practices in the United States — a fraction of the total of more than 470,000 physicians who filed Medicare claims that year, but enough that Congress asked the GAO in 2005 to examine whether the springing up of concierge practices might be somehow hurting Medicare patients or Medicare itself.
Concierge practices are concentrated in urban areas, the largest numbers found in the Miami, Washington, Philadelphia, Seattle, and Boston metropolitan areas. Three-fourths of concierge practices participate in Medicare.
The GAO and Department of Health and Human Services concluded in the 2005 report that the impact of concierge care on patient access to services thus far has been "minimal," with there being "widespread availability of physicians to treat [Medicare patients]."
But the medical community continues to cast a wary eye at the growing field of concierge medicine, whether because of the appeal of a small, intimate practice reminiscent of the personal care doctors gave patients two generations ago, or because of the concern that it creates a "haves" vs. "have-nots" tier of health care.
"I believe if the utilization savings hold, and hospitalizations and emergency room visits decrease, the savings we effectuate could make this a national model," says Edward Goldman, MD, president and CEO of MDVIP Inc., a Boca Raton, FL-based national network of physicians practicing concierge care.
A national model for health care?
MDVIP practitioners — the "VIP" stands for "value in prevention" — account for about 120 of the fewer than 200 doctors currently practicing concierge medicine in America. MDVIP helps physicians get their concierge practices up and running, and receives a percentage of the annual fee generated by the new practice.
Contrary to what some critics say, Goldman insists, concierge care is not about better care for the rich, or making doctors richer — though both are side effects of this type of medical practice.
The doctors affiliated with MDVIP are primary care physicians, as are almost all concierge practices in the United States, and they are, Goldman says, filling a need in health care.
"There's no question we have to change primary care practice as it is today. It's not patient-friendly or doctor-friendly, and it costs us more every year," he suggests. "If preventive care really works, and it's been well established that it does, then we can take the savings [created by the healthier patients he says concierge care results in] and use the savings to construct smaller traditional practices, where those patients will get better preventive care."
Concierge practitioners emphasize that they are all about having the time to give each patient what he or she needs to keep that patient healthy. An average patient load of 2,500 in a traditional practice means the doctor does well to devote a few minutes per office visit, as opposed to hour-long visits typical in a concierge practice.
"What our doctors are interested in is being able to do prevention and early detection in their practices, and that gives them a professional satisfaction they don't ordinarily get," Goldman says. "We do the same comprehensive exam that Mayo [Clinic] or the Cleveland Clinic does, under a fee, and we also do extensive risk assessments for habits and risk factors; then we educate patients, provide them with tutorials addressing those risk factors, and use extensive applications to track those risks."
Each MDVIP patient has his or her own web site, where the patient and doctor can monitor risk assessments and wellness programs.
Concierge patients are roughly divided into two camps. The first is the upper middle-class and wealthier person, 55 years old and up, who might have a chronic health condition such as hypertension or elevated cholesterol, who is interested in preventing those conditions from getting worse and affecting their health in other ways.
The other cohort, which Goldman says is the fastest growing, is corporate executives, age 40 and older, who along with their employers have a vested interest in staying healthy. These patients want an array of prevention and wellness programs available to them on demand, on their schedules, to keep from getting sick and negatively affecting their careers and businesses.
The result of this high-level preventive care is patients who require fewer hospitalizations and who stay healthier longer, which Goldman says benefits everyone by keeping national health care costs down.
But when a physician elects to convert his traditional practice to a concierge practice, it comes at a cost — patients who cannot or will not pay the average $2,000 annual fee to join a concierge care practice have no choice but to switch to another physician, perhaps leaving behind the doctor they have used for years.
MDVIP physicians, as with any physician who migrates to a concierge practice, are required to help patients leaving the practice to transition to appropriate providers. Goldman says about 10% of the typical MDVIP patient population are "scholarship" patients who can't afford the annual fee but who the physicians do not want to lose.
"For those who don't join [the new practice], we don't go forward until we have a continuity-of-care plan for those patients, and until we identify other physicians who have openings in their practice who we can recommend to those patients based on their expertise and personality," Goldman says.
Ethical issues abound
Critics point out ethical dilemmas related to concierge care, starting with eliminating some patients who might not want to leave the physician's practice.
The American Medical Association has weighed in that concierge, or retainer practices, "are consistent with pluralism in the delivery and financing of health care," but cautions that physicians who engage in this kind of practice should be vigilant about not compromising patients' insurance coverage and should make special efforts to seek out ways to provide indigent care.
"Ethics come up all the time" when people ask him about concierge medicine, Goldman says. "And I ask, is it ethical to give a person an eight-minute office visit, where you're not able to spend time to find out the background history, genetics, and emotional history that went into that illness? What about the ethics of not giving patients the proper time to treat the illness they have? That's an ethical issue that's not written about."
Goldman says doctors who consider concierge practices already feel ethically conflicted because they don't think they are giving their patients adequate care under their current practice setup.
"They see patients coming in with illnesses they could have stopped but didn't have time to devote to prevention," he points out.
What about the argument that concierge care creates a two-tiered system of health care? Goldman says we already have a multi-tiered system.
"HMO patients are restricted. They don't have the same care that a PPO patient has, so they pay more money and become PPO patients," he offers as an example.
Because concierge medicine on a large scale is still very new, evidence is still being collected as to its impact on access to care. The Journal of the American Osteopathic Association in 2005 published a study, "Impact of concierge care on healthcare and clinical practice," that sought to establish what effect, if any, concierge practices have had on access to care thus far.
"[E]vidence suggests that concierge care satisfies consumer criteria for value, based on an individual patient's willingness to pay extra for some measure of health care and status," the authors wrote. "Concierge care's effectiveness, defined as a measure of the ability of an intervention to bring about a desired outcome [such as an increase in patient-physician satisfaction], is also suggested by evidence."
Further, the authors conclude, "Affluent consumers who choose concierge care do not represent a large portion of the overall health care consumer population. Thus, they should not be expected to disrupt society's economic equilibrium as it relates to providing health care services."
Hospitals get into concierge care
While primary care makes up the lion's share of concierge medicine, hospitals — Virginia Mason Medical Center in Seattle and the Tufts-New England Medical Center in Boston — have also added concierge components to their roster of services.
Virginia Mason advertising for the concierge care at its Lewis and John Dare Center touts it as "old-time medicine," appealing to patients who might recall days when doctors made house calls.
The 2005 study published in the Journal of the American Osteopathic Association points out that in the case of practices like those at Virginia Mason and Tufts-New England Medical Center, there is a greater good served by concierge arrangements.
"Concierge care programs have shown success in providing needed financial support for some primary care services, such as those at Tufts-New England Medical Center and the Virginia Mason Medical Center," the authors report. "Thus, it is reasonable to conclude that concierge care offers a mechanism to maintain a limited number of programs that are necessary for health care access for all citizens — programs that might face elimination without some form of economic subsidization."
Tufts cites that aspect of its program in its public information, reporting that the annual fee paid by patients of its Pratt Diagnostic Center concierge practice provides funding for low-income and uninsured patients seen at the medical center, as well as underwriting medical school and hospital residency programs.
Sources/Resources
For more information:
- Edward Goldman, MD, president and CEO, MDVIP Inc. 6001 Broken Sound Parkway NW, Suite 100, Boca Raton, FL 33487. Phone: (866) 602-4081. Web site: www.mdvip.com.
- U.S. Government Accountability Office, "Considerations for Medicare — Government Accountability Office Report, 2005." Available at www.gao.gov/new.items/d05929.pdf, or by telephone order, (202) 512-6000.
- Pratt Diagnostic Center at Tufts-New England Medical Center, 750 Washington St., Boston, MA 02111. Phone: (866) 696-3847.
- American Medical Association, Council for Ethical and Judicial Affairs, policy on retainer practices (E-8.055). Available at www.ama-assn.org.
- Linz AJ, Haas PF, Fallon Jr, LF, et al. Impact of concierge care on healthcare and clinical practice. JAOA2005; 105;515-520.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.