May 21, 2013

Ante Up for Concierge Medicine? Three Key Questions and My Decision

As I've mentioned, I face a decision: whether to continue with my longtime internist now that he is converting to concierge practice, a subscription-based arrangement available for a $1,500 annual fee. If you haven't already, you may well need to make a similar choice soon. More and more internists, especially senior doctors, are shifting to concierge medicine.

It hasn't been an easy decision. But I've benefited from your blog comments, emails, phone calls, and personal chats. In making my decision, I focused on the three questions:

1. Can I Afford It?
This is the threshold issue. Fortunately for me, it's the easiest question to answer. Yes, I can afford it.

For many others, this issue isn't so easily dismissed. Coughing up an extra $1,500 or more every year can be difficult. And remember: under these arrangements, you will still pay the usual charges for all office visits.

Those who can't afford it will need to find another doctor at a time when there is already a shortage of internists. That squeeze will only get tighter when the Affordable Care Act ("ObamaCare") offers medical insurance to about 30 million people who are now uninsured.

2. Are the Extras Worth the Fee?
"There's little value added. It's a rip-off." That was the assessment I got from an astute, knowledgeable friend . . . and I'm inclined to agree. Here are some of the "extras" I'd get as my internist's brochure described them:
  • An expanded physical of up to 90 minutes. One of the many things I like about my internist is that he already allows plenty of time to talk about my health concerns and offer advice. I don't need more time. Nor do I think I need more tests as part of my physical. Many health authorities are questioning the need for annual physicals. A Danish research team found no benefit to the risk of death or serious illness among apparently healthy people who had general checkups compared to those who did not. The American Academy of Family Physicians itself has recommended against routine annual EKG screenings of asymptomatic patients -- a screening I've been getting every year as part of my annual physical. Sounds like my "less is more" mantra applies here.
  • Cutting-edge, Web-based research in any area of health concerns. I enjoy doing my own online investigations. The concierge brochure gives as an example of this benefit the use of a drug-interaction model to check on how my various medications interact. I showed the description of this model to my CVS pharmacist, who said it was the same model they use. Just this week, she informed me a pain medication my internist prescribed showed a potential interaction with my Parkinson's medications (which are known to my internist).
  • "You will continue to have 24/7 access to the on-call doctor" at my internist's group and "every effort will be made to contact your personal doctor 24/7 for assistance with serious medical problems" As the word "continue" suggests, I think I already have this benefit.
  • A secure internet site for e-mail communication with your doctor. This I like!
  • An electronic summary of your health records on both a thumb drive and a secure internet site. This is also a nice addition. 
So there are a few features I like . . . but are they worth $1500? Not to me.

3. What Value Do I Assign To Sticking with My Current Internist?
For me, this is the key question. For us seniors, answering that question depends to a large extent on the answer to another crucial question:
How good a diagnostician is my internist?
As we age, what we need most are really good diagnosticians. My internist has been pretty good on this issue over the years, but he missed the big one. Four years ago, I reported losing my sense of smell, an early warning sign of Parkinson's Disease. He essentially suggested that I not worry about it. A year or two later, I reported that my right arm wasn't swinging as freely as my left (another PD sign). Again, "not to worry."  Then I told him I was having trouble keeping my balance. He gave me a prescription to see a good physical therapist, who I now realize quickly recognized that I might have Parkinson's, since at almost every session he'd ask: "Have you told your doctor about your right arm not swinging?"

Eventually, my kids persuaded me to see a neurologist about my stiff right arm, and the Parkinson's was diagnosed. Actually, I'm not annoyed about the diagnosis delay. I'm not sure earlier treatment would have made much difference. Yes, I might have begun taking the Parkinson's meds sooner, but their side effects become more serious the longer you take them. And if the diagnosis had come earlier, I might not have enjoyed that time as much as I did being "blissfully ignorant."

My Decision
The failure to diagnose the Parkinson's notwithstanding, I'm still reluctant to abandon my internist. I've enjoyed working with him for nearly 20 years. I think he's helped me achieve the relatively good health I enjoy today.

Fortunately for me, I have an option not available to many when their internist switches to a concierge practice. In the group of doctors to which my guy belongs, only three of the more senior internists are starting the concierge practice. The others will stay in general practice. I've been assured that if I decide not to join the concierge practice my doctor will make every effort to pair me up with another internist.

So, that's the route I'm taking. Perhaps what influences this decision as much as anything is my tendency to favor the new and different over the tried and true. (See my post on "My Name Is John and I'm a Neophiliac"

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