May 1, 2013

Concierge Medicine: The Case For and Against

Developed in 1996 mainly for affluent patients, "concierge medicine" offers fee-paying subscribers a higher level of personal attention. This type of practice is growing, becoming a more affordable option for many more people. 

Last year, there were about 4,400 concierge doctors in America, and 1,000 practices opened in 2012, according to Tom Blue, executive director of the American Academy of Private Physicians. The number is expected to double in the next three years, Blue adds.

When concierge medicine started in 1996, annual membership dues averaged $10,000 or more. Fees have now drifted down into the $1,500-$1,800 range.

The Problem: Primary Care Doctors Are Getting Scarce
Increasingly, private practice doctors have given up their independence for employment at hospitals, clinics, and elsewhere. Independent physicians have dropped from 57% in 2000 to 39% in 2012, according to an Accenture study. Of those who remain in private independent practice, Accenture says, a rapidly increasing number are adopting subscription-based models.

Traditionally, primary care physicians have not made as much money as their specialist counterparts -- a primary cause of the primary care physician shortage. More medical students opt for a specialty practice, rather than primary care, because it promises more money. The median salary of primary care physicians is $160,000 a year, about half what anesthesiologists earn.

The shortage of primary care physicians will become even more acute in 2014 when the Affordable Care Act's individual mandate takes effect and requires everyone to be insured. The law will enable 30 million previously uninsured people to get coverage through an expansion of Medicaid.

By 2020, the Association of American Medical Colleges estimates, there will be 45,000 fewer primary care doctors than the country needs.

Against this background, let's take a look at the pros and cons for concierge medicine.

The Case for Concierge Medicine
Doctors who convert to subscription-based models shift their focus away from service volume and gain the flexibility to get back to the basics of patient care. They see their peers who remain in traditional practices struggling to stay afloat at a time when administrative costs are rising and  insurance payments have basically stayed flat.

Many doctors, even those still in private independent practice, have rejected the old insurance-driven model of medicine in favor of direct pay. "This is all doctors want to talk about," says Jeff Goldsmith, a health-care industry analyst and trend spotter. "I'm done billing Blue Cross. I can't deal with this anymore. It's destroying my life and my relationship with my patients."

Similar sentiments have led many doctors to decline accepting new Medicare patients. The headaches involved in dealing with the regulations and paperwork are too onerous and take too much time away from the practice of medicine, in their view.

Were it not for the switch to direct pay and concierge medicine, it is argued, the already short supply of primary care doctors would be further depleted by early retirements of older doctors, and by the opting out in favor of other jobs or just quitting altogether by burnt-out younger doctors.

Proponents of concierge medicine say patients are also rewarded by gaining enhanced access to care that focuses on preventive medicine. That particular focus would help correct bad patient behaviors and lead America to healthier living as concierge doctors take on more of an active role in their patients' lifestyles. Under the old insurance model, lifestyle advice and follow-up phone calls and emails are not usually reimbursed.

The Case against Concierge Medicine
Concierge medicine has been accused of promoting a two-tiered health system that favors the wealthy, decreases the number of doctors available to those who cannot afford annual fees, and burdens the middle and lower classes with higher insurance costs.

Some physicians feel they can't abandon  patients who are unable or unwilling to pay annual fees. 

Those offering concierge medicine often tout as a selling point -- and I quote here from Dr. Schubert's brochure -- "an expanded physical of up to 90 minutes." But many experts now question the need for annual physical exams for asymptomatic  patients. Those tests, they claim, have little benefit, lead to unnecessary procedures, and have been abandoned by other nations. For example, a Canadian government task force in 1979 recommended against annual physicals, citing a lack of evidence that they help. Other critics suggest those tests even cause harm.

I wrote about this debate in a post last July. Earlier this week, I reported on a recent Danish study that found little merit in annual physicals.

The Hybrid Model
There's an alternative approach to concierge medicine that does not completely disenfranchise patients or exacerbate the physician shortage. Under this model, the physician limits the number of her concierge subscribers. Her other patients -- not part of the concierge arrangement -- stay with her. The difference in service? The fee payers get a special contact number, dedicated appointment times, and other benefits that enable the doctor to offer more face time and advice.

The proposal I received from Dr. Schubert is halfway between the exclusive concierge plan and the hybrid model. If I elect not to subscribe to his concierge  practice, he will help me find another doctor, presumably within his existing group practice. Only a few of the doctors in his group are joining Dr. Schubert in the  concierge practice. Moving to another doctor in that group would keep my medical records of 20+ years with Dr. Schubert where they are. I'd be treated in familiar surroundings with the same lab, etc.

Tomorrow, I'll share my preliminary thoughts about whether to sign up.

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