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ADDENDUM: A recent editorial in Medical Economics gave new perspective to the concierge practice model. Specialdocs, a company that transforms fee-for-service practices into concierge practices, has noted several trends in the concierge realm. They are:

1. The number of concierge medicine patients served by Specialdocs increased

           “significantly” in ‘20-‘21. 

     2. There has been a gradual but steady lowering of member patients’ ages signaling a 

           broader appeal of this model.

     3. Physicians struggling in fee-for-service practice found a shift to concierge practice gave

           them more time to care for patients, and financially enabled them to stay in practice. 

           The change resulted in a “rejuvenated staff” and improved quality of care.

     4. Doctors planning to retire or quit early now had new energy and interest in practice.

     5. Doctors had more time for their spouse and family.

     6. Every concierge physician regained, or preserved, their overriding passion for medicine.

The author states “I believe that 2022 will be a year when concierge medicine shifts from niche solution for a few to a mainstream model for many.”

The above-listed factors certainly appeal to me as they would most physicians. Self esteem is important to physicians. You want to feel respected, admired, and needed. Doctors’ have egos that need stroking! The assembly-line, one-patient-after-another, practice model is a path to burnout. The concierge practice model promotes a closer, one-to-one doctor-patient relationship, and greatly improves patients’ access to their physician, a good thing for both parties. Feeling wanted, needed, and trusted is important to prevent physician burnout. The concierge model is a good method to channel those feelings, regain self-worth, and provide competent, timely, and personal service.

Reference: Careers/Opinion Bauer T. Pivot to Concierge: Will personalized membership practices redefine medicine in 2022? Medical Economics 2022 Jan:27.

Adaptation and modification are two terms very familiar to physicians. All doctors have to adapt to rapidly changing situations and modify their approach depending on the circumstances. You may think I mean this in a medical diagnostic or therapeutic sense, but no,  not really. This refers to the efforts required by physicians to keep their practice (business) alive and financially solvent.

Medicare and private insurance companies have reduced payments to physicians so drastically over the past 20 years that physicians, especially family physicians and general internists, have had to adapt to the reductions and modify how they generate revenue to keep their practice afloat. The modification chosen by an ever-increasing number of non-procedure-performing physicians is the Concierge Practice Model. 

In the Concierge Model, patients enroll with a specific physician, pay him an annual retainer fee, and see him exclusively for primary care needs. The retainer, or membership fee, is paid annually in lieu of a payment at each visit, and entitles the patient to immediate access to the doctor. This fee may be as little as $350 or as much as $5000 a year, depending on the physician’s individual situation. To improve access, the doctor limits the number of patients he has enrolled. Instead of the usual 2000-3000 patients for whom a typical Family Physician might provide care, concierge doctors have only 400-600 patients. These patients are his only responsibility.

For this “retainer” fee, the doctor provides exclusive service to the patient, and allows immediate access to himself by sharing his cell phone number and email address. Patients can then contact him at any time; no answering service intermediary. Wait times for appointments are shorter because fewer patients are vying for slots, and the doctor also has more time available to spend with each patient. Instead of needing to see 25-35 patients a day just to break even, the concierge doctor can see 6-10 patients a day, spend as long as he needs with each, and still be able to make a living. Patients have no co-pay, deductibles, and only need to buy health insurance that covers hospitalizations, specialist fees, and lab and X-ray, ie. catastrophic coverage. 

For the physician, this practice model is a plum. Through the retainer fee, he is able to maintain a livable, guaranteed income without the hassles of billing Medicare and private insurers. Practice satisfaction increases and burn out is much less likely. The retainer enables the doctor’s business to sustain itself. Although he sees fewer patients per day, the extra time he has to spend with each one improves the quality of care, patient satisfaction, and communication. Paperwork for billing is eliminated saving money in overhead expenses. Same day appointments are offered. More time is available for comprehensive wellness assessments and chronic disease follow-ups. 

It is still important for the doctor to emphasize documentation of medical history and physical findings in the medical record, but now he has more time to focus on that important aspect of medical care. Knowing you have a guaranteed source of revenue, and knowing you don’t have to work yourself to death to earn it, results in far greater practice satisfaction and quality of life. A viable, calmer, less busy practice improves staff morale, as well. When you’re not overwhelmed by dozens of patients, and the phone isn’t ringing off the hook, your attitude improves greatly. 

For some physicians to remain in business, this model is a necessity. Others choose to become employees of a large group or a hospital. Hospital-employed physicians are continually pressured to see more patients to justify the salary they are receiving. If your audit shows you’re not generating the required revenue, your salary will be lowered (it happens all the time).   

This type of practice, of course, is open to a lot of criticism. Many critics call it “elitist” and available only to the rich. Doctors are often accused of “cherry-picking” only healthy patients for their panel at the expense of those with chronic diseases. Minorities are often singled out for exclusion. It also leaves current patients who opt out of the retainer with no doctor. Having a “closed practice” reduces the number of physicians available to the general public, thus limiting access to care. But the Concierge model allows physicians to return to a manageable number of patients, spend more time with each one, and be able to make a living doing what they love to do. Autonomy is restored, and the doctor no longer feels like an indentured servant of Medicare and private insurers.  

Some critics also say physicians have an ethical obligation to take any and all patients, and that limiting your practice to a small number of people makes the physician liable to sanctioning for abandoning patients. It would be similar to an ER denying some patients and accepting those who have better paying insurance.

The Concierge model does “promote high quality individual care.” To earn a living, the doctor no longer has to run an assembly-line practice seeing patients quickly and often. He can now  spend more time examining, counseling and educating the patient because financial viability doesn’t depend on it. 

Dr. G’s Opinion: I left solo practice because of all the hassles Medicare and private insurers impose on physicians. It was harder and harder to make a profit (pay myself) so I had to do something. The Concierge Model was an option, but at age 63, it was not something I wanted to take on. When a doctor does choose it, his most important move is to properly figure out what his annual retainer fee should be. Without adequate revenue from this source he will fail. To be successful, he should be in it for the long haul, and not just “try it on for size.” I have not known anyone who was bold enough to make a go if it. The doctor’s practice must be located in an affluent area to attract enough patients to make it work. I don’t think my location was that place. I might have tried it at a younger age, but I would have been a pioneer in the wilderness. 

Some day, the government will legislate this model, and private practice, out of existence and force all physicians to be salaried employees of the Department of Health and Human Services. That is a day we should all rue, but I’m certain it’s coming. The incredibly poor reimbursement by Medicare is forcing doctors to “cry uncle” and practice in groups or as employees of a hospital or third party payer. Doctors will become civil servants, healthcare will be free, and our income taxes will be unbelievably high. Bureaucrats would like nothing better. Until then, the Concierge Practice Model is the best option available for financial viability. 

References: Concierge Medicine https//:www. RheumatologyNetwork.com

Dahn JE, Alpert JS Concierge Medicine is here and growing Am J Med 2017 Aug 1;130(8):880-881.

Serena DC Lifestyle medicine in a Concierge Practice: My Journey Am J Lifestyle Med 2019 Jan 7;13(4):367-370.

Paul DP, Skiba M Concierge Medicine: A valuable business model for (some) physicians of the future. HealthCare Management 2016 Jan/Mar;35(1):3-8.

Martinez W, Gallagher TH Ethical Concierge Medicine? Virtual Mentor 2018 July 1;15(7):576-580.

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