a different type of IM practice??

[DoctorJekyll]

I recently heard of a different type of IM practice--one that would seemingly allow an internist to make a salary that's competitive with other fellowship-trained subspecialists...

Rather than running a traditional practice, the physician creates a practice in which he sees only a limited number of patients (500-750) who pay a yearly fee ($500-$1000) for service. Rather than being just one of the crowd of thousands, these patients have a doctor who knows them through and through and can expect to be treated like a VIP. They can expect that the physician will always be available for a last minute visit and will always be the one to see them if they are in hospital.

Any thoughts on this type of practice? I know of one doctor converting his current practice into this type, but I forget the term he used. Any thoughts? Lucrative? Too much work? Ethical issues?

---

Members don't see this ad.

 

[dragonfly99]

this is called boutique medicine.
There are firms, like MDVIP, that you can pay to help you convert your practice to this.
I think this only works in places where there are enough folks with money willing to pay for that service...also they'd have to be unhappy with their current insurance/medical care in order to be willing to pay extra to have access to you. Also almost all docs who do this already have established practices...that's where they get their patient bases.

Only time will tell if this idea really takes off. It's kind of in its infancy.

 

[mig26x]

seems like a lot of work. So they can call you whenever they want (1am, 3am, 5am) with problems and you are the one admitting them to the hospital? again at any time?

Feels like been on call everyday.

 

[Doowai]

It would require some sales. My experience is that few MD's have the ability to sell anything - I do not mean that in a mean way, its just been my experience.

Ex. I was doing a surgical rotation in med school. The surgeon was doing breast cancer patients and coordinating everything from the tumor removal to the brachytherapy. The majority of the work had been done, it was January of 2006. The patients insurance changed at the beginning of the year, she now had a $70 copay with this surgeon (since she was out of network) for routine follow up visits and could see another surgeon for a smaller co-pay in network. The patient told the doctor that she had to go see another surgeon because of the copay.

The surgeon, without any resistence (selling) said "Okay, I understand". I was amazed. After the lady patient left I said something like "Wow, that lady had told me she was getting her teeth whitened at the dentist - she is willing to pay hundreds of dollars cash for that luxury, but won't pay a few dollars more to see you, for CANCER. Heck, she is probably going to go out and buy pizza this week and spend the difference between in-network and out-of-network; but she values the pizza more. Wow, you are treating her cancer and she does not see it as worth her money, like having whiter teeth. Wow. I mean people spend a thousand bucks on a refrigerator without using insurance or caring about deductibles, but for cancer....I mean seriously...a life threatening illness like cancer.... they don't see you as worth spending actual money.Wow" I felt kind of bad at how crestfallen the surgeon looked when she realized her treatment of a life threatening condition was valued less than white teeth, a refrigerator or pizza. All that training, such a serious condition, and the MD lacked the skills to help the patient understand why continuing with her might be worth a few hundred dollars out of pocket. This surgeon had gone to special training to help her do these special surgical techniques so that the breast looked more natural afterwards- at the time she was one of the only ones in this area doing this ,so that her patients had more normal looking breasts after the surgery. in my opinion, after years of being a chiropractor and having so little covered by insurance (I mean, for real - Medicare use to require x-rays for chiropractic treatment, but would not pay for the x-rays.... yet MD's got paid to take blood pressure).

People EVERYWHERE have $500-1000. Its a single car payment for many. Its a matter of making it worth $2000 to them. Its a matter of selling. Sure they may have to do without some pizza's, or put off whiter teeth - but even in these times the vast majority of people an scrape up $500. I doubt the idea will catch on though - most MD's cannot ask for the money effectively. Heck, I have seen patients raise HECK when insurance denied some $20 service to MD's and the MD just folded and ate the cost, because they could not explain to the patient why they should be responsible and pay. WHen would Walmart let a customer walk out with a refrigerator for free? But the again Walmart expects to SELL their products

 

[DrJosephKim]

Concierge medicine (boutique medicine) is gaining tremendous traction. You may be interested in checking out the SIMPD:
http://www.simpd.org/

Whether it's ethical depends on your personal moral values.

 

[Good Solutions]

Concierge medicine (boutique medicine) is gaining tremendous traction. You may be interested in checking out the SIMPD:
http://www.simpd.org/

Whether it's ethical depends on your personal moral values.

There is nothing unethical about a direct practice. It is how medicine was practiced traditionaly before the onset of insurance and managed care. It is the bastion of freedom for the patient and physician. When and if universal health care comes it will be the refuge for both.

As it is right now insurance companies, HMOs and medicare are tools for covert rationing. If you have the desire to fight for our profession and our patients, this is exactly the practice we need more of in general IM and FP.

Our country is crashing down on physicians. Getting rid of pharmaceutical influences and gifts. Flushing out the industry payments to academics. Stark is running rampant in congress oppressing physicians. The argument is rising against free samples to the indigent in one's practice. If anything, current practices are unethical. They permit insurance companies to alter the ancient pact between patient and physician. They have propagated the use of less trained 'providers' in the name of cost savings. When you sign up for medicare you are by default saying you are only 15% better than an NP. Primary care can save itself. It only has to do one thing...

JUST SAY NO.

www.simpd.org is a great source for retainer practices
http://impmo.org/ is a great source for reducing staff and overhead through determination and technology to improve the patient/physician relationship while working in the current insurance system.
www.aafp.org/ do some searches here and you'll find a wealth of knowledge

 

[DoctorJekyll]

There is nothing unethical about a direct practice. It is how medicine was practiced traditionaly before the onset of insurance and managed care. It is the bastion of freedom for the patient and physician. When and if universal health care comes it will be the refuge for both.

As it is right now insurance companies, HMOs and medicare are tools for covert rationing. If you have the desire to fight for our profession and our patients, this is exactly the practice we need more of in general IM and FP.

Our country is crashing down on physicians. Getting rid of pharmaceutical influences and gifts. Flushing out the industry payments to academics. Stark is running rampant in congress oppressing physicians. The argument is rising against free samples to the indigent in one's practice. If anything, current practices are unethical. They permit insurance companies to alter the ancient pact between patient and physician. They have propagated the use of less trained 'providers' in the name of cost savings. When you sign up for medicare you are by default saying you are only 15% better than an NP. Primary care can save itself. It only has to do one thing...

JUST SAY NO.

Beautiful--I totally agree. This type of medicine allows physicians to make themselves independent of the cumbersome, crooked government and insurance companies. Why shouldn't they be allowed to operate like every other business in the world and charge their customers directly for the service they are providing?

My concern though is that the insurance companies or medicare and the government will find a way in to next 10-20 years to impinge on this type of practice and make it illegal or less lucrative. Any thoughts?

 

[souljah1]

It is ethical. If you can afford to pay out of pocket for services then you should be able to. Don't expect concierge medicine to be the solution to our current systems problems, though.

 

[DoctorJekyll]

Don't expect concierge medicine to be the solution to our current systems problems, though.

It's not a solution to the system but an escape from it for those smart/lucky enough to practice it. Sure, you might still have to deal with billing insurance companies/medicare. But when that billing accounts for 150k of 750k practice, it's not such a big deal any more. They're no longer your primary source of income.

 

[Good Solutions]

You are right. Concierge medicine will not be the solution to all our healthcare issues. But direct access, via abdication of the yolk of insurance, is the solution to the foundation of our health system. Primary care, or best known as comprehensive care.

Here is the scale of direct access practices:

<Concierge...Retainer...Fee for service (i.e. price transparency)...Barter>

These practices are not all $20,000.00 a year buy ins but a gradient on this scale. Once again, all have the common theme of no insurance. Can you see where people of different financial capabilities fit in? I can. This is why direct access is the solution to the comprehensive care problem.

Here are some real life examples of Retainer practices
http://www.warshawmd.com/MembershipInfo.html $1500
http://www.privatemedicaldoc.com/fees.htm $1850

Retainer & Fee for service hybrid: http://www.poncepreventive.com/fees.html

Fee for service (i.e. price transparency, quasi urgent care). http://www.patmosemergiclinic.com./index.html
http://www.simplecare.com/about.html
http://www.aafp.org/fpm/20070600/19brea.html

And here are some excellent blog posts on how universal healthcare may lead us back into the world of bartering.
1) http://covertrationingblog.com/new-...gies-for-the-battle-over-universal-healthcare
2) http://covertrationingblog.com/gene...e-medical-services-under-universal-healthcare

 

[gutonc]

I don't have a dog in this fight. My wife is a patient of a hybrid practice which has an annual fee ($300 or $30/month) and then accepts insurance for most of the routine primary care she gets from them. She hasn't been unhappy with her care but doesn't feel that her 1-2 visits per year (on short notice if needed) justify the extra cost. If she had any chronic medical issues (even just one which required routine monitoring) it would probably be more than worth the cost.

 

[Good Solutions]

Dollars are votes. Why doesn't she vote by spending her money elsewhere with a different physician?