January 10, 2012
Paying for an open medical door
Michael Campagna finally had enough of the jammed waiting room at the orthopedic surgeon’s office, the rapid-fire exams once he got in and the lack of results with his chronic ankle and knee problems. He’d gone 25 years without health insurance, got it shortly before a motorcycle accident, then wondered why he’d bothered.
“It was a nightmare,” he said of the three-month regimen of twice monthly visits in Alexandria, Virginia. So he entered a small but fast-growing segment of American health care, paying US$1500 a year to see a doctor who offers a “personalized” approach known as concierge medicine.
Now the waiting room he visits has two chairs, one for him and another empty. Instead of seven minutes with the doctor, he gets at least 30, plus email consultations day and night, an annual physical lasting 2.5 hours, appointments within 24 hours, follow-up when he’s referred to a specialist and an intense focus on preventive care. “It’s like old times,” says Campagna, in his mid-60s, “when the family knew the doctor and we had house calls. … This allows a doctor to be a good doctor. It unleashes the inner doctor.”
The personalized approach is variously known as direct care or retainer-based, membership or even cash-only medicine, and involves a “direct” financial relationship between a patient and a physician in the form of an annual or monthly fee. It’s typically charged for some manner of additional care in addition to the fees charged for the normal procedures that are provided. Some providers of concierge medicine do not accept insurance of any manner, whether private or from the government under the federal Medicare and Medicaid programs for the elderly and poor respectively. They’re cash-only (or cheque or credit card) but are still considered concierge if they charge a monthly or annual fee, instead of, or in addition to, the fees they charge for each medical procedure they perform. Most providers of concierge medicine, however, accept insurance. But the fee for retaining the concierge doctor comes out of the patient’s pocket.
For patients, the appeal is more ready access, while for physicians, the lure appears to be a lighter workload. A Congressional advisory committee found that the number of concierge physicians had risen fivefold between 2005 and 2010 to more than 750. Those doctors were serving 100 to 425 patients each, down from more than 2000 they saw while working in a traditional practice. Most were internal medicine specialists or family physicians
Many fear the growth of concierge medicine, should it continue apace, will exacerbate the growth of a two-tiered system under which attentive physicians delivering quality care are available primarily to the well-heeled. But proponents argue that it was ever thus and that concierge medicine is increasingly becoming more affordable to the middle class, even if it does constitute a substantial hit on their wallets.
Although annual fees are increasingly being charged by Canadian physicians, they are typically for services not covered by Medicare plans, such as providing proof of a visit to the doctor’s office or providing an expert opinion Some Canadian physicians now charge an annual administration (block) fee that covers immunizations, completion of medical forms, photocopying of files and returning calls.
The growth of concierge medicine in the United States has left the chairman of the MedPAC advisory committee, Glenn Hackbarth, fretting about the potential impact on access to primary care for the average American. Many doctors could bail from Medicare completely in favour of a concierge practice, he once told a public hearing . “There’s too much money to pass up,” he said. And the result could be a “dramatic erosion in access in a very short period of time” in traditional care, particularly Medicare. “So that’s my nightmare.”
Critics of concierge medicine say that it’s essentially a cash grab by physicians, who are being paid a hefty premium to do the job they are supposed to do anyway.
But advocates say that it’s not quite so cut and dried, particularly when it comes to physician workloads. As the population ages and President Barack Obama’s health care reforms expand access to care for millions more people, practitioners are racing to keep up and sometimes getting burned out. Exasperated by rising costs and complex regulations, physicians appear to be abandoning private practice in droves, with many opting to work for hospitals or large networks instead.
Among those left in traditional care, concierge medicine has become very tempting. “As the doctor shortage worsens, you see family docs step out and go into concierge medicine,” says Dr. Doug Pittman, a family and sports medicine practitioner in Whitefish, Montana, in the heart of ski country five hours south of Calgary, Alberta. “It’s the closest thing to a primary doctor strike. We are withdrawing because we can’t get paid for what we do, and our patients are going to outlive us because we are killing ourselves to try to keep up.”
Pittman switched to concierge medicine in 2009 after family practice left him stressed and bored. “All I was doing was putting out fires.” Instead of seeing 25 patients daily, he’s limited his practice to 100 patients overall. He charges each $1900 for a year’s services. Married couples get a discount ($3400), while snowbirds who are gone for the winter pay $1300 apiece or $2500 per couple. Pittman also throws in “scholarships” to cut the fee to $1100 for some older patients, teachers and folks who work on the mountain.
Instead of seeing patients for eight minutes, each now gets 80 minutes, he says. “You have control of everything. I answer the phone, take out the garbage. No matter where I am, they can get a hold of me.”
“It restores a physician’s independence, and you get paid an equitable wage for what you’re doing, preventing illness. It allowed me to pursue the type of medicine that I did the first 10 or so years.”
It also results in improved care, says Dr. Floyd Russak, an internal and geriatric physician in Denver, Colorado, who runs a personalized practice limited to 300 patients paying $1000 to $1500 annually. Russak had been seeing 30 to 40 patients a day and decided to “get off the hamster wheel” in 2010 because he felt he wasn’t “doing an exceptionally good job with any of them.”
His clients now get a half hour of his time during a routine visit and round-the-clock access. If they go to the hospital, so does Russak. “For patients that can afford it, it’s much better care,” he says.
There’s no question the care is improved, claims the California-based SignatureMD, a network of concierge practices involving 50 doctors in 14 states which was launched seven years ago. “The goal was to create a more direct relationship between patient and physician, a more direct financial relationship which facilitates better health care,” says CEO Matt Jacobson.
Is it elitist?
Not in Jacobson’s mind. “Should we send our kids to private school if that’s something we value?” he asks. “Some people put value on health care, and want to put investment in health care. We have a democratic society.”
For its part, the American Medical Association’s stance on concierge medicine is equivocal. On the one hand, it offers advice on establishing a concierge practice. But its code of ethics suggests that the quality of care should not be dependent on a patient’s ability to pay extra fees .
“Physicians have a professional obligation to provide care to those in need, regardless of ability to pay, particularly to those in need of urgent care,” the code states. “Physicians who engage in retainer practices should seek specific opportunities to fulfill this obligation.”
