April 14, 2014

Call the Concierge

My mother got a letter from her doctor this week informing her that he is going into “concierge medicine.” If she wants to keep him as her doctor—and she does (she’s 88 and has known him for years)—she will have to sign up for his new plan, paying a retainer fee of $3500 a year on top of what she pays for Medicare A, Medicare B, and Medicare D. I know what her doctor will get from this arrangement: if he succeeds in limiting his practice to 400 people, he will collect an additional $1.4 million of revenue a year, minus whatever he loses by shrinking the size of his panel. But what would my mother get?

According to the doctor’s letter, she would have more same-day appointments in case of emergency (though major emergencies still require a visit to a hospital emergency room), longer appointments (she's never felt short-changed by an appointment), and the opportunity to exchange emails with her physician (which she already does). She would also have the services of the doctor’s staff to help make appointments with specialists and to coordinate care (which the secretary does routinely)--this is presumably the “concierge” in the title of the practice. In short, the only reason for my mother to shell out a retainer fee of $300 every month is to be able to keep her current physician.

As is probably pretty clear, I don’t much care for this arrangement. Not only do I see little benefit for my mother, but I am also concerned it is creating a two tier medical care system, with one level for affluent people who can afford concierge medicine and one level for everyone else. And while there are ample examples of inequity in medical care today, the tendency is to try to remove disparities, not to create new ones. In addition, fee-for-service medicine in general and solo practice medicine in particular are widely reported to be on their way out—they have proved to be poor strategies for addressing the complex needs of today’s patients. Concierge medicine is a trend in the wrong direction. What’s going on here?

By all accounts, the first “concierge practice” was set up by two internists in Seattle in the mid 1990s. They were interested in having a small panel of patients with whom they could have a strong, personal relationship. Like all the doctors who have joined or established concierge practices since then, they wanted less stress and less burn out and they wanted to practice a more old-fashioned style of medicine, less driven by algorithms and protocols and with fewer forms to fill out. 

The appearance of concierge practices engendered some fairly heady criticism: one physician expressed concern that while such practices increase continuity of care for the minority of patients who stay in the practice, they increase discontinuity of care for those who leave and have to find care elsewhere.  He worried that these practices would undermine the cross-subsidization that is essential for universal coverage—the whole idea of insurance assumes that risks are shared across a large pool. Concierge practices are a form of cherry-picking patients. And shrinking patient panels could further exacerbate the shortage of primary care physicians. 

What we actually know about how many such practices there are and how they operate is based largely on two government-commissioned reports. A GAO report in 2005 found that there are several different types of concierge practice. There are the fee-for-extra-service models, which accept health insurance but offer something that conventional insurance doesn’t pay for (longer visits, more visits, round the clock physician access). There are the fee-for-care models, which do not accept health insurance and where the fee paid to the physician is supposed to cover care. And there are hybrid models, where physicians offer the patient a choice of either arrangement. The GAO found only 146 doctors with concierge practices in its survey. A MedPAC study (Medicare Payment Advisory Commission) in 2010 tried to determine if concierge practices were complying with Medicare rules  and whether they were adversely affecting the access of Medicare beneficiaries to care. This report identified 756 concierge practices, though they obtained estimates of anywhere between 1000 and 2500, nation-wide. It found the average panel size was 250, about a tenth that of the physician’s practice before he or she adopted the concierge model. MedPAC concluded that after 15 years of concierge practices, they remained a small niche and not a major threat to the viability of primary care.

To add to these reports, a recent survey of 13,500 physicians for the Physicians Foundation found that nearly 7% of respondents said they planned to switch to concierge model in the next 3 years. And another survey, this one by the Concierge Medicine Research Collective found that among physicians already practicing concierge medicine, 55% were very satisfied, 27% were somewhat satisfied and 18% were dissatisfied. The majority, but not everyone (62%) reported an increase in income. 

All these surveys, statistics, and ethical analyses pay relatively little attention to the root problem that is leading to the growth of concierge medicine. What does the very existence of this phenomenon say about the state of primary care? And what can be done to make both physicians and patients happier?

I suspect that the fundamental driver behind concierge medicine is the belief by many physicians that to do a good job caring for their patients, especially those with multiple medical problems or advanced illness, common characteristics of elderly patients, they have to spend a lot of time. And if they spend as much time as they feel is appropriate, they won’t be able to see as many patients as they do now and will therefore make far less income than they do now. If this analysis is correct, we need to ask: how much time do doctors really need to spend? Are they spending their time in the best possible way today? Do insurance company mandates to do various tests and fill our certain forms promote or hinder good care? What are the financial constraints under which they are working?

Now it seems to me that while time is one aspect of taking good care of patients, the real problem with primary care is that doctors need to do a better job sharing responsibility with physician extenders, patients, and their caregivers. Someone needs to make sure patients are adhering to the standard of care, say, for diabetes, by assuring they get appropriate foot care and the necessary eye exams--but it doesn't have to be a doctor; it could be a nurse. Someone needs to monitor chronic conditions, say weight in a patient with heart failure--but it could be the patient's spouse. Physicians need to spend more time on advance care planning (talking about what overall approach to care makes sense for a given patient) and less time on assuring tight control of diabetes in 85-year olds, where such control is probably not useful. The way forward is the team model used in geriatrics, palliative care, and HIV care, enhanced to include patients and patients' caregivers.

But primary care doctors are unlikely to pursue this path with current reimbursement rates. Geriatrics, palliative care, and HIV doctors are among the least well paid of any physicians. To help stimulate greater use of this model, compensation for primary care will need to rise and, in this era of cost-cutting, the only way that can happen is if specialty income falls. A 2013 report on physician compensation in the US found that the mean salary for an orthopedist is $405,000 (with many orthopedists earning considerably more than this), the mean salary for a cardiologist is $357,000 and the mean salary for a family physician is $175,000. Internists are paid only slightly more, at $185,000. Moreover, salaries for orthopedists have gone up by 27% and those of cardiologists by 13% since 2011, compared to salaries for family physicians, which have gone up only 5%. My proposal will encounter enormous resistance by the well-organized lobbies for subspecialty medicine. But it is an important first step.

If we want to stem the growth of concierge medicine—and I think we should—we will need to repair primary care.

1 comment:

Unknown said...

Dr. Gillick,
As always, you raise interesting and important points.

Re whether we can afford primary care, the recently released 2012 Medicare spending data revealed that we spent $12 billion on outpatient visits, out of $600 billion. In other words, 2%. (Of which I'm sure most went to specialists, not PCPs.)

Do you think there's any chance we can convince society to spend more on primary care?

Re geriatric team care, it's a wonderful thing but seems to me it's usually not financially viable, outside the setting of PACE (which leverages Medicaid money because the states are trying to avoid nursing home placements). Many geriatric team practices are subsidized by academic medical centers, grants, or philanthropy.

At some point, I hope you'll consider blogging about how we might make geriatric team care more financially feasible.

Thanks for your blog, it's terrific. best, leslie kernisan