Concierge/boutique medicine

[ngkats]

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This has been brought up on the pre-med forums a couple of years ago, but this is the first time I've heard of concierge medicine.

http://www.cbsnews.com/video/watch/?id=1820104n

The video isn't that informative, but you get the idea pretty quick what kind a physician's practice might look like if he/she adopted this model of care.

A friend of mine who knows a physician who practices concierge medicine described to me all of the services the doc offers: depending on how much you pay him per month, he will take calls at all hours of the night, personally take patients to the emergency room (calling the emergency room ahead of time and having them prepare for your arrival with all the relevant information), babysit hospitalized patients, etc.

1) Would anybody practice this kind of medicine?

2) And this kind of medicine in mind, I think there is no doubt that the rich can get better care than the poor. So, what do you think of concierge medicine's reinforcement of this ubiquitous American health care controversy?

EDIT: here's a link to a doctor's perspective-- http://www.thehealthcareblog.com/the_health_care_blog/2008/01/concierge-medic.html

 

[Aladdin]

This has been brought up on the pre-med forums a couple of years ago, but this is the first time I've heard of concierge medicine.

http://www.cbsnews.com/video/watch/?id=1820104n

The video isn't that informative, but you get the idea pretty quick what kind a physician's practice might look like if he/she adopted this model of care.

A friend of mine who knows a physician who practices concierge medicine described to me all of the services the doc offers: depending on how much you pay him per month, he will take calls at all hours of the night, personally take patients to the emergency room (calling the emergency room ahead of time and having them prepare for your arrival with all the relevant information), babysit hospitalized patients, etc.

1) Would anybody practice this kind of medicine?

2) And this kind of medicine in mind, I think there is no doubt that the rich can get better care than the poor. So, what do you think of concierge medicine's reinforcement of this ubiquitous American health care controversy?

I don't know if I would do this, but in regards to your second point, the rich get better care than the poor already - nationalized (i.e. "socialized") health care will not change that.

 

[ngkats]

I don't know if I would do this, but in regards to your second point, the rich get better care than the poor already - nationalized (i.e. "socialized") health care will not change that.

Right, but this thread isn't about nationalized/socialized health care. In fact, it's pretty much the opposite of that.

 

[Aladdin]

Right, but this thread isn't about nationalized/socialized health care. In fact, it's pretty much the opposite of that.

Yeah I know. I was just making the point that either side of the spectrum allows for differential access to health care - not much is going to change that.

I know of a few cities that have a lot of the boutiques (Seattle, LA, Miami, Boca Raton, Boston). I would think that you will probably see more and more of these as people (and doctors) don't want to deal with insurance companies and govt oversight. From what I read about these practices a year or so ago, the payment is made directly to the physician without the involvement of the insurance company. The person might keep their health insurance for major operations, etc, but the primary care is done all directly from patient to doctor.

 

[phospho]

I would totally do it. If i put in the time and money for my education, I can do whatever I want with my degree, just like any other graduate in any other field. No one has any right to question my values or goals. In fact, I think it would make me a better doctor because I wouldn't have to focus on all the politics involved (medicare, billing, private insurance, etc). It would allow me to focus solely on my patients. Not sure how it works in real life, but I'd like to put a sign in my office that says: "Either pay me cash, or get the f**k out"😀 (j/k)

I'm not in this for the money, but I wouldn't do it if it wasn't for the money.

 

[ngkats]

I would totally do it. If i put in the time and money for my education, I can do whatever I want with my degree, just like any other graduate in any other field. No one has any right to question my values or goals. In fact, I think it would make me a better doctor because I wouldn't have to focus on all the politics involved (medicare, billing, private insurance, etc). It would allow me to focus solely on my patients. Not sure how it works in real life, but I'd like to put a sign in my office that says: "Either pay me cash, or get the f**k out"😀 (j/k)

I'm not in this for the money, but I wouldn't do it if it wasn't for the money.

No one can tell you what to do with your degree, but that doesn't make it right.

 

[DrWookie]

No one can tell you what to do with your degree, but that doesn't make it right.

I don't really see what about this kind of practice is right or wrong. We get a degree and we choose to do what we want with it. If we have a private practice we can do it however we like.

 

[Handy388]

2) And this kind of medicine in mind, I think there is no doubt that the rich can get better care than the poor. So, what do you think of concierge medicine's reinforcement of this ubiquitous American health care controversy?

EDIT: here's a link to a doctor's perspective-- http://www.thehealthcareblog.com/the_health_care_blog/2008/01/concierge-medic.html

nothing uniqiue about that.

 

[Aladdin]

No one can tell you what to do with your degree, but that doesn't make it right.

I agree with DrWookie. It also doesn't make it wrong. Just because you have an MD doesn't mean you have to be all-giving, 100% altruistic, etc. If you want to work for a NPO where you earn $20,000/yr treating third world countries, you can do it. If you want to work for a private practice, you can do that. If you want to work in a boutique, you can do that.

I can't stand when people think that all MDs have to be in it for everyone BUT themselves.

 

[phospho]

I agree with DrWookie. It also doesn't make it wrong. Just because you have an MD doesn't mean you have to be all-giving, 100% altruistic, etc. If you want to work for a NPO where you earn $20,000/yr treating third world countries, you can do it. If you want to work for a private practice, you can do that. If you want to work in a boutique, you can do that.

I can't stand when people think that all MDs have to be in it for everyone BUT themselves.

👍

 

[melanoleuca]

Oh and folks, stop calling it "boutique" or "concierge" medicine. Those are terms The Man will use to demonize doctors who don't want to deal with the cluster-**** known of Medicare, Medicaid, and private insurance.

Call it "retainer" medicine or just "Old School" Medicine.

Also, the idea that only the rich can afford "Retainer Medicine" is spurious. If I am a Family Physician and charge each of my families a $500 retainer fee per year plus the cost of a visit (say $60 for a 15 minute visit) you can see that this will bankrupt nobody. In fact, this kind of arrangement in conjunction with an inexpensive major medical policy is a good deal more economical (and efficient) than the current payment models and something to which we should aspire, at least if we are to believe President Hopey-Changey when he admonishes us to "get some skin in the game." Hell, the problem with the system now is that too many people have no skin in the game whatsoever.

 

[cpants]

http://forums.studentdoctor.net/showthread.php?t=594406

This thread from the family medicine forum might interest you.

 

[cbrons]

Old School medicine is an awesome business model. A big problem with it though is that a lot of insurance companies are starting to refuse covering procedures done by concierge docs because they feel their retainer plans are a form of competition. Also, if you run a practice where you accept either a retainer or cash-only (say, $60 for a half hour appointment), you may run into trouble when people on medicaid come in to pay cash for an appointment.

These people do have medical coverage but I know their options with medicaid are extremely limited (at least in my area of the state) so maybe they just want to pay out of pocket; well at least in this state I have been told it is illegal to charge medicaid patients for services that would otherwise be covered... at least you cannot charge them more than what medicaid would reimburse (which is well-under what the physician wants to charge) .... even if they don't mind paying the fee. So my worry is that physicians will have to charge the medicaid patients a much lower fee or have to refuse to treat them.

If I'm a patient with a wife, a couple kids, and a combined income of, say $90,000 per year, I would get catastrophic health insurance for all of us (emergency stuff only), and get on the concierge plan. You just get so much more for your money.

 

[Rebs28]

Also, the idea that only the rich can afford "Retainer Medicine" is spurious. If I am a Family Physician and charge each of my families a $500 retainer fee per year plus the cost of a visit (say $60 for a 15 minute visit) you can see that this will bankrupt nobody. In fact, this kind of arrangement in conjunction with an inexpensive major medical policy is a good deal more economical (and efficient) than the current payment models and something to which we should aspire, at least if we are to believe Mr. Hopey-Changey when he admonishes us to "get some skin in the game." Hell, the problem with the system now is that too many people have no skin in the game whatsoever.

Agreed. Here's another great article from last year about "old school" medicine. The end of the article talks about a group, Seattle Medical Associates, that has made this model work for lower-income patients:

http://webweekly.hms.harvard.edu/archive/2008/0303/student_scene.html

 

[melanoleuca]

Old School medicine is an awesome business model. A big problem with it though is that a lot of insurance companies are starting to refuse covering procedures done by concierge docs because they feel their retainer plans are a form of competition. Also, if you run a practice where you accept either a retainer or cash-only (say, $60 for a half hour appointment), you may run into trouble when people on medicaid come in to pay cash for an appointment.

These people do have medical coverage but I know their options with medicaid are extremely limited (at least in my area of the state) so maybe they just want to pay out of pocket; well at least in this state I have been told it is illegal to charge medicaid patients for services that would otherwise be covered... at least you cannot charge them more than what medicaid would reimburse (which is well-under what the physician wants to charge) .... even if they don't mind paying the fee. So my worry is that physicians will have to charge the medicaid patients a much lower fee or have to refuse to treat them.

If I'm a patient with a wife, a couple kids, and a combined income of, say $90,000 per year, I would get catastrophic health insurance for all of us (emergency stuff only), and get on the concierge plan. You just get so much more for your money.

As long as you don't take Medicaid or Medicare you can charge patients whatever you want even if they have Medicaid and Medicare. You cannot, however, as you note, accept Medicaid and Medicare and then "balance bill" or selectively bill or not bill your Medicaid or Medicare patients. When you accept government money, you unfortunately incur the legal obligation to comply with every one of the arcane and convoluted regulations under penalty of imprisonment or fines.

The idea is to take no insurance of any kind, something that you are perfectly within your rights not to do. In other words, until you decide to take Medicare and Medicaid, none of the state and federal regulations governing these programs apply to you. Even HIPAA doesn't apply.

And yes, with the exception of Emergency Physicians and those on call to the Emergency Department, doctors can and do refuse to treat patients for many reasons; the lack of payment being one of the most common. You cannot walk into a private medical practice of any kind and demand treatment.

To reiterate, just because the patient has Medicaid or Medicare does not mean that they have the right to your medical services at Medicaid and Medicare rates so long as you, the doctor, take no Medicare or Medicaid money. Plastic surgeons, for example, many of whom take no insurance at all, charge Medicaid and Medicare patients whatever they want to charge them.

 

[funkymunkytoes]

I'm not in this for the money, but I wouldn't do it if it wasn't for the money.

PERFECTLY stated. That will be in Bartlett's Book of Quotations one day.

 

[ngkats]

I don't really see what about this kind of practice is right or wrong. We get a degree and we choose to do what we want with it. If we have a private practice we can do it however we like.

I don't think you understand. I agree that you can do whatever you want with your degree, presuming its legal, safe, therapeutic, etc.

What I was trying to express is that some may consider wrong (i.e., immoral, elitist) to take primary care medicine (which all people need) and make it affordable only a select few.

I can't stand when people think that all MDs have to be in it for everyone BUT themselves.

I'm pretty sure I never stated this or even implied it. I was only suggesting that furthering the divide between the quality of care the wealthy receive and the quality of care the poor receive may not be the direction some (most, I hope) want medicine to go.

Also, the idea that only the rich can afford "Retainer Medicine" is spurious. If I am a Family Physician and charge each of my families a $500 retainer fee per year plus the cost of a visit (say $60 for a 15 minute visit) you can see that this will bankrupt nobody. In fact, this kind of arrangement in conjunction with an inexpensive major medical policy is a good deal more economical (and efficient) than the current payment models and something to which we should aspire, at least if we are to believe President Hopey-Changey when he admonishes us to "get some skin in the game." Hell, the problem with the system now is that too many people have no skin in the game whatsoever.

Most retainer fees are much more expensive than that. In my very brief research, the lowest charge per month I found for an individual was $100 (i.e., 1200 a year).

Expect to pay more than that a month for a family plus the cost of insurance (you suggest an "inexpensive major medical policy" but I'm not really sure what you mean by that) and it can get expensive quick.

And I'm not sure how you see this as more "efficient," unless the concierge or retainer physician does not accept third-party reimbursements at all (which is not common even for these kinds of practices).

 

[ngkats]

Old School medicine is an awesome business model. A big problem with it though is that a lot of insurance companies are starting to refuse covering procedures done by concierge docs because they feel their retainer plans are a form of competition. Also, if you run a practice where you accept either a retainer or cash-only (say, $60 for a half hour appointment), you may run into trouble when people on medicaid come in to pay cash for an appointment.

These people do have medical coverage but I know their options with medicaid are extremely limited (at least in my area of the state) so maybe they just want to pay out of pocket; well at least in this state I have been told it is illegal to charge medicaid patients for services that would otherwise be covered... at least you cannot charge them more than what medicaid would reimburse (which is well-under what the physician wants to charge) .... even if they don't mind paying the fee. So my worry is that physicians will have to charge the medicaid patients a much lower fee or have to refuse to treat them.

If I'm a patient with a wife, a couple kids, and a combined income of, say $90,000 per year, I would get catastrophic health insurance for all of us (emergency stuff only), and get on the concierge plan. You just get so much more for your money.

First of all, I think you mean medicare, right? I'm pretty confident that a medicaid patient would never be able to pay out of pocket.

Second, if you pay a retainer fee and have catastrophic insurance only (which I'm assuming is a high-deducible plan) how would you pay for specialist consults, prescriptions, procedures, and non-emergency but necessary surgeries? These things won't be covered in a retainer plan. If you're planning on doing that out of pocket, you'll be on medicaid yourself.

 

[JaggerPlate]

There is a ton of stuff about this in the FP forums, namely because right now practicing as a FP is horrible. The bottom line for most people is that it's a nice practice model, and does allow for a far better salary, but it takes a while to build up your practice this way ... and you see more older docs doing it compared to guys first starting up. However, I really hope more and more people start doing it ... the PCP fields deserve this type of money, and it would let people know that docs aren't going to put up with the bullsh*t anymore.

 

[melanoleuca]

I don't think you understand. I agree that you can do whatever you want with your degree, presuming its legal, safe, therapeutic, etc.

What I was trying to express is that some may consider wrong (i.e., immoral, elitist) to take primary care medicine (which all people need) and make it affordable only a select few.



I'm pretty sure I never stated this or even implied it. I was only suggesting that furthering the divide between the quality of care the wealthy receive and the quality of care the poor receive may not be the direction some (most, I hope) want medicine to go.



Most retainer fees are much more expensive than that. In my very brief research, the lowest charge per month I found for an individual was $100 (i.e., 1200 a year).

Expect to pay more than that a month for a family plus the cost of insurance (you suggest an "inexpensive major medical policy" but I'm not really sure what you mean by that) and it can get expensive quick.

And I'm not sure how you see this as more "efficient," unless the concierge or retainer physician does not accept third-party reimbursements at all (which is not common even for these kinds of practices).

Efficiency means that, because there is transparency of price between the doctor and the patient who has to pay for every routine thing out-of-pocket, the natural pressure will be to not waste money on unnecessary testing and imaging (something I assure you we do a lot of) instead relying on a little clinical judgment.

The whole idea of Retainer medicine is not to accept third-party reimbursements. In other words, the patient pays the entire bill and then works it out with his own insurance company. When you let the wolf in the door ("Third Party Payers" like the government and private insurance companies) you are forced to do things their way.

$100 per month is not a lot of money. Most American families, even those in the ranks of the Holy and Unwashed Underserved spend more than this on cell phones, cable TV and other various irregular pleasures. It is a sad testament to our silly and frivolous age that even the Future Doctors of America think so little of their future career that they find it inconceivable that anybody could possibly value their services.

Most of my Medicaid patients smoke, drink, and can always seem to find money for these and other expensive vices. i have long ago lost any sympathy for my Asthma patient who smokes a pack a day but can't afford 15 bucks for his MDI.

 

[melanoleuca]

First of all, I think you mean medicare, right? I'm pretty confident that a medicaid patient would never be able to pay out of pocket.

Second, if you pay a retainer fee and have catastrophic insurance only (which I'm assuming is a high-deducible plan) how would you pay for specialist consults, prescriptions, procedures, and non-emergency but necessary surgeries? These things won't be covered in a retainer plan. If you're planning on doing that out of pocket, you'll be on medicaid yourself.

You obviously don't know a lot of Medicaid patients.

And that's kind of the point of Major Medical: To insure yourself against rare events.

Additionally, why can't you have a cardiologist on retainer? Again, there is an advantage to having some price transparency as in maybe you don't need to see your cardiologist every two weeks on the taxpayer's dime.

 

[melanoleuca]

And I assure all of you, absent the requirement to document for billing (and not medical need), to wade through reams of government and insurance paperwork, to be hamstrung by an increasingly complex mass of regulations and guidelines which have nothing to do with patient care (but are instead blunt instruments to force doctors to covertly ration medical care) I could easily see twice as many patients or spend twice the time with the same ones.

The level of bureaucracy that we have to deal with in American medicine will stun most of you when you are first exposed to it. And it's only going to get worse under good 'ol President Hopey-Changey.

 

[BluntSurgeon]

There is a ton of stuff about this in the FP forums, namely because right now practicing as a FP is horrible. The bottom line for most people is that it's a nice practice model, and does allow for a far better salary, but it takes a while to build up your practice this way ... and you see more older docs doing it compared to guys first starting up. However, I really hope more and more people start doing it ... the PCP fields deserve this type of money, and it would let people know that docs aren't going to put up with the bullsh*t anymore.

I agree with you man. It's such a bummer because my main motivation for going into medicine is family practice. I would love the whole community doctor thing, with an established set of patients with whom I form long term relationships. Honestly, when I think of the word "doctor" I think of a family practitioner, but too bad the field has gone to utter **** (DNPs, PAs, low reimbursements etc etc). It business models like this that still give me hope.

 

[cbrons]

First of all, I think you mean medicare, right? I'm pretty confident that a medicaid patient would never be able to pay out of pocket.

come to my pharmacy for a day
see all the medicaid patients driving around in brand new escalades
then come spout your ignorant BS
No not all of them are like that, not even most. But a good percentage can afford a decent living, they just elect to make excuses on why they can't contribute meaningfully to society and leech off the rest of us.
I would say more but this summed it up:

You obviously don't know a lot of Medicaid patients.

Second, if you pay a retainer fee and have catastrophic insurance only (which I'm ass u ming is a high-deducible plan)

There are plenty of catastrophic plans that cover things like major Dx's (cancer, MS) and even ER visits... many of them are affordable. They are high deductable plans but they have very low monthly premiums (some for ~$30/month). If you stay relatively healthy and don't have health problems that can't be treated by a PCP, then you'll be fine. And even if you do have the **** hit the fan, you will still be covered.

how would you pay for specialist consults, prescriptions, procedures, and non-emergency but necessary surgeries?

If you want prescription drugs, get on the walmart $12 plan or the walgreens savings club. You can afford generic drugs out of pocket for less than $20 a month for the most common ailments (hypertension, high cholesterol, etc.) No it won't be the brand new repackaged **** that works no better than any of the older stuff but thats life in the big city.

 

[Law2Doc]

Oh and folks, stop calling it "boutique" or "concierge" medicine. Those are terms The Man will use to demonize doctors who don't want to deal with the cluster-**** known of Medicare, Medicaid, and private insurance....

Um, no. Actually these terms were adopted by the folks who set these plans up because they have POSITIVE connotations, not negative. This concept came from other fields (law, banking) who use the term "boutique" as a positive spin by small firms wanting to say they offered something specialized as compared to the larger general practices.

The big issue with boutiques is that because the number of people out there willing to pay cash out of pocket for something they already get through their work benefits is fairly small, there is only room for a few in each geographical area. So unless you are a first mover in a relatively lucrative area, you fail. Boutiques/Conceirge businesses only work because everybody isn't trying to do it. If a lot of people try this, the customer base is spread too thin, and folks go bankrupt. So it's only a good idea if you are one of the few. Which kind of means that anybody contemplating med school now has probably already missed the boat. I also would note that in tough economic times, such as the current one, people are more likely to want to maximize their work benefits and minimize their out of pocket healthcare expenses. Suffice it to say this will dry up this kind of expenditure fairly quickly.

There is nothing unethical about having a different, cash based business plan through which to distrbute your services. But that doesn't make it a smart idea at a time when the nation is moving toward some form of nationalized insurance, and people are tightening their belts in terms of out of pocket costs, and the various markets for these things are already quickly becoming saturated. You could have made bank if you were among the first to set up this kind of practice in a lucrative area such as Beverly Hills. You are now likely to go broke if you end up competing for a small amount of business in a well saturated market.

Once the topic of "boutiques" makes it onto discussion boards like this, it is probably too late. You have to be a first mover. The people who play copy cat all too often come too late to the game.

 

[ngkats]

The whole idea of Retainer medicine is not to accept third-party reimbursements. In other words, the patient pays the entire bill and then works it out with his own insurance company. When you let the wolf in the door ("Third Party Payers" like the government and private insurance companies) you are forced to do things their way.

Most retainer physicians STILL use third party reimbursements. They simply charge more to have certain luxury services (like being able to contact your physician 24 hours a day, having a physican 'babysitter' for hospitalizations). But on top of this charge, they still bill insurance companies for their services.

 

[ngkats]

come to my pharmacy for a day
see all the medicaid patients driving around in brand new escalades
then come spout your ignorant BS
No not all of them are like that, not even most. But a good percentage can afford a decent living, they just elect to make excuses on why they can't contribute meaningfully to society and leech off the rest of us.
I would say more but this summed it up:

Well, I worked in a free clinic for 3 years and saw some pretty poor people on medicaid, none of which showed on in cadillacs to the doctor's office. I help treat hundreds of patients who couldn't afford 5 dollars out of pocket for generic prescriptions. Where they lying? Maybe, but regardless they looked like they were in a pretty sad state (and their health proved it).

Sorry to spout my ignorance and being an advocate for lower income folks. I'm such a jerk.

 

[ngkats]

Additionally, why can't you have a cardiologist on retainer? Again, there is an advantage to having some price transparency as in maybe you don't need to see your cardiologist every two weeks on the taxpayer's dime.

I'm honestly trying to think about the practicality of this but it's difficult. Getting and MI and having a couple stents shoved in your coronary arteries is pretty expensive. The retainer fees for that would have to be pretty high for that to work.

I think that retainer medicine is pretty much limited to primary care.

 

[melanoleuca]

I'm honestly trying to think about the practicality of this but it's difficult. Getting and MI and having a couple stents shoved in your coronary arteries is pretty expensive. The retainer fees for that would have to be pretty high for that to work.

I think that retainer medicine is pretty much limited to primary care.

Sure. But most visits to the cardiologist are not for MIs or stents but for routine "primary care" cardiology.

Additionally, most heart catherterizations are unnecessary and, for people with stable angina, show no benefit in morbidity or mortality over medical management. In other words, it's not narrowing of the arteries from stable lesions that cause heart attacks but plaques that acutely rupture. There is no point, from a cost versus benefit point of view, of revascularizing (stenting) stable lesions which is what most heart caths are for.

The cardiologists know this but are not about to let go of their high-dollar, signature procedure.

 

[melanoleuca]

Oh, and let me say it again: Most medical care either unnecessary, harmful, redundant, or only marginally (and I mean extremely marginally) effective and the money spent on it is completely wasted.

I put the amount of this waste at close to 70 percent.

 

[maceo]

The level of bureaucracy that we have to deal with in American medicine will stun most of you when you are first exposed to it. And it's only going to get worse under good 'ol President Hopey-Changey.

no the level of bureaucracy is MIND BOGGLING. I think you mis spoke.

I think you are unfairly blaming obama. He has been around for less than 2 months. Nothing he has done has affected us yet. But you can blame clinton and bush for themess. At least he is trying to change the mess that we are in now. and all of us must agree the system needs to change.

I was watching oprah last night. Take it easy!!! (I couldnt sleep). And she had on that dr oz guy talking about medical mistakes. she also had dennis quaid. HIs new born twins got 10000 units of heparin instead of 10 units for the hep lock iv. they are ok now. The bottles of the two concentrations of heparin look the same except I think the top is a different color. This happened at cedars sinai medical center. If any of you have been there, its quite a place. Anyway, to prevent this from happening they spent 100 million dollars to institute a scanning type system where the provide scans his/her badge, then scans the medication and then scans the patient. Like a ****ing grocery store. Im thinking to myself greeeeeeaaat. Justanother thing to make it easier for nurses NOT TO THINK. I mean the best way to prevent this from happening is education. Educate them that there are different doses of heparin and they come in the same bottle. Make them look. Make them think about what they are doing. Im an anesthesiologist.. all id o all day is draw up medicine. You gotta look, all the time. If that device came to my hospital I would quit the same day. anyway 100 million dollars they spent. Thas a lot of ****ing money.

 

[maceo]

Oh, and let me say it again: Most medical care either unnecessary, harmful, redundant, or only marginally (and I mean extremely marginally) effective and the money spent on it is completely wasted.

I put the amount of this waste at close to 70 percent.

i agree there is a incredible amount of waste in this country. But what do you expect when you get paid for everything you do. Of course people are going to wanna do more. If you pay a hospital per urinalysis. guess what? every surgical patient is going to have a UA prior to surgery. if you do 13000 procedures anually at 100 bucks a pop average. thats 1.3 mil. Nice for an un necessary test that has absolutely no benefit. Not to mention the workups that are going to happen if you find microscopic hematuria,or tiny white cells. Next you know you are doing cystoscopys on all these. And let me tell you. Nobody needs a UA prior to surgery. xcept maybe if you are putting hardware in and you wanna be certain there is no infection. but even that is stretching it . ANd of course if someone has symptoms.. ANd thats one test. how about CBC chest films that people order for no reason. the list goes on and on and on. its an industry. it has to sustain itself.

 

[niranjan162]

First of all, I think you mean medicare, right? I'm pretty confident that a medicaid patient would never be able to pay out of pocket.

Second, if you pay a retainer fee and have catastrophic insurance only (which I'm assuming is a high-deducible plan) how would you pay for specialist consults, prescriptions, procedures, and non-emergency but necessary surgeries? These things won't be covered in a retainer plan. If you're planning on doing that out of pocket, you'll be on medicaid yourself.

It would be more like other insurance. My insurance company doesnt pay for my oil changes, they pay when there is an accident.

They should have things like if you smoke you pay more, if you're over weight you pay more.

I am all for helping people who cant afford medications and such as a result of things out of their control, but if you decide smoking 2 packs a day is more important thats your choice deal with it.

 

[scottyT]

This whole business model would really work great if it were recognized as a legitimate flex spending expense or health savings plan expense. If people could pay for it with pre-tax dollars, they could carry a less comprehensive major medical plan and their net cost would be similar. This type of service is currently disallowed for flex and HSA purposes.

Think of the possibilities: happier/better compensated PCPs, more satisfied patients, and a similar net cost. Just sayin ...

 

[scottyT]

First of all, I think you mean medicare, right? I'm pretty confident that a medicaid patient would never be able to pay out of pocket.

Second, if you pay a retainer fee and have catastrophic insurance only (which I'm assuming is a high-deducible plan) how would you pay for specialist consults, prescriptions, procedures, and non-emergency but necessary surgeries? These things won't be covered in a retainer plan. If you're planning on doing that out of pocket, you'll be on medicaid yourself.

To clarify, a high deductible plan is just like it sounds ... a plan with a high deductible. They require you to pay 100% of your medical expenses initially, then when you've spent some magic number like $1000 or $500 in a year, the plan kicks in. Primary care expenses, however, are covered at 100% even if you haven't yet met your deductible. All subsequent expenses are covered under the terms of the plan (eg, 80% of the cost for a hospital admission or 90% of an ER visit or whatever). It works like a normal plan once you've paid out the initial deductible in a year. These plans also feature "catastrophic" limits wherein if you pay some certain amount within a year, usually around $5000/individual, the rest of your expenses are 100% covered. This prevents you from going bankrupt when you need a new kidney.

HDHPs are coupled with HSA's, or health savings accounts. HSA's serve as a pre-tax saving account that you put money into for medical and dental expenses. You usually get a debit card and can use it at will for any medical or medical-related expense (subject to federal regulations about what qualifies; boutique/concierge medicine is not currently an allowed expense. Things like reading glasses, toothpaste, OTC medications are allowed). Many employers contribute some amount into your HSA in addition to whatever you contribute because they are saving money when you sign up for an HDHP. These plans are typically cheaper than full-service plans and they are essentially passing on part of the savings to you.

This is why I was hinting above that an HDHP coupled with a concierge practice could be a beautiful concept. You could pay for the service with pre-tax dollars that your employer subsidizes and you would still be covered for major stuff. Presumably, stripping the primary care benefit from an HDHP would bring the cost down by some amount. I'm not an actuary so I can't wager a guess about how much the cost would come down. An employee paying with pre-tax, subsidized dollars would only have to pay about 40% of the actual cost though and it would make the service more accessible to the working public.

I've personally thought this would be a wonderful idea for a company to sign on their own personal concierge service as a perk and only offer some sort of high deductible plan with no primary care benefit to employees. I would prefer that model greatly due to much better access and service. It would be fantastic for low utilizers like people in our age range.

 

[starfishprime]

Presumably, stripping the primary care benefit from an HDHP would bring the cost down by some amount.

Yeah, what's with primary care/prescription drug benefits anyway. My car insurance doesn't cover oil changes and brake fluid.

 

[sevenmints]

the guy has pretty much created a small scale hmo. It's not that revolutionary a concept...

 

[atomi]

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[atomi]

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[OnMyWayThere]

According to this guy, this type of practice may be VERY illegal! http://www.sackstierney.com/articles/boutique.htm

 

[Law2Doc]

According to this guy, this type of practice may be VERY illegal! http://www.sackstierney.com/articles/boutique.htm

No, that's not what he's saying. He's saying insurance fraud is illegal, and that many (but not all) folks who run boutique businesses are committing insurance fraud. You can either charge cash for your services, or request reimbursements from insurers. You can't do both for the same work, trying to get paid twice. That's insurance fraud. And it hopefully should be obviously wrong. So the guy who charges a flat fee for all medical needs each month can't also turn around and submit reimbursement requests for those patient's office visits. That's a felony.

As for why anybody on this thread already missed the boat on conceirge businesses and why it's always going to be a novelty and not a realistic path to take, see my post (#25) above.

 

[cpants]

No, that's not what he's saying. He's saying insurance fraud is illegal, and that many (but not all) folks who run boutique businesses are committing insurance fraud. You can either charge cash for your services, or request reimbursements from insurers. You can't do both for the same work, trying to get paid twice. That's insurance fraud. And it hopefully should be obviously wrong. So the guy who charges a flat fee for all medical needs each month can't also turn around and submit reimbursement requests for those patient's office visits. That's a felony.

As for why anybody on this thread already missed the boat on conceirge businesses and why it's always going to be a novelty and not a realistic path to take, see my post (#25) above.

But it would only be insurance fraud if you are guaranteeing medical services for the fees paid. What a lot of the docs are doing is saying the fee is a retainer, paid for access to the doc (cell number, e-mail address, same-day appointments, accompaniment to the ED, etc.). Any medical care provided is still on the insurance company. Why is that fraudulent? With the state of medicine, especially primary care, some patients are willing to pay extra for this access.

 

[thoffen]

Concierge medicine allows a physician to provide quality healthcare while being reimbursed fairly. It does not mean that the physician is making any more $$$ in the end, but I'm sure there is quite a wide spectrum even in concierge medicine.

On the downside, access is limited to those who can afford/are willing to pay for better healthcare.

Personally, I would have to weigh quality of care vs. access to care very carefully, as there is no way to ensure both within our current medical system.

 

[melanoleuca]

Do you call him out on it, or would this result in you getting fired?

Oh no. It is perfectly acceptable to speak you mind to your patients. You don't have to be a dick about it but pointing out to your smoking asthma patient that eschewing three packs of smokes a month would pay for his inhaler and improve his asthma is a legitimate part of your medical advice.

 

[Law2Doc]

But it would only be insurance fraud if you are guaranteeing medical services for the fees paid. What a lot of the docs are doing is saying the fee is a retainer, paid for access to the doc (cell number, e-mail address, same-day appointments, accompaniment to the ED, etc.). Any medical care provided is still on the insurance company. Why is that fraudulent? With the state of medicine, especially primary care, some patients are willing to pay extra for this access.

It's fraudulent because you are not allowed to collect both cash and insurance for the same services, and are not allowed to charge cash on top of whatever reimbursement you get. So no, you can't do this. And "dressing it up" by saying it's not for the medical services, it's for the "access" is a good arguement only if you like living in a cell. You don't get to play cute with insurance laws. and that's exactly what this has been determined to be, in many losing lawsuits. It's a substance over form issue -- if you take money from a patient and provide medical services, it is understood that this is partial payment for those services, regardless of what you indicate on his bill. You either take insurance for this patient or you take cash. If you already have cash as a retainer, and then go after the insurance, you just committed a federal crime. Doesn't matter if the patient is willing to pay "extra" -- you aren't allowed to accept "extra". You can either accept only cash or only the reimbursement, but not both. That's the law. It's insurance fraud if you go after the extra. Which is what that guy's article is saying. So no, don't try this. It's illegal. If you really know a "lot of docs" doing this, I would stay far away from them because the hammer can fall on them at any time.

 

[cpants]

It's fraudulent because you are not allowed to collect both cash and insurance for the same services, and are not allowed to charge cash on top of whatever reimbursement you get. So no, you can't do this. And "dressing it up" by saying it's not for the medical services, it's for the "access" is a good arguement only if you like living in a cell. You don't get to play cute with insurance laws. and that's exactly what this has been determined to be, in many losing lawsuits. It's a substance over form issue -- if you take money from a patient and provide medical services, it is understood that this is partial payment for those services, regardless of what you indicate on his bill. You either take insurance for this patient or you take cash. If you already have cash as a retainer, and then go after the insurance, you just committed a federal crime. Doesn't matter if the patient is willing to pay "extra" -- you aren't allowed to accept "extra". You can either accept only cash or only the reimbursement, but not both. That's the law. It's insurance fraud if you go after the extra. Which is what that guy's article is saying. So no, don't try this. It's illegal. If you really know a "lot of docs" doing this, I would stay far away from them because the hammer can fall on them at any time.

You're the lawyer, but I think you might need to do some more research on this one. Firstly, I am pretty sure that insurance is largely regulated by state laws. Secondly, and I know it's anecdotal, but my parents and my grandparents both use similar arrangements to this (ie. doctor collects retainer + insurance). They have unrelated doctors in different states. I have also seen numerous examples of this practice model in articles and on the internet. You can interpret it as billing for the same service twice, but it simply is not. The retainer fee only pays the doctor to keep his practice to a small size and to provide better access to care. This arrangement is likely clearly explained in the written contract between doctor and patient. The smartest thing is probably for docs just to stick to cash only, and charge patients whatever for treatment, leaving it up to them to seek out-of-network reimbursement from their insurers.

Also, it is not true that you must either accept cash or insurance reimbursement for your services. Doctors can accept anything in payment, or nothing for that matter, but it is also legal to bill patients for costs over what the insurance reimbursement covers. The reason most physicians cannot do this is not because it is illegal, but because it is prohibited in the contracts they sign with insurance companies.

From the articles I have read, including the one quoted above, the legal issue was not with retainer payments. The issue was with doctors setting up practices where patients paid monthly fees in exchange for unlimited care, effectively making the physicians private insurers subject to all of the regulation which goes along with that.