When he began his family medicine practice four years ago, Harald Lausen, DO, of Springfield, Illinois, implemented a practice model known as concierge medicine. Today, Lausen Family Practice and nearly 300 other practices in the United States are combining the traditional and the innovative, in ways that are meeting the needs of many patients and physicians.
According to a 2005 study by the U.S. Government Accountability Office (GAO), concierge medicine is "an approach to medical practice in which physicians charge their patients membership fees in exchange for enhanced services or amenities."
The GAO report goes on to state that most concierge practices are primary care practices located in major urban areas. Patients pay annual fees that range from $60 to $15,000 or more, with the average being $1,500 to $2,000.
The first concierge practice, MD2, was founded in 1996 in Bellevue, Washington. From 2000 to 2004, there were ten times as many concierge practices.
For the annual fee, patients receive services normally not covered by health plans, such as: comprehensive annual physical exams; alternative medicine; nutritional counseling; their own medical history and records on a small compact disc; same-day or next-day appointments; longer appointment times and more time spent with the physician; access to the physician via cell phone, pager and e-mail at any time; coordinating care during hospitalizations; wellness and preventive care services.
The annual fee is usually not covered by health insurance. Other medical services, such as diagnostic testing, are billed directly to the patient by the service provider.
A typical concierge practice has 500 to 750 patients. Within this model, practices vary widely in how they operate. Some operate on a cash basis; and others participate in Medicare, Medicaid, and insurance plans.
Some submit the patient's insurance claims directly, and others require the patient to do that. Some serve both member (those who have paid the annual fee) and non-member patients, and others serve only members. A common goal for all practices is treating the whole person, not just a symptom or an emergency.
Critics of concierge medicine say they find it disturbing that doctors with concierge medicine practices focus on small numbers of patients, while the number of uninsured Americans continues to rise. They feel practitioners are shirking their social responsibility to serve patients of all income levels.
From the patient's point of view, this approach is comparable to flying first class, buying a luxury vehicle, or ordering a satellite dish television package. From the physician's point of view, this can be a return to medicine as it was before the growth of health maintenance organizations and other forms of insurance and coverage for medical expenses.
Many report that concierge medicine is improving the quality of life for both physicians and patients.
"From a medical and ethical perspective, this method of delivering quality, timely care is fine," said Daniel R. Hoffman, MD, medical director at St. Mary's Good Samaritan hospital in Mt. Vernon. "I know of no one in Southern Illinois who is involved in this because the eligible patient base is small here."
"This is largely a rural area with small towns and a lot of retirees," Hoffman said. "I think this works better in a metro area with white collar workers who will pay for the privilege of having a personal physician."
Pros and cons for patients
Some believe that concierge medicine widens the gap between rich and poor in our country. The wealthier, healthier patients are getting the best care while others are finding it difficult to get primary care.
Some physicians have a concierge practice and a conventional practice operating side by side. MDVIP, a concierge practice management company, requires its physicians to shift all non-retainer patients to other physicians.
As the U.S. population ages, the need for primary care physicians continues to grow. The smaller number of patients per physician in a concierge practice increases this physician shortage.
Patients have the opportunity to benefit from medicine the way it used to be with house calls, no answering service, visits that last as long as the patient needs, and continuity of care with the same physician. Some like the feeling of having a personal physician who knows and treats the entire family. The increased emphasis on preventive care has the potential to reduce emergency room visits and hospitalizations.
"The physician is the first source of referral, the first contact," said Alex Goldstein, MD, of Marion. Goldstein had a family practice in Rosiclare from 1955 to 1971 and in Harrisburg from 1971 to 2003.
"A patient should insist on access to the diagnostic services that are available. No one wants a 'maybe' or a half answer. When I was making house calls, all I had were my eyes, ears, hands, brain and memory plus my stethoscope. Today's standards for diagnosis are higher because of what is now available," Goldstein said.
Physicians in a concierge practice are responsible for helping patients make connections to the diagnostic, therapeutic, and medical specialties that they need. Often these are dependent upon the patient's preferences and insurance coverage, as well as the physician's knowledge and professional relationships. Hospital admissions and visits are often included in the services provided.
According to MDVIP, most concierge practices accept insurance coverage. Patients need to be clear about what their annual fee actually covers and for what other charges, such as insurance premiums and co-payments, they are responsible.
Pros and cons for physicians
"Patients in my practice always had access to medical care, even when I wasn't available," Goldstein said. "In 1955, patients paid as they went. By 2003, almost everything was billed to insurance companies."
Today within a managed care system, physicians may see up to 40 patients daily and spend less than 15 minutes per exam. One physician may be caring for as many as 4,000 patients. They are constantly making decisions based on what is best for the patient's health versus what is required by the system.
According to Thomas B. Shapira, a corporate attorney who represents physician groups, insurance reimbursement for medical services is steadily declining and the cost of maintaining a medical practice is increasing. These circumstances often result in physicians' burnout and career dissatisfaction.
By contrast, many physicians adopting the concierge medicine approach have been in practice for several years and are seeking more time to focus on medical care instead of health insurance issues.
Physicians in concierge practices have the opportunity to practice medicine as they originally dreamed they would do it. They can spend more time on listening to, educating and treating their patients, and less time on paperwork and coverage restrictions. They have more time to develop closer relationship with their patients, including more follow-up care. They can devote more time to wellness and prevention, and less time to treating health problems.
Natalie Hodge, MD, of Personal Pediatrics in St. Louis started her concierge practice in 1995. She had been in a traditional practice for seven years prior to that. Her practice is totally mobile and entirely made up of house calls.
In addition to serving 50 patients, Hodge is also implementing a customized program that she is marketing to other pediatric physicians nationwide. "Standardizing a process for pediatric practice with software that would make it easier for doctors is a great opportunity," Hodge said. "Our company will license them our software and hardware system, a patented process, and they will continue to own their practices." The system also provides a pre-packaged, well thought out legal and marketing system.
According to MDVIP, patient retention is high with the concierge practice model. MDVIP allows a caseload of no more than 600 patients for their physicians. This has the effect of increasing the caseload for those physicians who don't choose this type of practice.
Concierge physicians have more direct control over their own practices and personal lives. They maintain and increase their income through patients' retainer fees rather than through taking on more patients. "My caseload is about 150 patients," Lausen said. "I spend half my time in clinical practice, and the other half teaching at the SIU School of Medicine [in Springfield]. I'm conscious of having my phone with me, that it's on, and that I have a signal all the time. I get at least one phone call every night. I never really get a break. This type of practice isn't for everyone. A lot of physicians don't want to be tied to a phone 24/7 or spend 60 minutes talking with a patient. It's not for every physician, and it's not for every patient."
Possibilities for the future
As healthcare continues to be defined and redefined, concierge medicine may be an option that will help attract more physicians into primary care practices. This more open partnership between patient and physician may also become more attractive for patients as health plans have higher deductibles.
"I think this will always be a small percentage of physician practices," Lausen said. "It will be a niche, not something that will catch on and take over. It won't explode, and it won't go away."
Did you know?
Concierge medicine is also known as boutique medicine, retainer-based practice, patient-financed medicine, fee-based practice, patient-supported practice, patient-focused practice, and personalized medicine.
Hot Button Concerns
Q: Is a patient's paying more money to a physician for preferential treatment ethical? Are the benefits provided by concierge medicine actually benefits that patients should already be receiving without paying extra?
A: According to Garrison Bliss, MD, in the April 2006 Journal of the American Osteopathic Association, in any healthcare system or model, the most important relationship should be between physician and patient. The availability of more than one type of healthcare model supports the ability of patients to maintain the right to choose their own physicians and types of practice they believe will give them the best value for their needs.
"Where I am [Springfield, Illinois], this is value driven," said Harald Lausen, DO, of Lausen Family Practice . "If a patient sees the value, he or she is willing to pay the annual fee. I tell my patients that if they don't see a value in this, then this is the wrong practice for you."
In the American Medical Association's 2003 Report of the Council on Ethical and Judicial Affairs, section E-8.055, "Retainer Practices," the AMA addressed these issues. To summarize the AMA's position, both physician and patient must be clear about and agree to the terms of their professional relationship. The physician's first consideration must always be quality of care for the patient, and the physician must offer the same standard of care and treatment to all patients. The physicians still has a professional obligation to provide care to those in need of care, particularly urgent care, regardless of the patient's ability to pay.
Q: How does concierge medicine impact patients with conventional health insurance?
A: According to Garrison Bliss, MD, of Seattle Medical Associates, the country's second concierge practice - healthcare and health insurance are different.
Health insurance is a promise to pay for some part of the cost of care and was originally designed to reduce the patient's out-of-pocket expenses and to provide protection against catastrophic expenses. It has evolved into a process for reimbursing most medical expenses.
With concierge medicine, patients purchase certain healthcare services directly from their physicians.
Q: How does concierge medicine impact Medicare patients?
A: According to a 2005 study by the U.S. Government Accountability Office (GAO), 76 percent of concierge practices are serving Medicare patients. In 2002, the US Department of Health and Human Services stated that, if properly structured, concierge medicine doesn't conflict with Medicare's requirements. To serve Medicare patients, concierge physicians have to be careful that the annual fee covers services that are not reimbursed by Medicare.
Q: What affect does concierge medicine have on the current physician-patient ratio in the United States?
A: According to the American Academy of Family Physicians, the number of medical students choosing family medicine continues to decline. New medical school graduates have significant student loan debt and are choosing higher paying specialties, such as cardiology and anesthesiology. In addition, physicians who are using the concierge approach may be treating as many as 80 percent fewer patients than family practice physicians are treating in their conventional practices.