May 2, 2013

Concierge Medicine: My Initial Reaction

For the past few days, I've been writing about the growing movement by primary physicians to concierge medicine. In this arrangement, physicians restrict their practices to patients willing to pay annual fees of $1,500 or more for a higher level of personal attention from their doctors. My investigation was prompted by a letter from my longtime internist announcing that he, too, will switch to a concierge practice.

Yesterday, I reported on commentators' assessments of the advantages and disadvantages of concierge medicine. Today, I'll review my preliminary thoughts as I decide whether to pony up and sign on.

My History with Dr. Schubert
Schubert has been my primary care doctor for about 20 years. He gives me an annual physical exam and always takes plenty of time to talk with me about my issues. I enjoy working with him because he's smart and caring and -- important for me -- has a great sense of humor.

He's part of a group of primary physicians whose offices are a five-minute drive from my house. They're located in a medical building that also houses my urologist and other specialists I've seen.

I hadn't thought anything about it when we bought our house 50 years ago, but one of its advantages now is the easy ten-minute drive to Sibley Hospital in one direction, and the same quick trip to Georgetown University Hospital in the other. As it happens, Dr. Schubert practices at both.

Many of the specialists I've seen over the years have offices nearby. Most of them know each other and work together. It's almost like having my own private Mayo Clinic in the neighborhood.

My Primary Concerns Today 
I'll be 84 later this month. My main health issues are my Parkinson's disease (diagnosed in 2009) and prostate cancer, an issue since 1995. Otherwise, I'm in pretty good health.

I've got a good neurologist for the Parkinson's, and I'm very satisfied with the urologist who's been monitoring the prostate cancer for nearly 20 years. Since Parkinson's is my primary concern, my neurologist is my primary physician in many respects.

My Other Options, If I Don't Sign On With Dr. Schubert
Here are some of the things I've considered:
  • CVS Minute Clinic: I wrote a recent post about a good experience getting my cholesterol checked at the nearby CVS Minute Clinic. I've thought this easy option might be useful for minor ailments and blood tests. Part of my annual physical with Dr. Schubert is blood tests: a CBC (Complete Blood Count) and a CMP (Complete Metabolic Profile). CVS Minute Clinics don't perform either test. They check mainly for cholesterol and blood sugar.
  • CVS Pharmacy:  The brochure from Dr. Schubert's office about his new concierge practice touts a "cutting-edge research." It describes the "genetically based drug interaction model" his office uses to predict "how various medications interact with each other and what, if any, medication adjustments are necessary." I showed this description to a CVS pharmacist I know, who said CVS uses the same model to review my prescriptions. Healthcare authorities typically recommend using a single pharmacy to reduce the possibility of adverse drug interactions. I've followed that recommendation, and CVS pharmacists often tell me they need a little more time to fill my newest prescription, so they can double-check possible problems with the doctors involved.
  • Forget about the annual physical? The concierge practice brochure also touts "an expanded physical of up to 90 minutes to review various details of your health and suggest preventive and wellness measures." Many medical authorities now question the need for annual physicals. 
  • Annual tests given by Dr. Schubert that are questioned: As I reported in February, the American Board of  Internal Medicine (ABIM) Foundation provided a list of diagnostic tests that are commonly used, but provide questionable results for many patients. Those tests include an annual EKG, annual blood work, and an annual cholesterol test. All are now part of my annual physical.
Is Switching to a Geriatric Specialist an Option?
Dr. Shubert has declined for about 10 years to accept new patients covered by Medicare. As a result, his practice presumably is not focused on geriatric care.

So, I thought maybe I'd just switch to a geriatric specialist. Ha! The growing shortage of primary care physicians is nothing compared to the scarcity of doctors specializing in geriatric care. I was having a hard time finding one, so I asked another doctor I was seeing for a recommendation.

He referred me to Dr. George Taler, Director of Long Term Care at the Washington Hospital Center. I learned that Dr.Taler practices only home-based primary care (how rare is that?) and doesn't even have an office. Unfortunately, due to Medicare restraints, he is restricted geographically and cannot practice in Northwest Washington, where I live. 

That news was unfortunate, since Taler provides a nationally recognized service of interdisciplinary care tailored to the needs of the individual. He wrote that we would "likely hit it off" since "my favorite patients are those who know their own illness at least as well as I do, take an active interest in their care and advocate for themselves as well as others who may be similarly afflicted."

He said establishing a NW DC satellite office was a possibility down the road, and promised to let me know "if the stars align."

His letter included this interesting, pertinent observation:
Health care payment policy may improve slightly for primary care physicians, but not enough to attract graduates into the field. In fact, the number of geriatricians continues to fall [!] as the baby boom generation is about to explode; the fastest growing cohort in our society is the group over 85 years of age.
Older patients are more complex, take more time, but don't generate any more income per visit, so there is a strong financial disincentive within the current reimbursement system to attend to this population. In addition, the current crop of primary care physicians will hardly be able to handle the influx of about 30 million patients who will gain insurance coverage in January 2014.
So those who want to maintain a practice that can care for elders have nearly all gone the route that your internist has taken. In your area, he is already late to the game.
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So, what do you think? Sign up or not? Let's talk tomorrow.

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