By Christopher Guadagnino, Ph.D.

Published December 2007

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WL: The current system of primary care is pretty much destroying primary care. The third-party reimbursement system, as it compresses reimbursements, is causing doctors to have to see a number of patients per day that far exceeds an efficacious number. Because of that, there is the need to consider the possibility of dropping out of health insurance plans, to be able to be paid directly, to keep the reimbursement rate per visit up to support a reasonable amount of time with patients, or other alternatives. The concierge program that we support and promote enables doctors to present to their patients choices in services and style of care, so that they can continue to support their practices – keep them economically viable and also to create an environment where other doctors will consider going into primary care. Given the proposed drops in Medicare payments over the next few years, physicians are going to be dealing with incomes that are dropping while their expenses are going up. It’s reaching critical levels with many physicians, and some are looking at early retirement or shifting out of medicine. It certainly is not a positive environment to encourage doctors to consider primary care.

WL: On a professional level, concierge medicine affords the doctor the opportunity to spend more time with their patients. It allows them to become more than just a caregiver – they can return to the things they’ve been trained to do as an advisor and a partner in a patient’s care. When you spend five or ten minutes with a patient, you tend to be a fireman – you become more of an urgent care-deliverer than a partner in managing one’s health. Given the reimbursement structures that exist today through third party and government programs, there just isn’t enough money to support that style of practice where a primary doctor sees two or three patients an hour, and spends quality time to help them manage their care in a much broader sense.

Doctors today have a number of different possibilities. One would be to drop all plans, cut their costs and be a cash-only doctor. But many patients are tied into their insurance plans and rely on them to cover much of the cost of medical care. It’s not a practical solution for a doctor who wants to continue to see many of his or her patients to go to a cash-only system, and frankly, it’s economically very unstable and may put them out of business. In a full concierge model, doctors consider the possibility of reducing their practice size from thousands of patients to hundreds of patients, who pay an annual fee for some defined group of services. That approach has the economic benefit of stabilizing their practice, and can be done by a few doctors, but it does create a disenfranchisement of many patients because the doctor is saying good-bye to so many. We worked on that problem and came up with a hybrid approach that we think is effective in offering choices to patients and to doctors, and enables the doctor to continue to see virtually all the patients that they’ve been seeing previously.

WL: In the hybrid approach, the doctor spends a portion of each day delivering an annual comprehensive screening physical, which is the cornerstone of the program. That time is also available to members of the program for follow-up care, as well. In the remainder of the day, the doctor continues their traditional practice. That enables them to transition slowly into this approach, and it does not create as much of a barrier of entry – the need to have hundreds of patient members, or a very high price point – to support the practice.

WL: In our model, the patient’s annual out-of-pocket cost is anywhere from $1,500 to $2,500, depending on what’s in the physical and what other services are provided. The ability of patients to pay that varies, obviously, based on economics. But we find that a surprisingly large number of people can afford that type of an out-of-pocket expense, and are very much interested in the enhanced services that come along with a concierge program. They’re interested in the convenience, the shift to a focus on preventive care, and the enhanced relationship that they have with their doctor. The average doctor may have 1,800 to 2,500 active patients in their practice – who they’ve seen within the last two years – and we average about 150 patients per doctor who join the hybrid program. You can do it with as few as 50 or 75 patients who choose the hybrid program, and be very successful. To support a concierge hybrid model, you may only need less than 10 percent of the practice’s patients to participate. The doctor, with our assistance, comes up with a price point that makes sense, based on the location of the practice and on the cadre of services that they include in the program. The average might be on the order of about $1,800 per year, per person, to support a specific set of services not covered by their health insurance.

WL: Generally, it includes an annual preventive screening physical, which includes some standard items like blood work and additional work that isn’t normally done in physicals, including EKGs and other tests. Many times doctors consider doing some nutritional review, a review of addictive behaviors, and a mental state exam. Some doctors have added more involved testing, such as abdominal and carotid artery ultrasounds and calcium scores, as preventive measures. Each doctor has designed their own particular program using a variety of elements that they’re comfortable with, and together we price out a program that we think fits best for the patients of that doctor. In order to deliver a true preventive wellness program, the doctor needs to have more time to facilitate the plan that is generated from this kind of program, and allocates a certain amount of time each day to do that.

Generally, given the width of the screening physical, these are not covered services under traditional health insurance. In Medicare, there is only one period of time – a "welcome to Medicare" interval – in which a preventive physical is covered, so this is not a generally covered service for Medicare. It is a very defined set of services, and follow-up visits are not covered. Follow-up care usually is handled the same way it was previously, through whatever insurance plans or direct payment that the patient would have had with the physician. Most patients who participate have some kind of insurance, or are part of a government program like Medicare. Their insurance does not necessarily allow them the opportunity to have this combination of convenience and focus on prevention. We’re proposing to the patient, as an option, a set of choices that they may be interested in. If they are not, they continue to see their doctor as they have before.

WL: It’s a practice in which the doctor has been around long enough to establish one-to-one relationships with their patients, not one that is clinic-like, where you don’t see a particular person each time. We’ve done this with doctors who have been in practice as short as three years, but it tends to be a little longer than that – maybe five years or more. It’s doctors who themselves are interested in giving more time, but have been compelled to shorten it down in order just to keep the lights on and the door open. It’s a practice where there are patients who are interested in convenience and extra advocacy – being able to call and get the doctor on their cell phone, and have same- or next-day appointments, which come with this type of a program. The type of doctor who this would work for is an internist or family practitioner, but there are some specialists who are quasi-primary care doctors – like endocrinologists and rheumatologists – who could possibly go into this type of a program.

WL: So far, the number of doctors who do this is still relatively small – perhaps one to three percent of the primary care population might be able to support this, or would be interested in it, at this time. There were surveys done a couple of years ago by the General Accounting Office which estimated that there were a couple of hundred physicians doing concierge medicine. I would guess there are currently a thousand, at the most, who are in concierge care at this point. We are just at our 50^th practice and are doing three or four practices a month. One of the reasons more doctors haven’t done this is that they don’t quite know how to do it. They don’t know how to market, they’re not business people. Our company is hired specifically to communicate and get the message out to patients and inform them, in a professional way, what their choices are.

WL: There are many solutions we offer to a doctor to make sure that this does not become a worse situation. A simple solution might be to close your practice to new patients and just by general attrition reach equilibrium over a period of time. Sometimes it involves changes in hours. Sometimes this encourages the opportunity to bring on more physicians in a practice, or creates other opportunities that didn’t exist previously. Remember, doctors oftentimes will be working frantically and then spend a couple of hours each day just trying to catch up with the paperwork. There are opportunities that exist in reshaping the practice, and we custom tailor those solutions for each practice to take care of the changes within the practice. In a hybrid practice, the way it’s been designed, you can’t lose, economically; you can only gain. In most instances we’ve pre-screened the practices for either some capacity or some ability to make this transition comfortably.

WL: There are many. The reason that we’re hired as a company is to guide the doctor through the minefield of possible mistakes. For example, you’d have a problem if a program designed by a doctor included covered services under Medicare. You can’t charge for covered services. There are marketing mistakes, which are much more subtle. Our experience with payors has generally been that they’ve comfortable with this type of a program, as long as it is voluntary and does not prevent people from continuing with their doctor. That is the key issue in a hybrid approach: that the same care is given and there is no differentiation, so that you don’t create a tier of second-class citizens. Patients still get the same doctor, medical advice, and excellent care that they’ve been used to before. It’s not about taking away things. It’s about opportunity for people who have different needs to be able to buy more of what they need. There’s a base level that we have a social responsibility to be able to afford to give to everyone. We should also encourage the opportunity for people to choose which hospitals, doctors and pharmacies they go to. Choices are extremely American and appropriate, and this is just yet another set of choices.

WL: We’re about to start working in our eighth state, and we believe there are doctors and communities in New Jersey where this type of program is appropriate. We’re interested, not necessarily in a drive per state, but into the regions that make the most sense. We’re starting to see more doctors in New Jersey consider the possibility, and we’re doing more work with doctors in the northeast. This is a relatively new move for us, as we’ve spent most of our energies on the west coast. Since we’re a New York-based company, we’re interested in bringing it back this way, and we anticipate that doctors will go into concierge programs in the next couple of years in a slow progression – this is not about revolution – because it is truly a win-win for the patient, the doctors and the communities. I think it’s ethically the best solution to deal with the problems that we’re facing in primary care. I believe, as more doctors go into concierge medicine and the public supports it, that it may be a basis under which doctors can feel good about primary care again and be rewarded for excellence and for relationships. Their patients will be the decision-makers, not a government agency or a private company that pays.