New concierge doc mod­els fo­cus on em­ploy­ers, with some of­fer­ing spe­cial­ists

Modern Healthcare - - NEWS - By Steven Ross John­son

Dr. Louis Mali­now had be­come in­creas­ingly dis­sat­is­fied with the amount of time he had with pa­tients in his fam­ily medicine prac­tice in Bal­ti­more. He was rush­ing through as many as 30 pa­tients a day. “I knew there was a bet­ter way to prac­tice,” Mali­now said.

“That chronic state of worry about be­ing able to keep up with what was just a su­per­hu­man amount of work is now gone.”

Dr. Louis Mali­now

Driven by these con­cerns, Mali­now in 2008 shifted his prac­tice from a tra­di­tional in­sur­ance-based model to one where pa­tients pay him a flat an­nual fee of $1,500 to $1,800 for pri­mary-care ser­vices not typ­i­cally cov­ered by in­sur­ance. For that fee, he of­fers pre­ven­tive ser­vices, in­clud­ing com­pre­hen­sive screen­ings and di­ag­nos­tic ser­vices. He signed up with MDVIP, a Boca Ra­ton, Fla.-based concierge prac­tice firm that pro­vides ad­min­is­tra­tive sup­port to pri­mary-care doc­tors who work un­der re­tainer fee ar­range­ments, in ex­change for re­ceiv­ing a third of their re­tainer fees.

“I used to worry in the old days when I would come in with a packed sched­ule how I was go­ing to fit same-day vis­its in, stay on time, or deal with all of the phone calls,” Mali­now said. “That chronic state of worry about be­ing able to keep up with what was just a su­per­hu­man amount of work is now gone.”

While the num­ber of mostly pri­mary-care doc­tors in re­tainer-based ar­range­ments re­mains rel­a­tively small —about 6,000 across the U.S.—it has grown by as much as 25% over the past few years, ac­cord­ing to the Amer­i­can Academy of Pri­vate Physi­cians, which rep­re­sents concierge prac­tices.

Such growth oc­curs as the de­mand for pri­mary care is ris­ing, health sys­tems strug­gle to hire more pri­ma­rycare doc­tors and job sat­is­fac­tion among pri­mary-care spe­cial­ists is de­clin­ing. In March, the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges es­ti­mated that de­mand for pri­mary-care physi­cians would ex­ceed the sup­ply of doc­tors by 45,000 in 2020.

The first concierge prac­tices in the 1990s tar­geted high­in­come pa­tients who paid thou­sands of dol­lars a year for a per­sonal physi­cian avail­able any place and any time. But com­pa­nies such as MDVIP, Pal­ad­ina in Den­ver, Qliance in Seat­tle and MedLion in Ne­vada have tar­geted a broader con­sumer base by re­duc­ing the price point.

These com­pa­nies, some of which em­ploy staff physi­cians, of­fer en­hanced pre­ven­tive and well­ness care, same-day or next-day ap­point­ments, and longer vis­its to a mid­dle-in­come mar­ket. Some sys­tems, in­clud­ing Vir­ginia Ma­son Med­i­cal Cen­ter, Seat­tle; Scripps Health, San Diego; and UC San Diego Health have launched their own concierge prac­tices.

In ad­di­tion, some di­rect pri­mary-care providers are part­ner­ing with em­ploy­ers to im­prove work­force well­ness and re­duce healthcare costs. For in­stance, Pal­ad­ina Health con­tracts with em­ploy­ers to of­fer pri­mary-care ser­vices to work­ers. This model “al­lows pa­tients at all in­come lev­els to have ac­cess to such ser­vices,” said Jami Doucette, Pal­ad­ina’s leader for long-term growth.

Other providers, such as Bev­erly Hills, Calif.-based Lux Health Net­work, are go­ing be­yond pri­mary care, of­fer­ing ac­cess to a broader range of spe­cial­ists.

Fees for re­tainer-based care run from $80 a month to $25,000 a year, with most doc­tors charg­ing about $100 a month, ex­perts say. A typ­i­cal concierge physi­cian has about 600 pa­tients com­pared with the 2,500 or so pa­tients of a typ­i­cal pri­mary-care physi­cian. Mali­now said his typ­i­cal work­day con­sists of about eight ap­point­ments, in­clud­ing two to three longer vis­its that can run as long as two hours.

But some ex­perts warn that re­tainer-based prac­tices threaten to ex­ac­er­bate the pri­mary-care physi­cian squeeze, given that concierge doc­tors see far fewer pa­tients. Carolyn En­gel­hard, as­so­ciate di­rec­tor of the Cen­ter for Health Pol­icy at the Univer­sity of Vir­ginia School of Medicine, said re­tainer-based medicine cre­ates a two-tiered sys­tem of healthcare, where high­er­in­come Amer­i­cans have bet­ter ac­cess to care. “What di­rect pri­mary care does is re­duce pa­tient pan­els a lot,” she said. “Where are those other pa­tients go­ing to go?”

Some physi­cians say concierge medicine has re­duced the ad­min­is­tra­tive bur­dens and costs in­volved in deal­ing with in­sur­ance, in­creased their abil­ity to serve their pa­tients, and im­proved their in­comes and qual­ity of pro­fes­sional life. Re­tainer-based physi­cians of­ten are able to main­tain and in some cases boost their in­come com­pared with the tra­di­tional prac­tice model, said Michael Te­treault, editor-in-chief of Concierge Medicine To­day, an in­dus­try trade pub­li­ca­tion.

There are sev­eral types of re­tainer-based prac­tice, in­clud­ing full concierge medicine for more af­flu­ent pa­tients, di­rect pri­mary care and a hy­brid model where doc­tors of­fer tra­di­tional ser­vices and a concierge op­tion for some pa­tients. In some mod­els, the re­tainer fee cov­ers most or all pri­mary-care ser­vices and doc­tors do not bill in­sur­ance. In other mod­els, the fee cov­ers ex­tras such as an an­nual phys­i­cal while the pa­tient and in­surer con­tinue to pay for other ser­vices.

Ser­vices gen­er­ally in­clude en­hanced ac­cess to physi­cians, some­times even 24/7; in-depth, ex­ec­u­tive-style phys­i­cal ex­ams; same-day or next-day ap­point­ments; ready physi­cian ac­cess via e-mail; and longer vis­its. Some of these prac­tices ac­cept pri­vate in­sur­ance and Medi­care, while oth­ers do not.

“To­day, there are more doc­tors and more con­sumers in­ter­ested and will­ing to do this,” said Bret Jor­gensen, chair­man and CEO of MDVIP. “It’s still a small per­cent­age of the mar­ket but it’s grow­ing, and it’s an im­por­tant al­ter­na­tive for a lot of con­sumers.”

“The con­sumer au­di­ence for pri­vate medicine is be­gin­ning to ex­pand fairly dra­mat­i­cally where once this was sort of a ser­vice cat­e­gory that was most ap­peal­ing to wealth­ier se­niors,” said Tom Blue, chief strat­egy of­fi­cer for the Amer­i­can Academy of Pri­vate Physi­cians. “Leg­isla­tively, the cli­mate for pri­vate medicine is only get­ting more friendly,” he added.

In Au­gust, Sen. Bill Cas­sidy (R-La.), a physi­cian, in­tro­duced leg­is­la­tion to al­low peo­ple to pay fees for di­rect pri­mary-care ser­vices through tax-ad­van­taged health sav­ings ac­counts. His bill would also al­low Medi­care to pay re­tainer-based prac­tices a flat fee for pri­mary-care ser­vices and let Medi­care Ad­van­tage plans con­tract with di­rect pri­mary-care prac­tices.

But En­gel­hard ques­tions whether ser­vices such as ex­ec­u­tive-style phys­i­cal ex­ams with a bat­tery of test­ing re­ally im­prove qual­ity of care, and whether conciergestyle prac­tice re­duces care co­or­di­na­tion. “Sure, it would be won­der­ful to know you could get in and see your physi­cian the same day you wake up and have the flu,” En­gel­hard said. “But on the other hand, you’re out of a co­or­di­nated net­work. You can’t rely on that physi­cian to have ad­mit­ting priv­i­leges in the hos­pi­tal, or to even talk to peo­ple in the hos­pi­tal on your be­half.”

There also are le­gal and reg­u­la­tory chal­lenges for concierge physi­cians. They face lim­its on the ser­vices they can pro­vide if they want to re­ceive pri­vate in­sur­ance or Medi­care pay­ments. More than 60% of concierge providers re­ceive such in­sur­ance pay­ments. Fed­eral rules bar doc­tors from charg­ing Medi­care ben­e­fi­cia­ries for the same ser­vices that are cov­ered by the pro­gram.

In some states, there are ques­tions about whether di­rect pri­mary-care prac­tices func­tion as health in­sur­ers and should be reg­u­lated as in­sur­ers. But Blue said more state reg­u­la­tors have de­cided not to de­fine di­rect pri­mary-care ar­range­ments as in­sur­ance prod­ucts.

Another is­sue is that di­rect pri­mary-care plans are not deemed qual­i­fied health plans un­der the Af­ford­able Care Act pro­vi­sion re­quir­ing nearly all Amer­i­cans to ob­tain com­pre­hen­sive in­sur­ance. The law al­lows di­rect pri­mary-care ser­vices to be of­fered through the ACA in­sur­ance ex­changes only in con­junc­tion with qual­i­fied high-de­ductible health plans.

But En­gel­hard said buy­ing both di­rect pri­mary-care ser­vices and a high-de­ductible plan can be ex­pen­sive. That’s why Cas­sidy is push­ing to let peo­ple pay for their pri­ma­rycare plan through an HSA. En­gel­hard said in­sur­ers would pre­fer to see lim­its on re­tainer-based medicine be­cause they see such ar­range­ments as com­pe­ti­tion for cus­tomers.

Still, some re­tainer-based prac­tices want to con­tract with in­sur­ers, ar­gu­ing their fo­cus on well­ness and preven­tion helps pa­tients bet­ter man­age their health con­di­tions, re­duc­ing emer­gency room vis­its and hos­pi­tal­iza­tions. MDVIP’s Jor­gensen said con­sumers ben­e­fit in terms of health while in­sur­ers ben­e­fit in terms of cost sav­ings.

When Mali­now tran­si­tioned into his concierge prac­tice, Bal­ti­more at­tor­ney Howard Kur­man, now 64, was one of his pa­tients who agreed to pay the an­nual mem­ber­ship fee of $1,500 to keep see­ing him. “If you have a 9 a.m. ap­point­ment, you’re go­ing to be seen at 9 a.m. You’re not in a wait­ing room for an hour or two,” Kur­man said. “It’s a very ef­fi­cient prac­tice, it’s very re­spon­sive, and from a pa­tient’s stand­point, it’s very user-friendly.”

Sup­port­ers say re­tainer-based mod­els al­low prac­ti­tion­ers to bet­ter en­gage with pa­tients and coun­sel them on lifestyle is­sues such as obe­sity and smok­ing. Hav­ing those of­ten-lengthy talks was dif­fi­cult un­der the tra­di­tional fee-for-ser­vice model, which re­quired them to see as many pa­tients as pos­si­ble.

Pal­ad­ina was started in 2012 by DaVita HealthCare Part­ners af­ter DaVita ac­quired di­rect pri­mary-care prac­tice ModernMed, which pro­vided on-site and near-site clin­ics for em­ploy­ers. Pal­ad­ina claims a pa­tient-sat­is­fac­tion rate of more than 90%, with 77% of pa­tients sur­veyed re­port­ing they felt their health had im­proved af­ter see­ing a di­rect pri­mary-care physi­cian.

In Au­gust, Lux Health Net­work launched the first mul­ti­spe­cialty concierge physi­cian prac­tice, which of­fers care co­or­di­na­tion through its net­work of 40 physi­cians. For an an­nual fee of $7,500, Lux pa­tients can get same-day ap­point­ments to see a pri­ma­rycare physi­cian, who can re­fer them to a spe­cial­ist in the net­work for a next-day ap­point­ment. “A lot of pa­tients are sign­ing up for concierge medicine just for pri­mary care,” said Lux CEO Akiva Green­field. “We thought there would be a mar­ket for the same level of VIP care across ev­ery spe­cialty.”

The po­ten­tial im­pact of re­tainer-based medicine on the broader U.S. healthcare sys­tem de­pends on how much the sec­tor grows. De­spite in­creased in­ter­est, Wayne Lip­ton, man­ag­ing part­ner and founder of Concierge Choice Physi­cians, a New York-based concierge firm, said the per­cent­age of doc­tors en­ter­ing concierge-style prac­tice re­mains rel­a­tively small. But it’s pro­vided com­pe­ti­tion to the tra­di­tional prac­tice model rather than dis­rupt­ing the sys­tem, he said.

“I’m a re­al­ist,” said Lip­ton, whose com­pany of­fers a hy­brid model in which its doc­tors see both concierge and non­concierge pa­tients. “If we took all of the best doc­tors and turned them into full concierge doc­tors, it would cre­ate an eco­nomic bar­rier to (ex­cel­lent care). But in fact that is just not the case.”

“Leg­isla­tively, the cli­mate for pri­vate medicine is only get­ting more friendly.” Tom Blue, chief strat­egy of­fi­cer for the Amer­i­can Academy of Pri­vate Physi­cians

In some states, there are ques­tions about whether di­rect pri­mary-care prac­tices func­tion as health in­sur­ers and should be reg­u­lated as in­sur­ers.

Dr. Louis Mali­now switched his Bal­ti­more med­i­cal prac­tice from a tra­di­tional in­sur­ance-based model to a concierge prac­tice, al­low­ing him to spend more time with pa­tients.

Dr. Lewis Weiner, a Providence, R.I.-based MDVIPaf­fil­i­ated physi­cian, vis­its with a pa­tient.

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