Concierge Medicine

[Doctor Grim]

Putting the ethical issues aside (seeing only patients who can afford to see you), how realistic is it to start a practice like this for primary care?

When I was interviewing for a job last year, one of the medical directors I met in a group practice was doing this on the side. Because his concierge practice had picked up so many patients, he decided he just wanted to do part time and eventually leave and hence they needed to hire a new physician.

Well, he told me that he had 250 patients in his concierge practice and each patient pays $200/mo. So that was $50K per month-CASH. He didn't deal with insurance at all and his patients had access to him 24 hrs per day. Because his patients were all "white collar" managerial, high exective type, he wasn't worried about people calling him at night, unless it was an emergency, because his patients all "had a life." His patient population was mainly 40-65. And once they have Medicare, he no longer sees them.

There are also Integrative Medicine Services that I came across that basically charges a fee for service and are also quite successful. They absolutely do not do any primary care and again, they don't deal with insurance companies. Initial visits would be $350/hr and any follow ups would be $250/hr-CASH. And quite a few of them have a waiting list of about 2-3 mo because they can only see a limited number of people per day.

So my question is, are these types of successful practices hard to establish in today's practice environment? There is a lot of money that can be made if it is designed properly...

Any ideas? What are some of the obstacles or difficulties?

---

Members don't see this ad.

 

[deleted87716]

We've had several threads on that subject here before. Here are a few:

http://forums.studentdoctor.net/showthread.php?t=283610

http://forums.studentdoctor.net/showthread.php?t=360272

http://forums.studentdoctor.net/showthread.php?t=135751

http://forums.studentdoctor.net/showthread.php?t=245368

They contain not only discussion, but also several links to relevant articles that should help answer your questions.

 

[Old_Mil]

Any ideas? What are some of the obstacles or difficulties?

If you're the right person in the right market, I think such a setup could be very successful. In addition to being a good technician, you'd have to be a person with a great deal of individual charisma in a relatively wealthy-but-underserved part of the world.

 

[Good Solutions]

There are no ethical elements to concierge medicine. Concierge medicine is a horrible name for it. It is medicine in its original form, the patient and physician. The real question isn't, "Is this feasible?" The real question is how much risk are you willing to take and how do you want your practice to be set up?

These direct practices are the future of primary care.

 

[andwhat]

There are no ethical elements to concierge medicine. Concierge medicine is a horrible name for it. It is medicine in its original form, the patient and physician. The real question isn't, "Is this feasible?" The real question is how much risk are you willing to take and how do you want your practice to be set up?

These direct practices are the future of primary care.

up to 65 and didn't call him at night? wellllll ummmmm errr...

 

[DrJosephKim]

I've read about some interesting stories on Sermo. You may want to take a look as well.

 

[LaGrelius]

I am the president of SIMPD, the national society of direct practrice and concierge doctors. I came across your forum and decided to join and comment on this thread. I practice concierge medicine in Torrance, CA and am also a clinical instructor of family medicine at USC.

Many of the problems of high cost and poor access have to do with the virtual destruction of primary care over the past forty years. That resulted from well intentioned but misguided activities of government, employers and some insurance companies hoping to “fix” health care without ever asking doctors and patients in the trenches how that might be done. The beginning of a solution is the restoration of adequate primary care. The question is how to do this.

Most now agree that patient centered primary care medical homes for all Americans are indeed the solution, but how do we pay for them? Thousands of doctors have learned the way to do just that. By limiting our practice size to 1000 patients or less and charging a periodic fee around $100 per month to each of these patients directly (direct practice) the patient centered primary care medical home becomes a vibrant reality. I know. I run one and have the honor of heading a national organization of doctors who run such direct practices.

Most of these practices are very affordable to 90% of Americans, costing far less then Americans spend on trivialities. There are no ethical negatives to direct primary care practice in my opinion. I do wonder about the ethics of taking on too many patients, spending only seven minutes with each of them after an hour wait in a packed waiting room, failing to follow patients when hospitalized and failing to be accesable as most primary care doctors now are. These behaviors are part of the reason we make so many errors that kill so many patients and cause so many malpractice actions. The fact is, not one single concierge doctor has every had a malpractice action filed to date. There is good reason for that fact.

In these practices patients are seen immediately when ill, on time and at length. They stop going to emergency rooms because they can find their doctor and get care from him or her directly at any time 24/7/365. Our data demonstrates up to 80% reductions in hospitalizations, which if applied to all Americans would mean our hospitals would work again without having to build more ER rooms and inpatient beds. This results in huge savings.

Most patients today with multiple medical problems have multiple doctors, one for each problem. Direct practice primary care medical homes take care of most of these problems in one place and all at once, eliminating the need for many of these consultants entirely and reducing the frequency of visits to many more, resulting again in more huge savings, better care and coordinated care.

Students who see how cheerful, well paid and professionally fulfilled are such direct practice doctors gain hope that they too can have such a practice. My last USC family practice clerk is now and FP resident.

We need 400,000 such practices if we are to care for our population properly. Currently the numbers of primary care doctors are rapidly dwindling to below 300,000 of which 150,000 may quit in frustration in the next few years. Only eight percent of medical students elect any primary care pathway. Not long ago that figure was 50%. Short of coercion no system except direct practice primary care medical homes will draw the students we need.

I would be happy to discuss this with anyone at any time and am willing to give pesentations to medical students almost anywhere or send one of our SIMPD Board members. I have my own airplane and love to fly.

My national organization SIMPD is having its annual meeting at the Marina Marriott Hotel in San Diego May 6-9 and I invite you to come to discuss these ideas. One of our board members Steven Knope, MD recently authored an excellent book titled "Concierge Medicine--The New System to Get the Best Healthcare" and I recommend it to you highly.

Check out and study the SIMPD web site. It is packed with information. Also check out the web sites of our members there linked. They are packed with even more information.

Sincerely,

Thomas W. LaGrelius, MD, FAAFP
President SIMPD, The Society for Innovative Medical Practice Design, http://www.simpd.org
Owner, Skypark Preferred Family Care, Torrance , CA http://www.skyparkpfc.com

 

[secretwave101]

Two of our grads tried to do this...cash only, and ended up groveling at the feet of Mr. Insurance Man within 6 months. There simply aren't many people who want to pay $100/month on their health care. Never mind that they pay at least $80 on cell phones.

Bottom line in my experience (above commercial notwithstanding):

Concierge medicine - Bel Air, not Brooklyn.

 

[Good Solutions]

LaGrelius' speech is anything but a commercial. It is good info to let the word out that primary care docs don't need to peddle lasers and botox. It shows people that primary care can a wonderful specialty with autonomy, respect, income, and improve patient outcomes all at the same time.

Yes, people will fail, but the question we should be asking is why? These practices take anywhere from a year to seven to reach capacity. Did they go 'big' too soon? Did they buy too much office space? Hire too much staff? Did they help to explain that HSAs are a good means to pay for these practices? There are a lot of ways to mitigate the risk and increase viability.

More details are needed.

 

[secretwave101]

LaGrelius' speech is anything but a commercial.

Fair enough. I spent some time on the website and although he is promoting his group, I'm glad the info made it into the thread. I would LOVE for this to work. I may see if our residency program will have him come talk to us, since we do a career day at the end of each year.

Somebody's gotta fix primary care medicine. Maybe this is the answer.

 

[Manicsleep]

Two of our grads tried to do this...cash only, and ended up groveling at the feet of Mr. Insurance Man within 6 months. There simply aren't many people who want to pay $100/month on their health care. Never mind that they pay at least $80 on cell phones.

Bottom line in my experience (above commercial notwithstanding):

Concierge medicine - Bel Air, not Brooklyn.

The cash only part is tough. It has been a year for us now and we started out with of our PCPs doing concierge and moved to 2 by January (total 6 providers, 2 of which were midlevels). We continue to take insurance however and also had initial financial support.

We have also created a 'plus' model for every physician, without reducing panel sizes, that costs 50 dollars a month and have gotten a decent number of patients to sign on. Their after hours person is an NP however. We will eventually move all these patients to 1 PCP plus NP with a mid sized panel. We are trying to figure out a way to expand this 'plus' model to mental health as well.

However, I think brooklyn or bel air. Doesn't matter. We are in a middle class area. Not upper middle and definitely not bel air.

 

[deleted87716]

We have also created a 'plus' model for every physician, without reducing panel sizes, that costs 50 dollars a month and have gotten a decent number of patients to sign on.

Re: the "plus program," what do patients get for their $600/year that insurance doesn't cover?

I should add that having a "split" practice where a subset of any given physician's patients are enrolled in a "plus program" but others aren't creates an obvious disparity, and potential medicolegal issues. You don't want to create the perception that you're "holding back" in terms of the type of care you deliver to anyone based on their ability to pay.

Every patient in the practice should receive the same level of care. If you're going do concierge/retainer medicine, you need to do it 100%.

 

[digitlnoize]

Re: the "plus program," what do patients get for their $600/year that insurance doesn't cover?

I should add that having a "split" practice where a subset of any given physician's patients are enrolled in a "plus program" but others aren't creates an obvious disparity, and potential medicolegal issues. You don't want to create the perception that you're "holding back" in terms of the type of care you deliver to anyone based on their ability to pay.

Every patient in the practice should receive the same level of care. If you're going do concierge/retainer medicine, you need to do it 100%.

I'm guessing it's some combo of the usual: 24hr doc access, longer appointments, next day appointments, no waiting times in the office, perhaps a cushier waiting room with refreshments of some kind...

I'd like to know the real answer too though...

 

[JackADeli]

...charging a periodic fee around $100 per month to each of these patients directly (direct practice)...

Most of these practices are very affordable to 90% of Americans, costing far less then Americans spend on trivialities...

I have to agree in this respect. We continue to send a message of ~entitlement to free care. It is troubling to see how much our patients spend in tobacco and alcohol per year. How about the amount spent to enroll kids in every kids league for the year and accompanying gear (football, softball, soccer, baseball, etc...)? How about the cost of premium cable or direct TV? How about "pimping" their cars? How about nail salons and hair appointments? I always love to see the "poor patient" that comes in with $100 dollar french manicures and etc....

We are in a "recession". Yet, every new release iPhone goes on wait list with lines of people. The iPad was also back ordered. The Xbox and play stations.... back ordered.

Our patients need the message to invest in their own healthcare and consider it a priority. They will get the quality they pay for... they just need the message that they need to start paying for it!

PS: the current tariffs and taxes far exceed in most cases the $100/month model. A vast majority of those that went uninsured did so because they had other "priorities" that they "preferred" to spend their money on....

 

[JackADeli]

Just caught part of Judge Judy..... plaintiff upset, wants money back for a $500 Brazilian hair weave.... that if the weave worked perfectly, it would only last 3-4 months!

 

[MJB]

seeing only patients who can afford to see you

Now...don't get me wrong as I'm all about helping those in need...but why and when did the above statement become so taboo in medicine.

It isn't like the plumber is going to cut you a break just cause you're poor....

and the lawyers don't wanna cut me a break on the 1500 dollar bill for "drawing up a will" to protect my 6 month old son's interests and care in the event his mother and I die....even though I'm a medical student already 200K + in debt...

 

[MedMan25]

and the lawyers don't wanna cut me a break on the 1500 dollar bill for "drawing up a will" to protect my 6 month old son's interests and care in the event his mother and I die....even though I'm a medical student already 200K + in debt...

A little off topic but you can get a will written up and notarized without a lawyer. Even with a child in the picture, if you have relatively few assets to deal with you could easily get it done for less than $100

 

[JackADeli]

Now...don't get me wrong as I'm all about helping those in need...but why and when did the above statement become so taboo in medicine.

It isn't like the plumber is going to cut you a break just cause you're poor....

and the lawyers don't wanna cut me a break on the 1500 dollar bill for "drawing up a will" to protect my 6 month old son's interests and care in the event his mother and I die....even though I'm a medical student already 200K + in debt...

Yep. This self-sacrifice, servitude model seems to only apply to physicians. we have so undervalued ourselves to the point that patients find more value in their hair stylist then they find in us. We need to get over this facade of being so cheritable with limited financial motives.

Take a look at the healthcare industry.... yes, it is an industry, a business! The people that are taking the "high road" of compassion and the cuts .... physicians. The insurance companies, the pharma companies, congress, lawyers, etc.... make huge bank out of this industry. But, they are all quick to try and point out how noble and self sacrificing the physicians are and how they are "answering a higher calling"!.... that is until we ask for more income. Then we are greedy. Then they rally the troops to engage the ~class warfare arguments of how over paid we are. I can't tell you how many interviews I have been on in which the whole "nobility" sales pitch is dripping from the CEO's walls. They go on and on about how much charity work that I can provide and how the hospital is all about community need and "we will help support your giving back to the community". Wake up. We are being duped into social obligation so these individuals can milk the system.

Yes, I care. Yes, I do charity work. But, I am not going to buy this game that while I work only the administration, politicians, lawyers, and other components of industry can profit.... because somehow I am too noble to get paid?

 

[deleted87716]

I'm guessing it's some combo of the usual: 24hr doc access, longer appointments, next day appointments, no waiting times in the office, perhaps a cushier waiting room with refreshments of some kind...

I'd like to know the real answer too though...

I know an ophthalmologist who identified some of her patients as "VIPs" by using a red chart folder. She stopped doing this on the advice of her risk management folks. Again, creating intentional disparity in the level of care you provide is asking for trouble.

 

[MedMan25]

...

 

[rjmn]

.

 

[Slack3r]

Yes, I care. Yes, I do charity work. But, I am not going to buy this game that while I work only the administration, politicians, lawyers, and other components of industry can profit.... because somehow I am too noble to get paid?

Charity ceases to become charity at the point of a gun.

 

[JaggerPlate]

Yep. This self-sacrifice, servitude model seems to only apply to physicians. we have so undervalued ourselves to the point that patients find more value in their hair stylist then they find in us. We need to get over this facade of being so cheritable with limited financial motives.

Take a look at the healthcare industry.... yes, it is an industry, a business! The people that are taking the "high road" of compassion and the cuts .... physicians. The insurance companies, the pharma companies, congress, lawyers, etc.... make huge bank out of this industry. But, they are all quick to try and point out how noble and self sacrificing the physicians are and how they are "answering a higher calling"!.... that is until we ask for more income. Then we are greedy. Then they rally the troops to engage the ~class warfare arguments of how over paid we are. I can't tell you how many interviews I have been on in which the whole "nobility" sales pitch is dripping from the CEO's walls. They go on and on about how much charity work that I can provide and how the hospital is all about community need and "we will help support your giving back to the community". Wake up. We are being duped into social obligation so these individuals can milk the system.

Yes, I care. Yes, I do charity work. But, I am not going to buy this game that while I work only the administration, politicians, lawyers, and other components of industry can profit.... because somehow I am too noble to get paid?

 

[TypeADoctor]

I'm only just starting to learn about concierge medicine. But when you sign up a patient do you give them a set of disclaimers? I mean if you set up an office, got yourself set up with some EMR and such, but you can only take care of so much. Do you tell your patients you can't treat everything, such as appendicitis, retropharyngeal abscess, ect..? I know that people are paying for convenience and so they know they are to carry insurance to cover emergencies and surgeries?

And what about labs, would someone contract out with a stand alone lab?

Do you invest in a digital x-ray machine and if so do you charge extra for an x-ray?

How far do most take these concierge clinics/practices?

 

[deleted87716]

I'm only just starting to learn about concierge medicine. But when you sign up a patient do you give them a set of disclaimers? I mean if you set up an office, got yourself set up with some EMR and such, but you can only take care of so much. Do you tell your patients you can't treat everything, such as appendicitis, retropharyngeal abscess, ect..? I know that people are paying for convenience and so they know they are to carry insurance to cover emergencies and surgeries?

And what about labs, would someone contract out with a stand alone lab?

Do you invest in a digital x-ray machine and if so do you charge extra for an x-ray?

How far do most take these concierge clinics/practices?

See links therein:
http://forums.studentdoctor.net/showthread.php?t=360272&highlight=Concierge