JB: I started the society last summer with the help of Katherine Harmer, who is president of a practice called Higher Care out in Colorado. The primary goal of the society is to help doctors across the country who are interested in practicing this way to transition their practice, or set up a practice from the start, in a legal, ethical and financially successful way. The movement toward retainer-based medicine is a very new development in the delivery of health care and everybody’s been doing it differently across the country. There are a lot of legal and regulatory questions about how one should go about practicing this model. I felt it would be a good thing to have a centralized clearinghouse for this information, keeping up on new developments and then disbursing those to doctors.

JB: It’s a nomenclature that we don’t like. It was coined originally in the media to describe the service where a patient would pay a fee for various types of personalized services, and we use the name "concierge" because it was the most easily recognizable way to get the word out about the society. But we don’t think it really describes what it is we’re doing. Basically, we’re offering more personalized services that can’t be obtained in the traditional setting, for a fee. In a sense, it’s going back to the way things use to be in health care when people paid a fee for services that were rendered. We’re going to be changing our name at the conference to try to describe the more personalized nature of the services that we offer. There have been a number of suggestions, including Retainer-Based Medicine and Patient-Driven Health Care.

There are three basic models that we’re seeing people practicing across the country. All of these models allow the doctor to reduce the number of patients that they take care of. By doing that, it allows them to see fewer patients per day, which then allows them to spend more time with patients, call them on the phone with their test results, have no waiting times in the waiting room, guarantee on-time appointments. Paying the fee is for access to those kind of personalized services. It’s recommended for all three models that there be a contract between the physician and the patient that specifically describes what services are covered for the fees that you are charging.

One model is where the patient pays a fee – and usually it’s a higher fee, which might range from $5,000 up to $20,000 a year – to the doctor for their services, and the doctor doesn’t bill insurance. A Seattle practice called MD Squared was one of the first practices that started providing this type of medicine in 1996. That model has come under some regulatory scrutiny in Washington State because they’re saying that, in essence, the doctor is working as an insurance company by guaranteeing both medical services and convenience-type services for the set fee. One way the practices have gotten around that is to bill in arrears: provide the service for three months and then the patient pays for those three months, or they pay all at once for the year and then the practice deducts out of an account as they go. It’s not necessarily illegal to do it that way, but it’s been scrutinized. The other problem with that model is that, under Medicare, you can’t charge more than 115 percent of the Medicare allowable so, if you have a Medicare recipient in your practice and you charge them $10,000 for the year for your service and they see you twice during the year, then you’ve gone over that 115 percent allowable. Some people are de-participating from Medicare to get around that.

There’s another model where the doctor charges the patient a fee – usually lower than the first model – and the doctor still bills insurance. The reason we continue to bill insurance is that there has to be a clear demarcation line between those services that are rendered for convenience and access, and those services that are medically related. You bill the patient for those services related to access, and usually it’s $65 to $100 a month.

The third model is where the physician charges the patient on a per-visit basis. It really gets back to the way things used to be before insurance. You go to your doctor’s office and you pay a straight cash fee for the services that are rendered, and then the doctor might give you a bill to submit to your insurance to see if they would pay it, or help to submit the bill on your behalf.

JB: One of the issues that people have with the model is that all physicians will end up doing this. That won’t be the case because the law of supply and demand will apply. There’s a demand right now for this service, and that’s proven by people pulling out their checkbooks and paying for it. The whole formation of this movement and the drive thus far has been patient-driven. Patients want this and, as more and more baby boomers enter stages of their lives that require access to health care, they’re going to want it too. I think we’re going to see a steady growth as the baby boomers all start accessing health care more and more, and it will cap out and the demand will be filled somewhere over the next ten years.

I think it will take a very small number of doctors to meet the demand and I don’t think it will ultimately impact the supply of doctors in our country. There’s only so many people that can afford an additional fee for these services. I think that it will all even out in the free market: prices will come down as the competition increases and eventually we will settle at a price for it that people are willing to pay for this additional service. Once that demand is met, there won’t be any more doctors able to go into it.

Those of us who are providing this kind of service feel that we can make a very positive impact on the problem of the uninsured. Virtually every physician member in our Society is either providing more free care for the uninsured today than they did when they were in the traditional setting, or they’re donating financially to clinics that provide care for the uninsured, or they’re doing more overseas mission work. A larger problem with the medical industry in our country is that we have 40 million uninsured people in our country. We’re failing to provide even basic health care needs for a large majority of our population, and I think that problem is wholly separate from the question of whether, if someone has the ability to pay extra for additional services, they should be able to do that or not. I don’t think it’s going to adversely impact the problem of the uninsured.

JB: Right now, it’s a decision that has to be taken very seriously on the part of physicians because there are pitfalls throughout the whole process. It’s by no means on stable ground at this point, from a legal or regulatory standpoint. There’s a lot of controversy about whether we should even be able to provide this kind of health care. Most doctors that have done this have found that their income goes down initially, even though anticipated income ultimately will be anywhere from 10 to 30 percent higher than what they can earn in the traditional setting. When you’re going to transition your practice you’ve got to have a feel as to how many people in your practice are going to be willing to pay this fee. A lot of factors go into that: How long have they been in the practice? How much affinity do they feel for you as a physician? What are the socioeconomic demographics of your practice? Some people have decided to transition their practice, sent out letters, and found out no one wants to join them.

Physicians have done this primarily because of a lifestyle issue: they realized that they weren’t able to provide the kind of quality or service in their health care delivery in the traditional setting that they could in this new model. That’s a very personal thing. There are some physicians who provide excellent service and quality at very high volumes. But there are some of us, myself included, that are just not comfortable in that kind of a high-volume practice and deliver better care in smaller volumes. Among the specialties that are making the transition are primary care, dermatologists, gynecologists, OB/GYNs, and cardiologists.

JB: I don’t think it can be done in tandem. There may be a transition period that occurs while you’re building the practice, but you can’t have a situation where you’ve got a full schedule of traditional patients and this person who’s paying an extra amount calls and now you move them to the front of the line, they walk through your waiting room and right in to see you. That, I think, presents ethical complications. I think it’s ultimately an all-or-nothing issue.

JB: We’ve haven’t been able to put our finger on that because you have private physicians doing this without anyone really knowing. We peg it at somewhere between 150 and 200 in the nation. We’ve got about 30 members in our society from across the country, ranging from single physician practices to practices with three physicians.

JB: It would be probably more viable in cities, but it really depends on the demographics and the value that people place on their health care. You could have a rural town or city that had one primary care doctor and the doctor says, "I’m going to bring in a partner and I’m going to offer these more personalized services but there’s going to be a fee associated with it."

JB: From a legal standpoint, there are issues related to making sure you have a very clear contract or consultant agreement with the patients who join the practice so they know exactly what they’re paying and what it’s for. The insurance department in Washington state said it doesn’t think this model should be legal because it is insurance, and insurance should be subject to insurance regulation. They also said that it’s a violation of private contracts with insurance companies because of charging the patient an additional amount over and above what insurance pays for medical services. We don’t feel either argument holds much water and the legislature in Washington feels so as well: a bill to enact those objections died before getting anywhere. In Massachusetts there was some discussion in their legislature about Medicare’s 115 percent rule. That’s why we bill the patient for the access and convenience and bill insurance for medical services. Another issue is providing for the smooth transition of care for patients who don’t decide to go into this model. The AMA has also put out a set of guidelines outlining the ethical recommendations for how to practice retainer-based medicine.