Concierge Medicine- Better Medicine, but for Whom?

A patient having his blood pressure taken by a...

Concierge medicine goes by many names, direct care, retainer based medicine, boutique medicine. Basically what it means is that the patient pays an extra fee (usually in the $1000 to $2000 range) per year to have access to same day visits, emails or phone calls whenever needed with their physician. Also, visits tend to last longer, sometimes as much as an hour to two hours if needed. But of  course all this extra time the physician spends with their patients means they can see fewer of them so to make up the difference they charge the fee.

When I was an idealistic medical student I was completely against this idea. I saw it as healthcare for the privileged at the expense of the poor. I was already frustrated with the gap in the quality of care I saw between the rich and poor clinics I visited. This seemed like yet another way rich people would get better care than the poor and would pulling more resources away from those who desperately needed them. I kept this attitude through much of my residency but as I entered the world of private practice and left the confines of the academic institution I was exposed to what quality of primary care was really going on out there. I was appalled at what I saw. Patients often had medication lists that made no sense. Despite being highly educated individuals they had no knowledge of their medical conditions or medications and what they were for. And they all expressed to me the same frustration, that their doctors simply did not spend time with them explaining anything. I was amazed to hear that the short period of time I spent talking to them in the emergency room was the longest any physician had ever spoken to them.

One may read this and feel that I was witnessing the results of callous uncaring doctors who were only interested in making money, but that simply is NOT the case. Most of the primary care physicians I met in the area were wonderful, down to earth, kind, caring physicians with the best interest of their patients at heart. The problem was with insurance reimbursement for primary care getting smaller and smaller and cost of overhead going up, the only way to make ends meet was to see more patients. Many of them were seeing 20 to 30 patients a day. The average visit is scheduled for 15 minutes. But this is not 15 minutes of talking with the patient. That 15 minutes includes reviewing the chart, typing up a note documenting the entire visit, filling out orders for imaging or labs, insurance paperwork and pre-approvals and so on. It ends up being about 5 minutes of distracted talking between doctor and patient. At this rate no physician can really practice medicine.

Then I started to meet some of these concierge doctors and their patients. Their patients had medication lists that made sense. They knew about their illnesses and understood the treatments and what each medication was for. And the doctors were truly happy. They finally felt like they were practicing medicine and not just filling out paperwork, and I started to question my attitude towards this way of practicing. Clearly they were providing superior healthcare to their patients and who could fault them for that?

But there is no avoiding that there is a cost, both financially and to society. The fee of $1000 to $2000 a year is far outside the reach of most Americans. And those physicians treating only those who can pay that fee are that many fewer physicians not working in poor areas where there is already a devastating physician shortage.

I see only two ways address this.

The first would be for insurance companies to pay more for primary care. Currently even a primary care doctor seeing 20 to 30 patients a day is still one of the lowest paid physicians. And medicare and Medicaid at this point pay so little that they do not cover the clinic overhead. This has to change. There is a HUGE savings to be had by good primary care. If doctors have time to talk to their patients and address their concerns and make them informed about their diseases, treatments and what to expect. This translates into far fewer emergency room visits and medication errors and redundant or needless tests.

The other way to approach this is far more earth shattering. Currently our health insurance is being used for things insurance was never intended for, predictable planned life events like yearly physicals, mammograms, colonoscopies. This is analogous to car insurance covering oil changes and tune ups or home owners insurance paying to repaint the shutters. At some point we may need to stop letting insurance companies dictate how much to pay primary care doctors by lowering premiums and taking away primary care coverage. People who can afford it would be expected to pay out-of-pocket from the savings of lower healthcare insurance premiums for their own primary care. This could have the effect of causing many not to get primary care but it could also have a beneficial effect. If people pay for their primary care they may take it more seriously and be more likely to follow recommendations. Also, if physicians had to get people to pay out-of-pocket for visits there could be a very real increase in quality and patient satisfaction that comes from healthy competition and market forces.

However, there is one big thing keeping any of this from happening. Fee for service reimbursement of medicine. In our current system doctors are paid for seeing patients and doing tests or procedures. The more visits and the more tests done the more money made. If primary care doctors were all spending an hour with their patients talking about their cases and addressing their issues there would be much less need for consultants and tests. However, an overworked doctor who has not time to think will have to delegate responsibility to consultants or instead of getting a diagnosis through history taking may just need to skip to a CT scan or MRI. This makes more money for the multidisciplinary group or hospital that often employs the primary care doctor. So currently there is no motive to have better primary care and there are many incentives to actually continue the current system. That is unless the ACO model put forth by Obamacare takes hold. Then the incentives change dramatically.

Either way, many patients are voting with their pocket-book and paying the fee for concierge medicine. This trend combined with the effects of Obamacare extending insurance coverage are going to cause a catastrophic primary care shortage. Something needs to be done or we will continue to have the distinction as the country that spends the most on healthcare with the worst outcomes.

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