Concierge medicine question

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EventualMD

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Some argue that concierge medicine is unethical.
 
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Go to the Family Medicine forum in the Resident forums. Look for threads with "Direct Primary Care" in the title, or anything written by AtlasMD.

If blue-collar concierge medicine is unethical, then health insurance itself is unethical. In either case you are paying a flat fee for basic medical access.
 
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EventualMD said:
People in the US pay 50 dollars a month just to use a phone so they can play angry birds while driving. Paying 50/month to see your family doctor at a moments notice is not out of reach for anyone.

Suppose as a primary care doc you had 1000 patients (is this too much to see "at a moments notice"?) and charged each patient 50 dollars a month to have access to see you. That's a substantial amount of yearly revenue (600K). I don't know what overhead is but I'd imagine it's less in FP than in, say, an ophthalmology clinic.

Why isn't this practice model the norm? I read a lot on here about docs complaining about EMR requirements and time with patients in medicine right now. Is it start-up costs? Risk? Difficulty in advertising services? I've read a lot of patients, especially younger people, gravitating towards high-deductible plans for catastrophic illness. This seems like such a good opportunity to complement that and offer services if you're really into getting to know and spending time with patients if they want to see a doctor.

There are threads on this but they date back to pre-obamacare and more so I wanted to get some fresh perspectives.

Thanks!
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People expect healthcare for free. As you mentioned, people will think nothing of dropping a few hundred a month for entertainment/phone/cable/internet, but ask them to pay a $500 copay on their insurance for something that would have cost $10,000 out of pocket, and they throw a fit.

You also have the very real issue that the $50 a month you are talking about might cover their PCP and some office services (some x-rays, labs, etc.) but if anything major happens, they will need additional insurance to cover that as well. Most people are angry about having to pay ANYTHING for their healthcare, so asking them to pay an additional $50 or so a month on top of their insurance is appealing to a very limited segment of the population. I believe some markets are already becoming saturated with concierge providers as it is.....
 
We have several concierge IM guys here. The typical model is capped at 300 patients, annual fee of $1500 per patient. They provide/coordinate in home care (blood draws, PT, wound care, doctor's visits) and see patients in the hospital. I was on stroke call and got a code stroke in the ER. The concierge doc was at the patient's bedside before I was and I literally ran down.
 
Most people already have health "insurance" through their employer, family, school, or government. It is difficult to convince people to pay extra for the same service when they have essentially already prepaid for the same service with their monthly premium. Suppose someone offered you a dining club membership where you could pay $30 a month and eat unlimited times at 90% of the restaurants out there for only $10 a month. Now suppose there is this new 5 star restaurant that opens up, but it doesn't participate in your plan. No matter how much people want to go there, they most likely won't because by doing so they (a) have to pay ~$100 instead of $10, (b) lose the perceived benefit of the $30 a month they pay to be a part of the club (i.e., a sunk cost they don't want to lose), and (c) can obtain meals pretty darn similar elsewhere at a participating restaurant.

Furthermore, you still need actual insurance for major medical conditions (vs. the prepayment of office visits we usually think of as "insurance"), and major medical (aka high deductible) insurance is ridiculously expensive to the point where it just makes more sense to buy a full-service plan. Also major medical is typically not offered by employers where most people get their insurance from.
 
art caplan is pushing a ridiculous extension of the "social contract" nonsense. The idea that physicians can't see less people because it's not fair to other physicians? The idea that it's unfair to offer exclusivity and higher services in exchange for a fee?

He can jump off a cliff with that noise.
 
I also have to admit, I thought it was pretty stupid when I started residency. But, after my experiences with our VIP/concierge guys here and after trying to navigate a hospital in another city as a patient's family in the ICU and then on the floor, I'm paying for a private guy to manage my family and my healthcare. It almost pays for itself that I don't have the hassles of trying to get my FMLA paperwork filled out.
 
mimelim said:
I also have to admit, I thought it was pretty stupid when I started residency. But, after my experiences with our VIP/concierge guys here and after trying to navigate a hospital in another city as a patient's family in the ICU and then on the floor, I'm paying for a private guy to manage my family and my healthcare. It almost pays for itself that I don't have the hassles of trying to get my FMLA paperwork filled out.
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i will likely seek one out for my family once i have funds as well
 
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sb247 said:
art caplan is pushing a ridiculous extension of the "social contract" nonsense. The idea that physicians can't see less people because it's not fair to other physicians? The idea that it's unfair to offer exclusivity and higher services in exchange for a fee?

He can jump off a cliff with that noise.
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Art Caplan, PhD is a complete ****, if you watch that video. If it's one thing I absolutely hate about this profession is people who AREN'T physicians commenting on what doctors should or shouldn't do. Have to wonder how much of his salary is subsidized by medical student tuition money bc I'm almost sure he has no actual clinical responsibility. I don't know if dentistry has the same tripe, maybe @fancymylotus might know.
 
mimelim said:
We have several concierge IM guys here. The typical model is capped at 300 patients, annual fee of $1500 per patient. They provide/coordinate in home care (blood draws, PT, wound care, doctor's visits) and see patients in the hospital. I was on stroke call and got a code stroke in the ER. The concierge doc was at the patient's bedside before I was and I literally ran down.
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So it sounds like you think highly of concierge medicine.

On paper it seems like it is good. Cheaper for the patients (especially if they have backup insurance). And it gives physicians the autonomy to continue practicing passionately. Seems like a win win.
 
look at the large, scaled models that have been implemented: Turntable in Las Vegas and Iora in Boston.

no, really. Just look at them.

now tell me that there is a net negative societal impact to this model.

The further we drive insurance from the delivery of healthcare (some insurance is of course both necessary and desirable), the better.

That said, organized labor did great things too, until it was co-opted as a source of ready cash flow by its leadership. The challenge for the ACO model and these ACO-derivatives is maintaining a healthy balance (pecuniary and operational) between management and labor. The Kaiser system provides reasonable evidence that this can exist -- rational management salaries, and a reasonably high degree of physician input provided by their very unique labor organization.

Change is not inevitable, nor is it always good, but ALL of these developments (done right and with the right oversight) are great steps towards reducing (insurance) waste and maximizing physician value and satisfaction.
 
Awesome Sauceome said:
So it sounds like you think highly of concierge medicine.

On paper it seems like it is good. Cheaper for the patients (especially if they have backup insurance). And it gives physicians the autonomy to continue practicing passionately. Seems like a win win.
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I like the idea of knowing that there is someone that I can count on. I went through dealing with an ICU, 4 different specialties, 2 different hospitals, and insurance companies a month or so ago from a patient family perspective. I live 1000+ miles from my parents and am a resident right now. For my loved ones, I can pay $1500/year/person and know that they #1 know who my family members are, #2 are pre-vetted in terms of credentials and #3 are going to answer my phone calls and solve problems rather than trying to dump it on anyone else that they can? I can think of far worse things to spend my money on.

Is this a solution to healthcare in the US? Absolutely not. Is it something that if it is something I can afford, I'm going to pay for? Absolutely.
 
repititionition said:
look at the large, scaled models that have been implemented: Turntable in Las Vegas and Iora in Boston.

no, really. Just look at them.

now tell me that there is a net negative societal impact to this model.

The further we drive insurance from the delivery of healthcare (some insurance is of course both necessary and desirable), the better.

That said, organized labor did great things too, until it was co-opted as a source of ready cash flow by its leadership. The challenge for the ACO model and these ACO-derivatives is maintaining a healthy balance (pecuniary and operational) between management and labor. The Kaiser system provides reasonable evidence that this can exist -- rational management salaries, and a reasonably high degree of physician input provided by their very unique labor organization.

Change is not inevitable, nor is it always good, but ALL of these developments (done right and with the right oversight) are great steps towards reducing (insurance) waste and maximizing physician value and satisfaction.
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Eh, Turntable is interesting but it looks like it's more focused on being a "wellness center" having you pay a monthly fee to take yoga classes and stuff rather than a typical conceirge medicine model. On the medical side, your fee seems to include office visits and basically nothing else. They also have as many "wellness coaches" as physicians (of which they only have 2) so I wouldn't exactly call it large scale.

Here's the thing with the concierge model...it works really well the way mimelim describes. Having basically a personal physician who will check up on you while you're in the hospital and use his special "doctor powers" to get stuff done as an admitting physician on staff is really useful. However, focusing on the "able to see your doctor on short notice" part of it is a little overrated. Not everyone with private insurance has a terrible time seeing their PCP. I used to be able to go see my family doctor within a day or two of calling pretty consistently. You'd really have to focus on markets where people are having a bad time with their PCPs and have the expendable income to pay for these services. That can be a hard line to draw. It's all about customer service with this stuff too...you really have to have the retail mindset of "the customer is always right, make the customer happy" to make people pay a thousand bucks a year just to have easy access to you.

And a thousand patients is too much to see at a moment's notice. Depending on the age distribution of your practice you could easily have 10+ of those patients in the hospital at any given time plus all the patients who have been promised to see you today or tomorrow.
 
this practice model is not the norm probably due to the massive socioeconomic gap that we have today in the U.S. the lack of insurance coverage prevents most American citizens from obtaining this service. i have not a clue as to how this situation will be resolved either now or, hopefully, in the near future. but, from what i've generally learned about it in bioethics thus far, "concierge" medicine is as concierge-y as it sounds. luckily, since it's such an up and coming thing, i still imagine that there are many more rich people who would be willing to pay out-of-pocket. it's kind of weird though... rich people paying extra money here to have a closer relationship with their doctors.
 
whizatphys said:
this practice model is not the norm probably due to the massive socioeconomic gap that we have today in the U.S. the lack of insurance coverage prevents most American citizens from obtaining this service. i have not a clue as to how this situation will be resolved either now or, hopefully, in the near future. but, from what i've generally learned about it in bioethics thus far, "concierge" medicine is as concierge-y as it sounds. luckily, since it's such an up and coming thing, i still imagine that there are many more rich people who would be willing to pay out-of-pocket. it's kind of weird though... rich people paying extra money here to have a closer relationship with their doctors.
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This is the beginning of the two-tier system that everyone claims they want to avoid. I'm all for it. This takes the burden of insurance paperwork off the physician, which frees them up to see more patients. The patients can get appointments rapidly with their PCP and have someone who knows them in the hospital when they happen to go to the hospital. Sounds like a win-win to me.
 
evilbooyaa said:
This is the beginning of the two-tier system that everyone claims they want to avoid. I'm all for it. This takes the burden of insurance paperwork off the physician, which frees them up to see more patients. The patients can get appointments rapidly with their PCP and have someone who knows them in the hospital when they happen to go to the hospital. Sounds like a win-win to me.
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i do agree. in fact, I believe I was tone of the only students who agreed out of my e entire class of 140 students during a bioethics discuss. Perhaps my opinion on the topic was misread, and that is my fault, my apologies. With all of the current pushing towards minority groups in the field of medicine, however, I am just mot sure as to how impoverished Americcam citizens may afford it, and that it my only qualm. Unfairenss in the health care system 🙁
 
whizatphys said:
i do agree. in fact, I believe I was tone of the only students who agreed out of my e entire class of 140 students during a bioethics discuss. Perhaps my opinion on the topic was misread, and that is my fault, my apologies. With all of the current pushing towards minority groups in the field of medicine, however, I am just mot sure as to how impoverished Americcam citizens may afford it, and that it my only qualm. Unfairenss in the health care system 🙁
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**please excuse my erroneous typos -- I just took a final exam this past Monday and my brain is still liquified lol.
 
whizatphys said:
i do agree. in fact, I believe I was tone of the only students who agreed out of my e entire class of 140 students during a bioethics discuss. Perhaps my opinion on the topic was misread, and that is my fault, my apologies. With all of the current pushing towards minority groups in the field of medicine, however, I am just mot sure as to how impoverished Americcam citizens may afford it, and that it my only qualm. Unfairenss in the health care system 🙁
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The unfairness that exists where those who are more productive have their money taken to fund everyone else? Or the unfairness that physicians want to be paid a market rate for their time?
 
In my opinion, politics and science should remain com
sb247 said:
The unfairness that exists where those who are more productive have their money taken to fund everyone else? Or the unfairness that physicians want to be paid a market rate for their time?
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could not have said it better myself. It seems that doctors have become the scapegoat for all society's modern-day qualms, which is not only unfair, but unjust.
 
theseeker4 said:
Why, exactly, is providing a service for a fee unethical? Or why do others argue that it is?
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Some junk about it creating a greater divide between haves and have-nots, inequity of care, physician obligation to society, etc. I think I'm all for free market in medicine, and I realize that my first post did not reflect that very well. Free market is fine when it benefits insurance companies but not when it benefits physicians? Something's wrong there.
 
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