ConciergePhysicians

One of the issues faced by doctors deciding to move into concierge medicine is whether their insurance companies will keep them on their panels. As we know, it is virtually impossible to predict what certain companies may do. A recent article in the Houston Chronicle sheds some light on what some companies in Texas are doing. Here are the first few sentences of the article that you can find at http://www.chron.com/disp/story.mpl/headline/biz/5618372.html “Doctors who charge an annual fee to patients in exchange for customized care including house calls are drawing the ire of some health insurance companies. United Healthcare confirmed it is dropping four local doctors from its network in April because the company disapproves of their so-called “concierge medicine” model. Cigna is also condemning the practice, in which physicians charge an annual retainer of $1,500 to $1,800 for patients who then receive more personal care. Cigna would not say whether it is dropping any Houston-area physicians, but spokeswoman Gwyn Dilday said, ‘Charging membership fees to guarantee access is a violation of our contract terms and may result in termination.’” 

Daniel Khani was feeling healthy, but he did have a medical problem or, rather, a problem with medicine: he thought he wasn’t getting enough of it. The basic physical he got each year was, well, basic. Khani, a wealthy real-estate investor, was accustomed to better treatment in the rest of his life. So in September, he went to the Concierge Medicine clinic in Los Angeles for what he considered the ultimate in medical care: the same kind the president gets. Go here for the full article.

If you consider the top five options noted in the report, with respect to anticipated revenue gains, this is a grim report which bodes ill for physicians and patients, effectively addressing in only one respect an urgent health care need.1. A center for medical effectiveness essentially marries data doctors have, about efficacy of treatments, to data on the cost of those treatments, which we don’t have. By making patients and physicians consider not just the benefit but the cost of a given treatment, and by increasing co-pays for treatments judged to be cost ineffective, the study projects the single largest savings — $368 billion over ten years. This is essentially rationed health care; I do think it’s coming, and it’s not going to be popular.2. By taxing sugar in sweetened drinks, the study projects savings of $283 billion, the next largest area of projected savings. Um, don’t bother. Obesity is by far the most important health care problem in the US. Effectively addressing it would save gobs of money. But any primary care physician will tell you the sugar in sweetened drinks is not even the tip of the iceberg that defines this problem. Obesity has to do above all with inadequate exercise, and that has to do with lots of things – depression, television, lack of discipline and abdication of personal responsibility, the burdens of working parents, the architecture of our towns and cities which abjure sidewalks for an extra lane on the road for cars, fast and processed food – I mean the list goes on and on. The consequences are devastating, including arthritis, diabetes, heart attacks, strokes, peripheral vascular disease, sleep apnea, insomnia and increased susceptibility to infection. The study is right to focus on this problem but wrong to suspect this feeble measure will make a difference.3. The next most valuable benefit comes from changing the basis for reimbursement from office or inpatient visits to a disease based model, ie, you’re paid a single amount for a given illness, regardless of the number of visits required to address the problem. Bad idea:
a. there are already incentives to limit the number of office or inpatient visits, in the forms of copays and the inherent limitations of time available for both patients and physicians;
b. there’s no way this model would accurately account for the varied needs of patients and would therefore encourage pruning from our practices the sickest patients. For instance, I see one patient about every two weeks, in my office. She has multiple medical problems, has a niece who lives nearby but who works two jobs and can’t pay her aunt the attention she needs, and I’ve found from hard experience that seeing this woman less frequently – let’s say once a month – results in hospitalizations to deal with the accumulated problems that have gone unaddressed. Switch this patient to an “episode of care” model and she’s in big trouble.4. Next comes a two dollar tax on cigarettes to reduce smoking, saving projected $191 billion. Good idea!5. Finally comes reducing reimbursements in high cost areas based on national averages, saving $158 billion. This is just a cost cut to physicians. Good luck with that and get ready for the increased attrition of doctors willing to accept Medicare.Overall, I think the study is discouraging and, from a primary care doctor’s perspective, all but ignores the single biggest area of potential savings – dealing with the awful consequences of our lack of daily sustained aerobic exercise – which by the way means an hour a day, seven days a week, on the treadmill, at four miles per hour or better. If you’re not doing that then stop fooling around, put on your sneakers and get going. And if you are doing that, guess what? You’re going to live a long healthy life, with relatively few incurred medical expenses. Joel Keenan

Here is what Keidi Dawley, writing for Medialife, had to say in this January 14th article: “Norman Rockwell thought so much of him that he drew him again and again through his long years as an illustrator famous for his iconic images of American life, and that he was, the family doctor.He was there on the corner, or the next block over, his offices a convenient walk. He delivered children, gave them their shots as they grew up, patched busted limbs, attended to the dying. He may have been ill-schooled–so much of the science of medicine didn’t exist 50 years ago–but he knew his patients and their families and what ailed them, giving the best advice he could from that knowledge. Then he was gone.A revolution in medicine came, and with it health plans and co-pays and HMOs, and with all of that assemblyline medicine. If it is the best in the world, as many argue, it’s also the most expensive, and at its root there is a lingering dissatisfaction over the sense that something had been lost. That’s individual care.Now the family doctor is returning. It’s an emerging approach to healthcare called variously concierge or boutique medicine, but in essence it’s old-fashioned family doctoring.For all the huge advances in medicine, especially in detecting illnesses at their earliest stages, a major flaw of assemblyline medicine is that it’s build to treat illness once it sets in. The aim of boutique medicine is to prevent illness, or better promote wellness, by reconnecting the patient with doctor who can read charts but also read his patients, truly knowing them, their histories, their family histories, and all the quirks of their bodies.”

See this new news article by David Gulliver yesterday in Sarasota’s HeraldTribune.com regarding the concierge practices in the Sarasota area.

An interesting article appeared in the November 12th issue of Business Week. Here’s the link to that article. The essence of the article is a report on the Commonwealth Fund’s recent study of the healthcare systems in seven countries, including the U.S. Their conclusion seems to be, based on patient surveys, that the U.S. is last in virtually all categories. As an example, 49% of U.S. respondents said that they could get same or next day appointments when they were sick, compared to 75% in New Zealand, 58% in Britain, and 65% in Germany. Only Canada (36%) was lower in this category. 34% of U.S. respondents said that the “system needs to be rebuilt completely,” compared to 18%, 15%, 12% (Canada), 27%, 9%, and 17% in the other six countries. Business Week points out that the other six countries surveyed have universal coverage but spend only half as much of their GDP on healthcare as does the U.S. See here the Centrist Policy Network’s thoughts about the Commonwealth Fund and its work.

Here’s a new post from a concierge physician, whose blog link has been added to the Blogroll (see conciergedoc):

“Ironically, I’m in the midst of starting our own retainer model practice, from scratch.  It’s actually along the lines of a hybrid model, where I am seeing both concierge patients, as well as traditional PPO,Medicare patients.  This way, I hope to have a better balance between the economics of startup and the downstream benefits of a retainer practice.  So far, we haven’t started really marketing the practice. But we are getting some patient’s from jsut word of mouth. The area the practice is in is fairly affluent and people to have higher expectations of service, which is also a reason why I think my practice will eventually have demand. However, I agree with the people above… there isn’t a line waiting to join…yet.  Maybe next year I’ll be at the conference. I did attend last year and found it very useful. I made some good contacts, including you John.”

See this blog posting at http://www.kevinmd.com/blog/2007/12/retainer-medicine-ethical-or-not.html

If you want some challenging and topical reading try this article published a couple of weeks ago by the Commonwealth Fund.

Jack Marquis

If you would like to post a message in prime, please send it to jmarquis@wnj.com and I’ll post it.

Thanks.

 Jack Marquis