Monday, April 18, 2011

Concierge Medicine

Yesterday the Boston Globe reported that two of the most respected physicians at the Newton Wellesley Hospital, five miles from where I live, are shifting to a mode of practice called "boutique" or "concierge."

In this format physicians limit their practice to 300 - 600, a much smaller number than is typical for primary care, and charge a fee ($1,500 and up) for membership in the practice. Patients are offered prompt appointments, more time for their visits, 24/7 access to their physician, and more. Insurance doesn't pay the membership fee. Patients need insurance to cover tests, office visits, specialty consultations, hospitalization, and other insurance-covered services.

Concierge practice is small in number, but like canaries in coal mines, it's the source of important information. I only know one physician in a concierge practice - Dr. Jordan Busch, co-founder of Personal Physicians HealthCare, a four physician practice near Boston. Jordan is a superb physician with strong caretaker values. He came to feel that he was not able to care for patients in the comprehensive, personalized manner he aspired to while at the same time making a middle class income. Insurance reimbursement (private insurance, Medicare and Medicaid) for primary care pays by the visit, at a relatively low level. Meeting office expenses and earning a middle class income required a large volume practice. For Jordan (and his colleagues), Personal Physicians HealthCare is a way to practice the kind of medicine he believes in.

I've visited the website of MDVIP, a Florida-based entrepreneurial organization that provides support for approximately 225 physicians in the U.S. (16 in my own state - Jordan's practice is not affiliated with it). I wish I could say I was impressed by idealism, but I wasn't. Much of the executive team comes from Proctor & Gamble. The marketing is pitched to affluent patients. I was struck by the absence of any reference to improving the health system. It presents concierge practice as a "solution" to the frustrations of individual patients and physicians by opting out of the larger system. Although the numbers are still small, each primary care physician who moves to a boutique practice makes it harder for patients to find their own physicians and makes practice even busier for those who don't opt out.

When I trained in psychiatry in the late 1960s, many of the best and the brightest chose to become psychoanalysts. I thought of psychoanalytic theory as a source of insight, but the idea of a small panel of affluent patients didn't represent the kind of diverse, population-oriented practice that I aspired to. I can understand the frustration many primary care physicians, perhaps most, feel at present. But if I were a PCP, I'd think of concierge practice the way I thought of psychoanalysis - a failed model from the perspective of societal needs and population health.

Over time, moving to accountable care organizations and other formats that pay physicians for the populations they care for, not for the visits they provide, is a much more promising and socially responsible direction than concierge practice. Concierge practice, like dead canaries in the coal mines, is a symptom of a societal problem, not a solution!


Blaisdell Lake said...

I thought your 2011 post was very thoughtful, unlike much of the marketing hype that comes directly from the likes of MDVIP's marketing department.

There are indeed benefits to becoming a member of a "retainer" or "concierge" primary care physician practice. But, I believe the benefits will only be as good as the physician and the concierge medicine practice management/consultant (e.g., MDVIP, Signature MD, etc.)

My primary concern with MDVIP was their lack of full disclosure and transparency with regard to how my insurance company (and insurance companies, in general) view concierge medical practices and their requirements for what they will reimburse and will not reimburse.

The AMA code of ethics outlines (excerpts from “Opinion 8.055 - Retainer Practices” shown below) outlines policies that the AMA expects physicians to adhere to:
“Individuals are free to select and supplement insurance for their health care on the basis of what appears to them to be an acceptable tradeoff between quality and cost. Retainer contracts, whereby physicians offer special services and amenities (such as longer visits, guaranteed availability by phone or pager counseling for healthy lifestyles, and various other customized services) to patients who pay additional fees distinct from the cost of medical care, are consistent with pluralism in the delivery and financing of health care.”

The AMA goes on to caution:
1. “Physicians who enter into retainer contracts will usually receive reimbursement from their patients’ health care plans for medical services. Physicians are ethically required to be honest in billing for reimbursement, and must observe relevant laws, rules, and contracts.”

2. “It is desirable that retainer contracts separate clearly special services and amenities from reimbursable medical services. In the absence of such clarification, identification of reimbursable services should be determined on a case-by-case basis.”

First, MDVIP provided me with no blanket “clarification” of services or “identification of reimbursable services on a case by case basis”; and second, documents that were provided to me over the course of my membership by my physician did not “square” with what MDVIP was telling me. They seemed to go out of their way to conceal information from me.

Thirdly, as I learned some six years after I joined MDVIP, my insurance company would reimburse me for the cost of an annual physical (since that is a considered a reimbursable medical service) that MDVIP says is included in the annual membership fee, but would not reimburse me for “non-medical” services, such as the $500/$600 fee that goes directly to MDVIP to support their overhead that also comes out of the annual membership fee. What I only recently learned, a fact that was confirmed by a prominent healthcare law firm, is that by bundling “medical” and “non-medical” services under one annual membership fee, MDVIP forces patients to forfeit reimbursement on some portion of what is considered by insurance companies to be legitimate “medical services” – at least that portion of the annual fee that is allocated to an annual physical.
As with many patients, I trusted my primary care physician and did not expect him to conceal this information from me, nor did I expect MDVIP to conceal this information from me. My advice for a patient that is considering joining a concierge practice is not join any concierge medical practice without a written annual contract outlining all of terms of the relationship, including the reimbursement policy of one's individual insurance company, which, is in part, established by the insurance company’s contract with the physician.

My experience with MDVIP and their lack of disclosure and transparency forced me to leave my physician’s practice after 30 years.

Jim Sabin said...

Dear "Blaisdell Lake"
I put the name into quotes because I'm guessing it's your on-line identifier, not what your best friends call you.
Thank you for the thoughtful comment. I only recently returned to this blog, which accounts for my delay in responding to you.
I'm not surprised at the confusion about what would be paid for by insurance. The concierge model is still relatively new, and the relationship with insurers probably varies from state to state. But not receiving clear guidance - including being explicit about what may not be knowable until you submit an insurance claim - isn't acceptable. I'm very sorry that your 30 year medical relationship was fractured by your distrust of and disappointment in MDVIP itself. I hope you gave that feedback to your physician and to the company.
Your comment led me to go to the MDVIP website, which I hadn't done since 2011. It made me sad about the current state of medicine in the US. The "special features" MDVIP is selling - being known as an individual, not as a number, and being responded to as a "whole person" - are what most medical students hope to provide in their future careers when they start their medical studies. As I said in 2011, concierge medicine is a form of canary in the coal mine. The statements by physicians on the MDVIP website cite their wish to know their patients better and to be able to spend the time they believed was right for the patient. How sad that they felt they had to exit from a more open and inclusive practice setup to follow their ideals.
Again, thank you for your comment.