Concierge Medicine

Last September, Denver internist Brent Cohen sent his patients an unusual, carefully worded letter.

He wrote that he was thinking of switching to an emerging kind of medical practice where his patients would get highly personalized, 24-hour-a-day care in return for a $3,000 annual payment.

"I should make it clear," he emphasized in the letter, "that I have not yet made a decision" to start one of the new concierge [also known as "boutique" or "retainer-based"] medical practices. But, in deciding, he wanted to know what his patients thought.

It was a big decision. Cohen had considered switching to a boutique practice before, but found himself confronting what he felt were some truly difficult financial, legal, professional, and ethical issues. Unable to resolve them by the time a prospective partner needed a commitment from him, Cohen had put the idea aside
temporarily.

Yet his professional life remained "not that great." In practice for 11 years, he occasionally felt frustrated and overburdened. He was seeing 25 patients a day. Workweeks could be a blur of exams, office hours, referrals, hospital duties, reimbursement worries, staff management, forms, and more. Worse yet, the pace was escalating. With reimbursements "going down and down and down," he might soon need to see another three or four patients a day just to keep his income steady.

By contrast, concierge doctors, he had heard, had reasonable workloads and managed to make money while practicing good medicine. They saw only six or seven patients a day, and spent about an hour with each. Many raved about the sheer professional pleasure and long-forgotten luxury of being able to concentrate at length on each patient's needs, habits, continuum of care, and compliance.

So he decided to reconsider boutique medicine.

His were the same reasons why many physicians nationwide -- no one knows exactly how many -- have switched to this type of practice. In them, doctors radically limit the number of patients they will see, and then charge an up-front fee -- anywhere from $15 a month to $125 per visit to $13,000 a year -- over and above what the physician gets in reimbursements. Patients, in turn, get what in the managed-care world looks like red-carpet service: quick or same-day appointments, real communication through e-mail, telephone, and in-person access to their doctors, an end to waiting room vigils and, perhaps most importantly, the promise of coordinated care.

Perhaps as a result, announcements of new concierge practices have come almost weekly during the past year in Ohio, Massachusetts, Virginia, Florida, Illinois, Texas, Maryland, California, Washington, and Colorado, among other places.

So Cohen went ahead and mailed the letter to his patients. Several weeks later he left for vacation to consider the responses and, with his wife and three kids, ponder his financial, legal and, ultimately, ethical concerns. His questions were the same that every physician would have to answer.

Financial and legal concerns

Financially, Cohen concedes, it was "hard to know what to expect" if he left his current practice, especially for an essentially new business model. He was unsure insurance companies would continue to contract with him as a retainer-based physician. Some payer contracts require a certain level of access -- requirements that would be violated if he refused to see patients that wouldn't pay the fee.

Legally, various regulatory and legislative bodies have been fitfully hostile. Regulators in Washington and Florida have challenged the model. Washington contended that, by accepting retainers, physicians were accepting risk without having the insurance licenses to do so. Florida investigated discrimination against patients who could not afford medical retainers. Massachusetts legislators introduced a bill in 2003 that would require insurers to prohibit their network doctors from accepting retainers.

Nationally, Medicare has forbidden patients from using its funds to pay up-front physician fees. Congress last year debated bills to prohibit retainer-based physicians from contracting with Medicare at all. (As of this writing, none of the state or federal bills has become law.)

John R. Marquis, a Grand Rapids, Mich., healthcare attorney who also heads the American Society of Concierge Physicians, likens the current environment to "looking down a road through a light fog. You can see through it, but you don't know exactly what's developing very far down the road." Are state insurance commissioners going to impose a toll? Will the legislature wave you ahead, or forbid you to go any farther?

Physicians should proceed with caution, says Katherine Harmer, a business adviser who helped set up the new retainer practice of James Benoit, MD, in Colorado. "You need excellent attorneys who understand the healthcare market. If you don't have that, you will run afoul."

Marquis thinks it will take two to four years before there is a clear path to follow. By then, there will be obvious regulatory guidelines and a firm legislative base for the model.

Ethical dilemma

Moral queasiness bothered Cohen more than financial and legal worries. Retainer-based medicine "feels elitist in some way. Some patients who I've had for years, I know would not be able to afford this," he explains.

That has been critics' central objection. "I have a great concern that this is going to provide care to the 'healthy wealthy,' but may limit the access of the rest of the population," says Michael Fleming, MD, president of the American Academy of Family Physicians (AAFP).

"Nobody" in the concierge movement "likes to use the word 'access'," Marquis cautions. "But if you take a practice that has 4,000 patients and you institute a concierge model and you reduce your practice to 1,000, well, you have 3,000 patients who don't have a physician." In the end, "we have this large body of people who may be displaced" by retainer practices. Even advocates, says Marquis, recognize "that there is an ethical issue involved."

In six guideline points released last June, the American Medical Association urged physicians who do switch to concierge practices to help patients who decide not to buy retainer contracts to find new caregivers -- and if they can't, to continue caring for them.
A dilemma like Cohen's highlights physicians' simultaneous need to find solutions for their personal lives while feeling a moral imperative to help society as a whole.

"I'm a practicing physician, and I know exactly how it is to feel the pressure ... to make my practice financially viable," says the AAFP's Fleming. "We have a very sick health system," but opting out of it ignores society's needs. The physician retains a personal responsibility to treat less-wealthy patients. It is, the argument goes, never good social policy to narrow patients' access to care.

Yet funneling 5,000 patients through a single physician often amounts to assembly-line medicine. The pressures are unfair, potentially harmful to the patient, and destructive to the doctor.

The plus side

Such pondering aside, some of Cohen's peers have found that concierge models make medicine a joy again.

"Even more so than I imagined, it's changed my life," says Benoit, an internist who left a 9-year-old, traditional pay-per-procedure practice to open a retainer-based practice in Colorado in October 2003.

"I've gone from getting up in the morning knowing I can't possibly do everything I need to do ... to being a part of [my patient's] life. I can be more active in prevention. I always believed in and tried to be involved in prevention, but you had to deal with the [clinical or operational] matter at hand."

In his prior practice, he scheduled appointments in 15-minute increments. Of that time, the patient would spend an average of two to six minutes in the waiting room, another five to seven minutes having weight and vital signs read and, finally, two to six minutes with Benoit himself.

The new model has "given me my profession back." He tells of spending 90 minutes with a patient who followed him from his prior office, and finding out for the first time about a number of social factors that might be contributing to her health problems. "Instead of being reactionary, we have time to be proactive."

There are technological opportunities as well. In Boca Raton, Fla., Robert Colton, one of the first and most visible of the concierge physicians, now offers patients DNA profiles that tell how they metabolize certain drugs. Most internists' access to such technology remains minimal at best. Colton's model, however, allows him to use it for patients who want to invest in it. They pay $2,100 for an initial profile, and an annual $250 to update it as they change or take new medications.

And there are personal payoffs. "My family," Benoit says, "loves it. I have coffee with my wife in the morning. I play with the baby, and the older kids have time with me. I see them off to school, and sometimes I'm there when they come home. I feel very, very content."

The decision

Brent Cohen got back from vacation with his decision in hand.
The responses to his letter had been encouraging. He'd sent out 3,000 and gotten "about a thousand back," a 33 percent response rate that most direct mailers would consider phenomenal. "I think I had enough patients to do this," he says.

But he won't do it. His reasons are both practical and sentimental.
On the practical side, he was very concerned about concierge medicine's time commitment. "If you're going to be available 24/7, getting away is not an easy thing."

Other physicians who'd switched told him that during the first three to six months in the program, patients called frequently "to make sure they were getting their money's worth." And although patients called less often after that, "you're still carrying that pager around all the time."

Cohen was also worried about politics. "I have young kids, and what if they legislate against this a couple of years down the road? Then I'd have to come back and start from scratch again."

"But mostly," he says, "it came down to leaving patients. I've had these relationships for years, and I'd have to let probably 95 percent of them go. And I had to ask myself, 'Do I really want to take care of 300 or 400 wealthy people, and that's it?' I just can't see doing it right now."

Bill Sonn can be reached via
editor@physicianspractice.com.

This article originally appeared in the February 2004 issue of Physicians Practice.